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Did Niacin Get a Bum Rap?
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
I had thought that my long-standing romance with niacin was finally over. Although it was a very early love of mine, reluctantly I had gone along with the mainstream consensus. It seemed that niacin had been sent into near-permanent pharmaceutical exile by the devastating one-two punches of the AIM HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) and the HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events) studies. I had even stopped taking my own self- prescribed niacin 2,500 mg twice a day, which I had been religiously consuming for over 2 decades. But before long, I found that I had real difficulty divorcing myself completely from the charms of this lipid-lowering Lorelei. Now, after agonizing over the issue for some time, I’m here to tell you that niacin almost certainly did get a bum rap and should be restored as an important tool in your therapeutic armamentarium.
Related: Niacin: Not Dead Yet, but on Life Support
A recent report that niacin seems to function partially as an inhibitor of the PCSK-9 enzyme accelerated my reconsideration. The inhibition of PCSK-9, an enzyme that removes low-density lipoprotein cholesterol (LDL-C) receptors from hepatocytes, is the hot new way of dropping LDL-C levels. And I mean really dropping LDL-C levels. Studies conducted with investigational compounds developed by Amgen and Pfizer have shown truly dramatic drops in LDL-C levels by as much as 80%—often down to ridiculously low levels (around 25 mg/dL).
Of course, we are still waiting for outcome trials, which will answer the critical question: Are these dramatic falls in LDL-C levels actually associated with meaningful reductions in the occurrence rates for cardiovascular events such as myocardial infarction and stroke? For now, inhibiting PCSK-9 seems to be a good way to change the lipid profile dramatically. Even if niacin is not nearly as potent an inhibitor of the PCSK-9 enzymes as some newer compounds, the fact that it has measurable inhibiting activity seems enough to earn it a second look.
The concerns over niacin derive almost entirely from the results of the AIM HIGH study and the HPS2-THRIVE trials. Thus, any effort to rehabilitate niacin will require a reckoning with each of these major trials.
Related: The Niacin Debate Continues: Higher Doses, Please
I was one of the original AIM HIGH investigators, but our study site at the Phoenix VA eventually was removed from the trial because of poor enrollment. Nonetheless, I had a front-row seat to observe the conduct of the trial, and it seemed less than optimal. The relatively infrequent monitor visits for this study probably contributed to the finding that the lipid differences between the 2 study groups were considerably smaller than they could have been. It was my impression that study sites did not have their feet held to the fire when niacin compliance became problematic for subjects randomized to the larger dose of niacin.
The study design also contributed to blunting the difference between the 2 study groups. Subjects in the control group actually received 200 mg of immediate-release niacin to help blind the study by ensuring that all subjects experienced a niacin flush. The statin dose wound up being higher in the control group, and the use of the add-on lipid-lowering agent ezetimibe was also greater (22% vs 10%) in the control group. All these factors would tend to blunt the differences between the 2 groups, and indeed lipid levels did improve significantly in both groups.
To add insult to injury, the trial was stopped after just 3 years. A number of other lipid trials that were ultimately positive had not yet reached a statistically significant separation between the control and the experimental groups after that relatively brief study interval. Although these study flaws are hardly fatal, when taken together, they suggest the need to maintain an open mind. If niacin is like Brylcreem and “a little dab’ll do ya,” then the small dusting received by the control subjects might have been cardioprotective enough to blunt any differences in event rates between the 2 groups, especially over the truncated period of the actual trial.
What about the much larger HPS2-THRIVE study; surely there can’t be similar flaws in that study as well? Well, a critical review identifies a number of significant shortcomings. Although conducted by British academics through the Medical Research Council, the trial was funded and largely designed by Merck, which had hoped it would demonstrate the clinical utility of its new combination of extended-release niacin and an antiflushing agent called laropiprant, a prostaglandin-inhibiting compound. One has only to remember the fiasco with the cyclo-oxygenase-2 inhibitor celecoxib to recognize the potential increase in cardiovascular events of any agent that blocks prostaglandins. Any failure of the niacin/laropiprant arm to show a reduced cardiovascular event rate on top of baseline statin therapy might have been because the laropiprant was increasing events enough to cancel any reductions the niacin might have produced.
Related: You'll Have a Dickens of a Time
A fair trial of the potential effectiveness of a niacin preparation on top of statin therapy should test niacin in a clinical setting in which it is typically prescribed. I’m not going far out on a limb by asserting that the majority of niacin prescriptions are written for patients who have low levels of high-density lipoprotein cholesterol (HDL-C), typically < 40 mg/dL but often much lower than that. Yet the mean HDL-C in the HPS2-THRIVE study was a robust 44 mg/dL, and the mean LDL-C level was a well-controlled 63 mg/dL. The subjects who were randomized to receive either placebo or niacin/laropiprant on top of their preexisting statin therapy were simply not the typical patients who would normally be started on niacin.
The supposedly airtight case against niacin isn’t really so strong after all. Where does this leave us? Let’s not forget that there is a sizable population of individuals who cannot or will not take statins. Surely these individuals would be better off on niacin therapy than on no therapy, particularly if they have a combination of low HDL-C levels, elevated triglyceride levels, and elevated LDL-C levels.
I currently prescribe this combination in patients who have persistently elevated triglyceride levels even after their statins have been maxed out, because I believe that lowering triglycerides in such patients may well translate into lower cardiovascular risk. Some recent evidence suggests that the epidemiologic association of low HDL-C levels with cardiovascular events may not be due so much to the low HDL-C levels per se, but rather to the very frequent association of elevated triglyceride levels—the true culprit, with low HDL-C levels. So if you have a need to lower either triglyceride levels or LDL-C levels in a patient already taking as much statin as they can tolerate, niacin would be a very reasonable drug to consider. My romance with niacin has been rekindled, and perhaps you’ll want to give it a second look as well.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Failure to warn or report
Question: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
Question: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
Question: A patient who is a school bus driver is also an alcoholic, but he continues to drive despite his physician’s warning against drinking and driving. He already has had one prior driving under the influence (DUI) conviction. Fearing a potential vehicular accident with injuries to the schoolchildren, the physician, with permission, informed the patient’s wife of the situation; but that did not make a difference.
Under the circumstances, which of the following is best?
A. The physician has discharged his professional duty by warning the patient and informing his wife.
B. It is unethical for the physician to report this to the employer, because it violates the principle of confidentiality.
C. The physician may have an ethical and legal duty to report, because the risk of harm to the school children is foreseeable and outweighs other considerations.
D. A and B.
E. A and C.
Answer: C. The issue in this hypothetical revolves around the failure to warn and report when a doctor has determined that his or her patient poses a significant societal risk. It places the health care provider in a dilemma, because it pits patient confidentiality against the public interest in safety.
There does not appear to be an appellate case precisely on point, but the well known case of Tarasoff1 offers useful insight.
In Tarasoff, a California court imposed a legal duty on a college psychologist to warn an intended victim of harm, even though that meant breaching confidentiality in a professional relationship. A jilted patient had confided in the university psychologist his intention to kill his ex-girlfriend. The information, though shared with campus security, was not released to the intended victim, the girlfriend, whom the patient stabbed to death 2 months later.
The California court found the psychologist and the University of California (as the psychologist’s employer) liable, reasoning that the protection of public safety was more important than the sanctity of the doctor-patient confidentiality relationship.
The court wrote: “We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. ... In this risk-infested society, we can hardly tolerate the further exposure to danger that would result from a concealed knowledge of the therapist that his patient was lethal.”
However, the duty to warn a third party may not be as clear cut where there is no readily identifiable victim.2
Further, the law is unsettled regarding a physician’s duty to report negligent conduct that poses a significant risk to public safety, e.g., where a patient insists on operating a vehicle against medical advice. Obviously, the doctor should spare no effort in trying to persuade such a patient to discontinue driving. When this fails, however, and depending on the circumstances, the physician should seriously consider breaching patent confidentiality by notifying the driving licensing bureau.
This opinion is in accord with the AMA Code of Medical Ethics: “Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely. In situations where clear evidence of substantial driving impairment implies a strong threat to patient and public safety, and where the physician’s advice to discontinue driving privileges is ignored, it is desirable and ethical to notify the department of motor vehicles.”3
What about informing the patient’s employer if the risk of harm arises in the work setting?
The duty to report is clearer if the physician is a company doctor specifically charged with the task of determining whether an employee is fit for work. However, a patient’s personal physician may be a different matter, because he or she does not share the same contractual obligation as a company employed doctor.
Still, the circumstances may well dictate the need to report. In the hypothetical scenario posed above, the patient is refusing to heed the advice of physician and spouse, and given the history of a DUI, can be said to be placing innocent children and others at risk. The physician may need to go beyond warning the patient and wife, even though revealing a patient’s diagnosis violates the principle of confidentiality.
Arguably controversial, the physician’s justification is that there is a higher ethical and legal duty to report, as the risk of harm to the school children is both unreasonable and foreseeable, outweighing other considerations.
The same analysis concerning reporting may be applied in uncooperative patients with certain medical diagnoses (e.g., uncontrolled epilepsy, serious mental illness, or disabling cardiac or cerebrovascular disease, to name a few) and in those taking mind-altering prescription medications or illicit drugs.
A key inquiry is whether the patient’s work activity is potentially hazardous, as in those who are entrusted with public transportation, e.g., bus drivers, pilots and train/ship engineers, or those who operate heavy machinery.
The most familiar example of the failure to warn (as opposed to report) is of course in informed consent litigation, where the physician is faulted for not warning the patient of the risk of harm and the patient in fact suffers that harm. It is framed as the failure to disclose material risks. The California Supreme Court has stated that “material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure”; that “a (material) fact must also be one which is not commonly appreciated”; and the scope of disclosure may be expanded in patients with “unique concerns or lack of familiarity with medical procedures.”4 There is, however, no legal requirement to deliver a “mini-course in medical science.”5
Another situation where there may have been a failure to warn is in medical products liability. Here, the plaintiff alleges that the defective product has caused injuries because the manufacturer has issued no prior warning to the health care provider or end user. A prime example is the current Lipitor and diabetes class action lawsuit against Pfizer.
In failing to warn a patient, a doctor may incur liability not only for injuries to the patient but also to nonpatient third parties.
In a 2002 Hawaii case, a car suddenly veered across five lanes of traffic, striking an 11-year-old girl and crushing her against a cement planter.6 The driver alleged that the prescription medication prazosin caused him to develop hypotension and lose control of the car, and that the treating physician was negligent in failing to warn of this potential side effect.
The Hawaii Supreme Court held that physicians have a duty to their patients to warn of potential adverse effects, and this responsibility should therefore extend to third parties.
Court decisions elsewhere have also found liability where, for public policy reasons, a “special relationship” is deemed to exist between the doctor and the injured third party. Foreseeability is one important factor in construing its existence, notwithstanding the absence of the traditional doctor-patient relationship.
References
1. Tarasoff v. Regents of University of California, 551 P.2d 334 (Cal. 1976).
2. Furr v. Spring Grove State Hospital, 454 A.2d 414 (Md. 1983).
3. AMA Code of Medical Ethics [2.24 (3), 2012-2013 ed.].
4. Truman v. Thomas, 27 Cal.3d 285 (1980).
5. Cobbs v. Grant, 8 Cal.3d 229 (1972).
6. McKenzie v. Hawaii Permanente Medical Group, 47 P.3d 1209 (Haw. 2002).
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii. He currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at [email protected].
Cosmetic procedures in pregnancy
Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.
Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.
However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.
The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.
The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.
Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.
The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.
References
Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.
Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.
Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.
Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.
Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.
Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.
Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.
Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.
However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.
The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.
The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.
Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.
The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.
References
Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.
Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.
Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.
Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.
Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.
Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.
Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.
Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.
However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.
The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.
The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.
Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.
The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.
References
Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.
Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.
Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.
Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.
Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.
Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.
Are you a victim of the cognitive load theory?
My job recently changed to include some administrative responsibilities, so having done purely clinical work for my entire career as a physician, I thought it wise to begin broadening my horizons to learn how to best meet the new challenges ahead of me. Fortunately, not only was the Hospital Medicine 2015 conference just an hour’s drive away, it occurred just when I needed it most, within days of my taking on a new role.
Naturally, I opted for the Practice Management track this year since I will need a different skill set than I currently have. In the first session, called Case Studies in Improving Patient Experience, I learned about a patient named John, who had developed typical ischemic chest pain during a weekly tennis game with his wife. His doctors did everything right, or so they thought. They exceeded the national guidelines for each quality measure, including the time it took them to revascularize his blocked artery. John had no significant residual damage and within 2 weeks was back on the tennis courts.
But there had been a huge disconnect. His doctors practiced excellent medicine, yet John was displeased with his care. The hospital team had not communicated well with John during his hospital stay. A great success story seen through the eyes of his medical team was a great failure as seen through the eyes of John and his wife. The hospital team’s lack of communication trumped the fact that they had played a huge role in saving John’s life.
As a matter of fact, John and his wife were so distraught over their experience that they went to the hospital administration to express their concerns about how poorly they had been treated.
This story also was aired as part of a segment on National Public Radio. Some of the comments of listeners echoed the sentiments we hear often, such as “doctors don’t know how to communicate with patients” and “doctors don’t care.” While the former statement may be true in many cases, the latter couldn’t be further from the truth. We do care. Why else would we sacrifice so much of our lives to help others? There are certainly other careers that pay more than medicine, especially considering all the time and financial investment that go into becoming a physician.
So why is it that as intelligent as we are as a group, we often fall short of meeting the communication goals that are so important to our patients? Some believe – and I am one of them – that most physicians are examples of the cognitive load theory. Our brains are simply overloaded. This theory, developed by psychologist John Sweller in the 1980s, refers to the total amount of mental effort used in one’s working memory.
There are three types of cognitive load: intrinsic, extraneous, and germane. Intrinsic cognitive load refers to how much effort goes into a particular topic, and in the field of medicine, the complexity of the information we deal with is very high, as is our intrinsic load.
Extraneous cognitive load refers to how this information is presented to us. When the pager is incessantly beeping, a line of nurses is waiting to ask a question, you desperately need to get to the ED to admit a potential stroke patient, and you eye a family member anxiously pacing the hallway and waiting for a chance to speak with you, your brain is bombarded with a variety of complex issues coming in all directions. In short, your extraneous load is through the roof.
The germane cognitive load refers to the work you put into processing information and creating a permanent store of that knowledge, creating a schema, so to speak. For instance, after much experience, it has become relatively simple to classify a patient as having heart failure if he presents with bilateral leg edema, progressive shortness of breath, and crackles on exam.
Experience helps us with our germane cognitive load and sometimes we have little control over our intrinisic load, but there are many potential opportunities to organize our extraneous cognitive load into chunks that flow more seamlessly, make our workday run more smoothly, and free up mental energy and time to deal effectively with other important issues. We all have our personal preferences for how we like our workday to flow. Chances are, with a little creativity, we can have a significant impact on our own extraneous loads.
Getting back to John, he is just one of many patients who feel emotionally neglected, not respected, or not kept up to date regarding their statuses. Considering his doctors, they were probably overwhelmed with the load they were carrying; the responsibility for a life is something only medical professionals can fully grasp. I know there have been times when I too felt simply overwhelmed and unable to do every single thing that would have been good, but not crucial, to the goal of curing the patient. Had I managed my intrinisic load better, perhaps I would have been better equipped to spend more time talking to patients and their family members. I suspect I am not alone.
My job recently changed to include some administrative responsibilities, so having done purely clinical work for my entire career as a physician, I thought it wise to begin broadening my horizons to learn how to best meet the new challenges ahead of me. Fortunately, not only was the Hospital Medicine 2015 conference just an hour’s drive away, it occurred just when I needed it most, within days of my taking on a new role.
Naturally, I opted for the Practice Management track this year since I will need a different skill set than I currently have. In the first session, called Case Studies in Improving Patient Experience, I learned about a patient named John, who had developed typical ischemic chest pain during a weekly tennis game with his wife. His doctors did everything right, or so they thought. They exceeded the national guidelines for each quality measure, including the time it took them to revascularize his blocked artery. John had no significant residual damage and within 2 weeks was back on the tennis courts.
But there had been a huge disconnect. His doctors practiced excellent medicine, yet John was displeased with his care. The hospital team had not communicated well with John during his hospital stay. A great success story seen through the eyes of his medical team was a great failure as seen through the eyes of John and his wife. The hospital team’s lack of communication trumped the fact that they had played a huge role in saving John’s life.
As a matter of fact, John and his wife were so distraught over their experience that they went to the hospital administration to express their concerns about how poorly they had been treated.
This story also was aired as part of a segment on National Public Radio. Some of the comments of listeners echoed the sentiments we hear often, such as “doctors don’t know how to communicate with patients” and “doctors don’t care.” While the former statement may be true in many cases, the latter couldn’t be further from the truth. We do care. Why else would we sacrifice so much of our lives to help others? There are certainly other careers that pay more than medicine, especially considering all the time and financial investment that go into becoming a physician.
So why is it that as intelligent as we are as a group, we often fall short of meeting the communication goals that are so important to our patients? Some believe – and I am one of them – that most physicians are examples of the cognitive load theory. Our brains are simply overloaded. This theory, developed by psychologist John Sweller in the 1980s, refers to the total amount of mental effort used in one’s working memory.
There are three types of cognitive load: intrinsic, extraneous, and germane. Intrinsic cognitive load refers to how much effort goes into a particular topic, and in the field of medicine, the complexity of the information we deal with is very high, as is our intrinsic load.
Extraneous cognitive load refers to how this information is presented to us. When the pager is incessantly beeping, a line of nurses is waiting to ask a question, you desperately need to get to the ED to admit a potential stroke patient, and you eye a family member anxiously pacing the hallway and waiting for a chance to speak with you, your brain is bombarded with a variety of complex issues coming in all directions. In short, your extraneous load is through the roof.
The germane cognitive load refers to the work you put into processing information and creating a permanent store of that knowledge, creating a schema, so to speak. For instance, after much experience, it has become relatively simple to classify a patient as having heart failure if he presents with bilateral leg edema, progressive shortness of breath, and crackles on exam.
Experience helps us with our germane cognitive load and sometimes we have little control over our intrinisic load, but there are many potential opportunities to organize our extraneous cognitive load into chunks that flow more seamlessly, make our workday run more smoothly, and free up mental energy and time to deal effectively with other important issues. We all have our personal preferences for how we like our workday to flow. Chances are, with a little creativity, we can have a significant impact on our own extraneous loads.
Getting back to John, he is just one of many patients who feel emotionally neglected, not respected, or not kept up to date regarding their statuses. Considering his doctors, they were probably overwhelmed with the load they were carrying; the responsibility for a life is something only medical professionals can fully grasp. I know there have been times when I too felt simply overwhelmed and unable to do every single thing that would have been good, but not crucial, to the goal of curing the patient. Had I managed my intrinisic load better, perhaps I would have been better equipped to spend more time talking to patients and their family members. I suspect I am not alone.
My job recently changed to include some administrative responsibilities, so having done purely clinical work for my entire career as a physician, I thought it wise to begin broadening my horizons to learn how to best meet the new challenges ahead of me. Fortunately, not only was the Hospital Medicine 2015 conference just an hour’s drive away, it occurred just when I needed it most, within days of my taking on a new role.
Naturally, I opted for the Practice Management track this year since I will need a different skill set than I currently have. In the first session, called Case Studies in Improving Patient Experience, I learned about a patient named John, who had developed typical ischemic chest pain during a weekly tennis game with his wife. His doctors did everything right, or so they thought. They exceeded the national guidelines for each quality measure, including the time it took them to revascularize his blocked artery. John had no significant residual damage and within 2 weeks was back on the tennis courts.
But there had been a huge disconnect. His doctors practiced excellent medicine, yet John was displeased with his care. The hospital team had not communicated well with John during his hospital stay. A great success story seen through the eyes of his medical team was a great failure as seen through the eyes of John and his wife. The hospital team’s lack of communication trumped the fact that they had played a huge role in saving John’s life.
As a matter of fact, John and his wife were so distraught over their experience that they went to the hospital administration to express their concerns about how poorly they had been treated.
This story also was aired as part of a segment on National Public Radio. Some of the comments of listeners echoed the sentiments we hear often, such as “doctors don’t know how to communicate with patients” and “doctors don’t care.” While the former statement may be true in many cases, the latter couldn’t be further from the truth. We do care. Why else would we sacrifice so much of our lives to help others? There are certainly other careers that pay more than medicine, especially considering all the time and financial investment that go into becoming a physician.
So why is it that as intelligent as we are as a group, we often fall short of meeting the communication goals that are so important to our patients? Some believe – and I am one of them – that most physicians are examples of the cognitive load theory. Our brains are simply overloaded. This theory, developed by psychologist John Sweller in the 1980s, refers to the total amount of mental effort used in one’s working memory.
There are three types of cognitive load: intrinsic, extraneous, and germane. Intrinsic cognitive load refers to how much effort goes into a particular topic, and in the field of medicine, the complexity of the information we deal with is very high, as is our intrinsic load.
Extraneous cognitive load refers to how this information is presented to us. When the pager is incessantly beeping, a line of nurses is waiting to ask a question, you desperately need to get to the ED to admit a potential stroke patient, and you eye a family member anxiously pacing the hallway and waiting for a chance to speak with you, your brain is bombarded with a variety of complex issues coming in all directions. In short, your extraneous load is through the roof.
The germane cognitive load refers to the work you put into processing information and creating a permanent store of that knowledge, creating a schema, so to speak. For instance, after much experience, it has become relatively simple to classify a patient as having heart failure if he presents with bilateral leg edema, progressive shortness of breath, and crackles on exam.
Experience helps us with our germane cognitive load and sometimes we have little control over our intrinisic load, but there are many potential opportunities to organize our extraneous cognitive load into chunks that flow more seamlessly, make our workday run more smoothly, and free up mental energy and time to deal effectively with other important issues. We all have our personal preferences for how we like our workday to flow. Chances are, with a little creativity, we can have a significant impact on our own extraneous loads.
Getting back to John, he is just one of many patients who feel emotionally neglected, not respected, or not kept up to date regarding their statuses. Considering his doctors, they were probably overwhelmed with the load they were carrying; the responsibility for a life is something only medical professionals can fully grasp. I know there have been times when I too felt simply overwhelmed and unable to do every single thing that would have been good, but not crucial, to the goal of curing the patient. Had I managed my intrinisic load better, perhaps I would have been better equipped to spend more time talking to patients and their family members. I suspect I am not alone.
Letters from Maine: Defining quality
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
If you decided to read past the title of this column because you were expecting to hear me launch into a rant questioning how third-party payers or any credentialing group can honestly and fairly judge the quality of an individual physician by measuring the outcomes of his or her patients, I apologize. This column is about the quality of time, specifically the quality of time a parent spends with his or her child.
From an article in the Washington Post (“Making time for kids? Study says quality trumps quantity,” by Brigid Schulte, March 28, 2015), I learned of a study by Milkie et al. published in the Journal of Marriage and Family (“Does the Amount of Time Mothers Spend with Children or Adolescents Matter?” J. Marriage Family 2015;77:355-72) in which the researchers found that the amount of time a mother spent with her child was unrelated to the child’s behaviors, emotions, or academics. The only exception was during adolescence when more engaged maternal time was associated with better outcomes and fewer delinquent behaviors.
The sociologists who performed the study had observed in their previous research that working mothers today spend as much time with their children as did at-home mothers in the 1970s. This observation surprised them, but clearly fits with their current data that suggest that quantity doesn’t matter.
What did matter was quality. In fact, the authors found that if a mother was sleep deprived or felt guilty, anxious, or stressed, her time with her child could actually be “detrimental” to the child. The only factors that consistently had a positive impact on the child were maternal income and educational level.
Measuring the quantity of time a parent spends with his or her child is relatively easy. Assessing the quality of that time is much more difficult. The findings in this study won’t be of much help to a parent who wants to enhance the quality of time he or she spends with her child. Meeting the criteria of being mentally healthy, unstressed, well-slept, and economically stable is easier said than done. However, let’s say that you are a parent who is fortunate enough to be able to pull it off. Does this mean that just because you have your act together that your child is automatically going to get quality time?
I would answer, “No!” Because if we really want to know, let’s ask the child, because it is the child who should be defining the quality of time he spends with his parent. Unfortunately, many parents lose track of the child’s perspective when they are evaluating the time they spend together.
For example, you come home from a tough day at work and find that your 3½-year-old has been cooped up inside because the daycare provider didn’t want to take the kids out in the rain. It’s 40 degrees. It’s more than a light rain, but not a torrential downpour. Your son wants to go out and play in the puddles. Your plan for quality time had been to read one his favorite books to him for the umpteenth time before you start to fix dinner.
If we let the child define the quality of your time together, it means that both of you are going to get wet. Clothes will have to be changed, and the dinner that he wasn’t going to eat very much of anyway is going to be delayed a few minutes. But let’s face it – a few minutes out in the cold rain has the potential of being an event that one or both of you will remember for a long time. Is it going to have the educational value equivalent to the language skills your son will acquire from hearing multiple repetitions of the spoken word? Will it enhance his chances of being a competent reader? Probably not. But your son may learn that there is fun to be had outside on a rainy day. Or he may learn that 40 degrees is a little too cold be outside if it is raining. But he will certainly learn that you are someone who likes to share experiences with him and someone who is will to give him some say in what those experiences are.
A parent might argue that if I let my child choose the things we do together, it means we will always be watching cartoons. My response to that observation would be, “You’ve already made one mistake by letting him watch cartoons in the first place; let’s not make a second one. Give him healthier choices, and don’t impose your notion of quality on your time together.” Sometimes just standing by and watching your child enjoy himself is quality time for both of you.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
How Can Dermatologists Help Dermatopathologists Work “Smarter” for Them?
In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.1
Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.
Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.
One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.
Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.
Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.
It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.
Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.
Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.
Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.
Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.
Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.
All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.
If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”
Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.
Reference
1. Cerroni L, Argenyi Z, Cerio R, et al. Influence of evaluation of clinical pictures on the histopathologic diagnosis of inflammatory skin diseases. J Am Acad Dermatol. 2010;63:647-652.
In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.1
Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.
Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.
One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.
Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.
Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.
It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.
Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.
Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.
Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.
Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.
Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.
All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.
If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”
Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.
In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.1
Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.
Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.
One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.
Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.
Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.
It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.
Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.
Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.
Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.
Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.
Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.
All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.
If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”
Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.
Reference
1. Cerroni L, Argenyi Z, Cerio R, et al. Influence of evaluation of clinical pictures on the histopathologic diagnosis of inflammatory skin diseases. J Am Acad Dermatol. 2010;63:647-652.
Reference
1. Cerroni L, Argenyi Z, Cerio R, et al. Influence of evaluation of clinical pictures on the histopathologic diagnosis of inflammatory skin diseases. J Am Acad Dermatol. 2010;63:647-652.
The intersection between pediatrics and addiction medicine
Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.
As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.
Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.
Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.
With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.
These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.
While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.
Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.
A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.
For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.
Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.
Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.
As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.
Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.
Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.
With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.
These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.
While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.
Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.
A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.
For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.
Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.
Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.
As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.
Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.
Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.
With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.
These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.
While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.
Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.
A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.
For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.
Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.
Forget kids – get a dog instead
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.
It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.
Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).
On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.
So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.
While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.
I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.
None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.
Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”
Experts weigh in: Mental illness and the Germanwings crash
To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?
For more, read our Storify page detailing the incident and the response from the mental health community:
To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?
For more, read our Storify page detailing the incident and the response from the mental health community:
To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?
For more, read our Storify page detailing the incident and the response from the mental health community:
Recognizing fetal alcohol spectrum disorder: An imperative
Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.
Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.
Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.
The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.
A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.
As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.
Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.
Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.
Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.
Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.
Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.
Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.
The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.
A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.
As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.
Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.
Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.
Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.
Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.
Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.
Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.
The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.
A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.
As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.
Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.
Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.
Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.
