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The Baltimore riots
Practically everyone who lives in America has heard about the Baltimore riots, precipitated by the death of a man while in police custody. Their scope was unprecedented; their implications, far reaching. I, like many Americans, stayed glued to the news to keep abreast of the latest updates for a variety of reasons, one of which was that I live and work nearby, and personal safety was a major concern. At the peak of the violence, when people were leaving the city in droves, I kept in close contact with my brother, a physician who works in a hospital at the epicenter of the chaos. Fortunately, he got out safely, as did most people. Yet many, including citizens and police officers, were injured, some seriously so.
No matter where you stand regarding the events surrounding the riots, the fact remains that we as physicians are not infrequently called upon to care for patients who have victimized or been victimized by others. We care for those who are slowly destroying themselves and endangering others with their abuse of drugs and alcohol, yet refuse any help we offer for their substance abuse. Some hospitalists work in hospitals with booming prison wards, and thus frequently care for murderers, thieves, child abusers, and others whom we may secretly fear, yet openly pledge to protect, respect, and care for. While I could not find a good scholarly article addressing how we as physicians do versus how we should handle these situations, I believe many of us have struggled with the personal emotions and ethical dilemmas raised by some of these cases.
How much can we and should we get involved? How do we mask our personal opinions of patients who have committed egregious acts and provide not only the best care possible, but do so while treating them with the respect and dignity that we allow for other patients? And if we go the extra mile to provide emotional support and encouragement, will we really have any positive impact on them, or will they just shut us out? Where do we draw the line between just being health care providers and being compassionate, nonjudgmental clinicians who can really impact their lives?
I don’t think there is an easy answer to any of these questions, and each patient is different. But I believe that many people still look up to their health care providers, and there will be those times when we can be more than their doctor; we can be their (much-needed) friend. Meanwhile, we need to guard against the natural human inclination to act as judge and jury toward those who have committed acts we personally find reprehensible. Every patient deserves our very best medical care, even when we cannot find it within ourselves to give this service with a smile.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Practically everyone who lives in America has heard about the Baltimore riots, precipitated by the death of a man while in police custody. Their scope was unprecedented; their implications, far reaching. I, like many Americans, stayed glued to the news to keep abreast of the latest updates for a variety of reasons, one of which was that I live and work nearby, and personal safety was a major concern. At the peak of the violence, when people were leaving the city in droves, I kept in close contact with my brother, a physician who works in a hospital at the epicenter of the chaos. Fortunately, he got out safely, as did most people. Yet many, including citizens and police officers, were injured, some seriously so.
No matter where you stand regarding the events surrounding the riots, the fact remains that we as physicians are not infrequently called upon to care for patients who have victimized or been victimized by others. We care for those who are slowly destroying themselves and endangering others with their abuse of drugs and alcohol, yet refuse any help we offer for their substance abuse. Some hospitalists work in hospitals with booming prison wards, and thus frequently care for murderers, thieves, child abusers, and others whom we may secretly fear, yet openly pledge to protect, respect, and care for. While I could not find a good scholarly article addressing how we as physicians do versus how we should handle these situations, I believe many of us have struggled with the personal emotions and ethical dilemmas raised by some of these cases.
How much can we and should we get involved? How do we mask our personal opinions of patients who have committed egregious acts and provide not only the best care possible, but do so while treating them with the respect and dignity that we allow for other patients? And if we go the extra mile to provide emotional support and encouragement, will we really have any positive impact on them, or will they just shut us out? Where do we draw the line between just being health care providers and being compassionate, nonjudgmental clinicians who can really impact their lives?
I don’t think there is an easy answer to any of these questions, and each patient is different. But I believe that many people still look up to their health care providers, and there will be those times when we can be more than their doctor; we can be their (much-needed) friend. Meanwhile, we need to guard against the natural human inclination to act as judge and jury toward those who have committed acts we personally find reprehensible. Every patient deserves our very best medical care, even when we cannot find it within ourselves to give this service with a smile.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
Practically everyone who lives in America has heard about the Baltimore riots, precipitated by the death of a man while in police custody. Their scope was unprecedented; their implications, far reaching. I, like many Americans, stayed glued to the news to keep abreast of the latest updates for a variety of reasons, one of which was that I live and work nearby, and personal safety was a major concern. At the peak of the violence, when people were leaving the city in droves, I kept in close contact with my brother, a physician who works in a hospital at the epicenter of the chaos. Fortunately, he got out safely, as did most people. Yet many, including citizens and police officers, were injured, some seriously so.
No matter where you stand regarding the events surrounding the riots, the fact remains that we as physicians are not infrequently called upon to care for patients who have victimized or been victimized by others. We care for those who are slowly destroying themselves and endangering others with their abuse of drugs and alcohol, yet refuse any help we offer for their substance abuse. Some hospitalists work in hospitals with booming prison wards, and thus frequently care for murderers, thieves, child abusers, and others whom we may secretly fear, yet openly pledge to protect, respect, and care for. While I could not find a good scholarly article addressing how we as physicians do versus how we should handle these situations, I believe many of us have struggled with the personal emotions and ethical dilemmas raised by some of these cases.
How much can we and should we get involved? How do we mask our personal opinions of patients who have committed egregious acts and provide not only the best care possible, but do so while treating them with the respect and dignity that we allow for other patients? And if we go the extra mile to provide emotional support and encouragement, will we really have any positive impact on them, or will they just shut us out? Where do we draw the line between just being health care providers and being compassionate, nonjudgmental clinicians who can really impact their lives?
I don’t think there is an easy answer to any of these questions, and each patient is different. But I believe that many people still look up to their health care providers, and there will be those times when we can be more than their doctor; we can be their (much-needed) friend. Meanwhile, we need to guard against the natural human inclination to act as judge and jury toward those who have committed acts we personally find reprehensible. Every patient deserves our very best medical care, even when we cannot find it within ourselves to give this service with a smile.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].
More than ever, diversity matters in dermatology
As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?
Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).
A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.
I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.
Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.
Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?
The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.
Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.
I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.
And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.
Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.
A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.
We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.
As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.
Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.
All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.
The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.
It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?
I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.
The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.
We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.
How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.
How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?
Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.
There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.
Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.
For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.
If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.
For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.
Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.
A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.
As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?
Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).
A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.
I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.
Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.
Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?
The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.
Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.
I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.
And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.
Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.
A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.
We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.
As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.
Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.
All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.
The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.
It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?
I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.
The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.
We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.
How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.
How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?
Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.
There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.
Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.
For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.
If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.
For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.
Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.
A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.
As a profession, I think it’s fair to say that dermatology has done a good job welcoming women and including them into this field of medicine. But how many of your physician colleagues are African Americans? How many are Latinos or Latinas?
Does the diversity of your clinician colleagues reflect our patient population? The 2013 census shows that 13.2% of Americans are African American and 17.1% are Latino. Because these populations are not represented in medicine at anything like these percentages, African American and Latino physicians are referred to as underrepresented in medicine (UIM).
A brochure for an upcoming medical conference states that by 2050, “half of the U.S. population will have skin of color.” This may well become a fact. But I argue that a professional workforce that is as diverse as the population we care for is a much better workforce.
I serve as the interim dean of the University of California, San Francisco (UCSF) School of Medicine, which is one of the great medical schools in the United States. The school has 632 students – 26% from underrepresented minorities, and 56% women – the most diverse student group in California and perhaps the United States. There are 2,180 full-time faculty members but less than 2% are underrepresented in medicine. The annual operating budget is more than $2 billion and the school is No. 1 in National Institutes of Health funding. But there are some important shortcomings.
Three things happened after I took the job as interim dean last year. First, the accrediting body of medical schools, the Liaison Committee on Medical Education, served us with a citation for our hiring practices and the lack of diversity among our faculty.
Second, I ran into something called the “climate survey.” We have all heard about climate change, but have you heard of a “climate survey”? No, it’s not an opportunity to complain about too much snow in Boston and too little water in San Francisco. People on every University of California campus were asked if they felt included in the organization that they worked in. Did they feel comfortable? Did they feel part of the club?
The UC survey found that at UCSF and its sister institutions, people from groups underrepresented in medicine – mainly Hispanics and African Americans, whether they were faculty, staff, or students – felt less comfortable than did their white counterparts. They did not feel our climate was inclusive. That’s not the same as being specifically excluded. It’s about not being included.
Third, there were the racially charged events in Ferguson, Missouri, and in Staten Island, New York, and the way our students responded to them. On December 9, 2014, our students organized a “die-in” protest to demonstrate their concern about racism in health care in our country. They called it WhiteCoats4BlackLives. So here I was, the dean of a medical school, and I find all of our students lying down in the street on campus in a very peaceful but profoundly moving demonstration to protest racism. Not only did our students protest at UCSF, they instigated the same WhiteCoats4BlackLives protest simultaneously at 83 medical schools across the country.
I recalled my own student days when we protested public events, and university administrators responded. But this time, as dean of medicine, I was the administrator. It gave me pause to think: What did those three pieces of evidence tell me? They made it clear that race matters. Once that realization finally became clear to me, the question was, what do we do? We were a few weeks away from our annual leadership retreat. The topic was going to be “strategic partnerships.” I sat down with the vice deans and said: Let’s talk about race instead.
And we did, and it turned into an amazing discussion. Just one example: Before the retreat, all of us took the Implicit Associations Test for race. This is a test designed to detect unconscious bias, the kind of bias we are not even aware of. Like me, many of us who considered ourselves fair and unbiased were shocked at the results. We were unconsciously biased for white people and against people of color.
Nicholas Kristof talked about this in the Feb. 21, 2015, edition of The New York Times, in a piece called “Straight Talk for White Men.” It’s worth reading the whole piece, but a study he cited especially struck me. Two scholars sent out fictitious résumés in response to help-wanted ads. Each résumé was given a name that sounded stereotypically black or white. The résumés were otherwise the same.
A résumé with a name like Emily or Greg received 50% more callbacks than the same résumé with a name like Lakisha or Jamal. Having a white-sounding name was more beneficial than 8 years’ work experience.
We heard stories from our students and faculty of color. I will highlight two. A medical student of color was called to the ED and was stopped by a nurse who thought he was a custodian. A senior faculty member was returning to his alma mater medical school in North Carolina as a visiting professor and was traveling from the airport to the medical school in a rental car. He was stopped and detained because he was black. His hosts came to his rescue and were required to prove that he was indeed visiting at their invitation. Needless to say these and other stories were startling in 2015. America is not post racial.
As a result of the retreat, we are now finishing a plan to make UCSF an inclusive institution for all who work here. The plan includes both short- and long-term elements, and an investment of at least $10 million to recruit and develop faculty from populations that are underrepresented in medicine.
Today’s doctor-patient relationship has become more and more collaborative. Patients actively look for doctors whom they feel they can talk to, who will understand their special concerns, their background, and their culture. There is neuroscience behind this. Research by Mahzarin Banaji, the coauthor of “Blind Spot,” found that we are in fact wired to react more positively to someone who looks like us.
All of us probably understand why a woman might want to choose a female gynecologist. Why a Chinese family will prefer a doctor who speaks their language. Our patients, too, are looking for physicians, for dermatologists, whose skin reflects theirs. They feel better if their doctor looks more like them.
The website Blackdermatologists.org is meant to help patients find exactly that. Guess how many black dermatologists are listed there in the whole State of California. Three. None of them are in San Francisco. None of them are across the bay in Oakland, a city with a large African American population. I did some research via other websites and found one African American dermatologist in the East Bay.
It’s one thing to be underrepresented in medicine, it’s another thing to be unrepresented. The lack of access to a physician who looks like our patients, whose background and experience might reflect theirs, is crucial. But what about the lack of research focused on African Americans, Latinos, and other underrepresented populations by people who understand the culture from the inside and what questions to ask?
I came across such an example in JAMA Dermatology, in an study titled, “Hair Care Practices as a Barrier to Physical Activity in African American Women” (JAMA Dermatol. 2013;149:310-4). My first reaction to this article was “what?” But that’s my unconscious bias talking. In fact, this study points to something significant. We know regular exercise is important for health. Research shows that African American women are the least likely to meet recommended levels of physical activity. Therefore, we want to be aware of any barriers to exercise for that population. But who would have imagined that one of the barriers to exercise for black women was hair care? This never would have occurred to me.
The people who did think to investigate this were in a team led by and including African American women dermatologists and researchers. So now that this is a known barrier, it can be addressed with patients. This is just one example of the type of knowledge we gain if we have a more diverse group of physicians and clinical researchers.
We know we don’t have enough practicing physicians of color in medicine in general, and in dermatology in particular. We easily fall back to the pipeline as the excuse for the situation. So, let’s look at the pipeline. Unfortunately, the current numbers are not encouraging. According to data from the Association of American Medical Colleges, from 1980 to 2013 the number of applicants to U.S. medical schools rose by 4,296. In 1980, 2,507 applicants were African American/black (7.1%), but by 2013 that number only rose to 3,490 (8.8%). During that same time period the number of Hispanic/Latino applicants rose from 5% to 10%.
How many of the applicants entered medical school? From 1980 to 2013 the number of African American/black students rose by 235: from 999 to 1,234, or 6.5% to 7%. At the same time, Hispanic/Latino students rose from 5.2% to 10.6% of entering students.
How many of the applicants matriculated? In 1980, 39.4% of African American/black applicants matriculated, but in 2013 the rate fell to 35%. What explains the data? Lack of role models? Lack of qualifications? Unconscious bias? An exclusive climate? Continued racism in our country? I don’t pretend to know the answer, but we always fall back on the pipeline as the excuse for the situation. So, what are we going to do about the pipeline?
Given the current state of the pipeline, the question may not be “what is the ideal” but “what is an achievable goal for dermatology?” In 2014, 47 of 731 applicants to dermatology programs were African American and another 47 were Latino. I don’t know how many of these finally matched, but only 6.4% of the applicants were either African American or Latino. This is well below their representation in the population at large.
There may be many reasons why physicians of color are not choosing dermatology as a specialty. Not surprisingly, many of them go into primary care. There is nothing wrong with that. You could argue that having African American and Latino doctors in primary care is where they are most needed, where personal relationships are most crucial. But that should not be an argument against trying to improve the general pipeline and diversify our own specialty pipeline. One goal could be to double the annual number of UIM applicants. I think this is achievable and would have an impact.
Here’s how we might get there. For those of us who are involved in the training of new dermatologists, we have to “lean forward.” Instead of receiving those who choose to come to us, we have to reach out to them. We have to engage, mentor, and ask questions. Find out about hidden bias, your own and others. Understand how your organization or institution can be enriched by having a more diverse pool of learners and leaders.
For those of you who are in practice, there is something you can do as well: You can plant a seed. You all see young people with skin problems. Many of them are and will be from underrepresented populations. Some of them may strike you as particularly bright and lively. So when you have the opportunity to talk to such a bright young woman or young man, ask, “Have you ever thought about becoming a doctor?” And if that strikes a spark, ask, “Have you thought about becoming a dermatologist?” Do this twice a day, 10 times a week, and 500 times each year.
If you do only that, whenever you have an opportunity, you may just plant a few seeds that will make a difference down the line. You will never know the outcome, but it’s worth doing. There’s no downside.
For those of you who are involved in organizations such as the American Academy of Dermatology or the Dermatology Foundation, what can the leadership in our field do? Think about mentorship, role models, scholarships, outreach, and pipeline programs. Think about recruiting colleagues who are UIMs into leadership positions. Let’s be the most inclusive specialty in medicine.
Ultimately, our goal is to have a workforce that mirrors our population. I know this is not achievable in the short term. It will take decades. But this will never occur if we don’t take the first step. To ensure the future of dermatology, let’s all lean forward and embrace this task. Diversity matters in medicine.
A board-certified dermatologist, Dr. Bruce U. Wintroub is interim dean of the University of California, San Francisco School of Medicine. He has been professor and chair of the department of dermatology at UCSF since 1985. This text was extracted from a plenary presentation he delivered at the 2015 annual meeting of the American Academy of Dermatology meeting in San Francisco.
To drink or not to drink – What do you tell your patients?
It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.
Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.
But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?
The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.
Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.
Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.
Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.
In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.
Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.
In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.
Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.
For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.
However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.
Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.
Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].
It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.
Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.
But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?
The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.
Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.
Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.
Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.
In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.
Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.
In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.
Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.
For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.
However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.
Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.
Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].
It has been more than 40 years since fetal alcohol syndrome was first recognized as a brain disorder leading to a wide range of learning and behavior problems – fetal alcohol spectrum disorders – in children prenatally exposed to alcohol.
Over that time, obstetric providers have played a key role in counseling patients, both preconception and during pregnancy, about the risks associated with various amounts and patterns of alcohol consumption. This advice is critical as about half of women of reproductive age in the United States consume some alcohol, and about half of pregnancies are not planned, leading to a high prevalence of exposure to alcohol prior to pregnancy recognition.
But how much alcohol at what specific time in early pregnancy leads to a known risk of learning and behavior problems as children reach school age?
The U.S. Surgeon General’s Office and the Centers for Disease Control and Prevention recommend that alcohol be avoided entirely during all weeks of pregnancy, as there is no known safe amount, type of beverage, or timing in gestation that a woman can consume alcohol. However, in recent years, a number of publications have suggested that “low to moderate” alcohol consumption in pregnancy is not demonstrably harmful to the developing fetus, at least in terms of learning ability.
Three recently published studies exemplify the dilemma. Colleen M. O’Leary et. al. examined educational achievement in 8- to 9-year olds in Western Australia (Pediatrics 2013;132:e468-75). The sample was a population-based cohort of 4,056 infants randomly ascertained with births between 1995 and 1997 whose mothers had responded to a postnatal survey about health behaviors including alcohol consumption. Researchers linked these infants to a midwives database to obtain birth details and to an educational testing database to obtain measures of school achievement.
Children were not evaluated for the physical features or a diagnosis of FAS or something on the FASD spectrum. Low alcohol consumption was defined as 1-2 standard drinks (10 g alcohol per standard drink in Australia) per occasion and fewer than 7 drinks per week. Moderate alcohol consumption was defined as 3-4 standard drinks per occasion and no more than 7 drinks per week. Binge drinking was defined as 5 or more drinks per occasion less frequently than weekly, and heavy drinking was defined as more than 7 standard drinks per week including binge drinking weekly or more often.
Underachievement in reading and writing was significantly associated with either heavy first trimester or binge drinking in late pregnancy. However, achievement in numeracy, reading, spelling and writing was not significantly impaired with low to moderate prenatal alcohol exposure.
In a study of a sample derived from the Danish National Birth Cohort, 1,628 women and their children were sampled from the original cohort based on maternal alcohol drinking patterns reported in pregnancy (BJOG 2012;119:1191-1200). The child’s IQ was assessed at 5 years of age.
Children were not specifically evaluated for the physical features of FAS or a diagnosis of something on the FASD spectrum. Levels of alcohol consumption were categorized as none, average intake of 1-4 standard drinks per week (12 g alcohol per standard drink in Denmark), 5-8 standard drinks per week, and more than 8 standard drinks per week. There were no differences in the performance of children whose mothers consumed up to 8 standard drinks per week at some point in pregnancy compared to children whose mothers abstained.
In a subsequently published study in which researchers used the same sample, the parent and teacher versions of the Strengths and Difficulties Questionnaire, a standard behavioral screening tool, were completed by the mothers and the preschool teachers (BJOG 2013;120:1042-50). After adjustment for confounders, overall there were no significant associations found for any drinking category compared to abstainers.
Many experts asked to comment on these findings emphasized that these studies were limited to a few measures of learning and behavior in young children that may not be reflective of the range of alcohol-related developmental effects. They also pointed out the great difficulty in obtaining an accurate report of alcohol exposure in the absence of a sensitive and specific biomarker.
For example, recall of specific quantities, frequencies, and timing of alcohol consumption either after delivery (the Australian study) or in a single prenatal interview that was conducted sometime between 7 and 39 weeks’ gestation (the Danish study) may be inaccurate. This could be because of difficulty in remembering these details, as well as the influence of the social unacceptability of drinking during pregnancy.
However, as emphasized in the conclusions drawn by both research teams, negative findings for low to moderate alcohol exposure should not be overinterpreted to represent a finding of no risk for this type of exposure. The data are clear that heavy prenatal alcohol exposure, and in particular binge drinking, pose substantial risks for alcohol-related problems, including cognitive and behavioral deficits.
Decades of research have also demonstrated that there is large variability in individual susceptibility to the effects of prenatal alcohol. In addition to the alcohol itself, alcohol metabolizing genotype, maternal age, socioeconomic status, nutrition, and other factors likely play a role in modifying or mediating the effects for the individual mother and her child.
Since obstetric providers and their patients cannot know who is most susceptible, the current CDC and Surgeon General’s recommendations are the most prudent.
Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She has no relevant financial disclosures. To comment, e-mail her at [email protected].
Are your patients vaccinated for travel?
Graduation season is rapidly approaching, with high school graduations, followed by summer vacations. While searching for that unique gift and /or summer experience, many of your patients may choose an international destination. Not to be forgotten are those who might travel to resource-limited areas to visit relatives, volunteer, or have extended stays because of parental job relocation. More U.S. high school graduates are participating in gap year programs, many of which involve extensive travel while providing the participant the opportunity to immerse and to actively participate in other cultures. For many, it may be their first experience in a country with poor hygiene. This week alone, I’ve helped prepare travelers, including adolescents and children, for a safari and one for 4 weeks of volunteerism in Tanzania. Another young traveler’s destinations were Rwanda, Uganda, and Kenya, and a fourth is planning to explore and trek regions in the high elevations of Bolivia and Peru. The question is, Will you be ready to help prepare young travelers to stay healthy and return home without any unwanted souvenirs?
For many, health concerns often are not the top priority when they are planning vacations. However, the primary care physician will most likely will be their initial call and resource once they realize their potential to be exposed to diseases and/or conditions not routinely encountered in the United States. Even if you receive the call late, there are still interventions you can provide.
To avoid that last-minute call, develop strategies to identify international travelers in your practice. Many practices send out reminders yearly for influenza and well visits, so consider developing one for international travel. Text-message reminders have been shown to improve influenza vaccine administration rates and are another form of communication that can be considered. Frequently remind families that if planning international travel, they should seek pretravel advice in a timely manner: Ideally advice should be obtained 4-6 weeks in advance, and definitely at least 2 weeks prior to departure. Remind them that adequate time is needed for the vaccine to become effective. In addition, depending on the patients’ destination, trip duration, and type of activity, two vaccines (rabies and Japanese encephalitis) may be recommended and are administered over a 28-day period. Yellow fever vaccine, which is recommended or required for entry into some countries, can be obtained only at centers designated by each state health department. It should be administered at least 10 days prior to travel.
Vaccine interventions are based on the potential risk for disease exposure/acquisition. Factors to consider include the age of the travelers, their health and immunization status, in addition to their destination, duration of stay, accommodations, activities, and reason for travel (such as business or visiting friends and relatives). If you have a child with a chronic disorder or who is immunocompromised, comparable medical care may not be available at all international destinations. In addition, not everyone may be a candidate to receive some recommended or required vaccines. Involvement with a health professional prior to booking the trip would be advisable.
Identify a travel health specialist in your area as a local resource who can provide the most up-to-date information and recommendations. Ensure that individual is willing to see children of all ages.
Make sure routine immunizations are up to date for age. Measles is the one exception. I know you have heard it before, but outbreaks persist, even in the United States. Travelers 6- to 11-months-old should receive one MMR dose prior to international travel. This dose will not count, so these children should receive two additional doses of vaccine once they are at least 1 year old. Many children travel with adults. All travelers at least 12 months of age and born after 1956 should have two documented doses of MMR prior to international travel unless they have serologic evidence of immunity. The second dose can be given as early as 4 weeks after the first. If two doses at least 4 weeks apart are administered when a child is at least 12 months of age, no additional doses are necessary.
In 2014, there were 668 cases of measles from 27 states in the United States. The United States is still experiencing a multistate outbreak of measles at press time, which began December 2014. As of April 24, 2015, 166 cases have been reported from 19 states. The Centers for Disease Control and Prevention analyzed the virus type (B3). It is identical to the one responsible for the outbreak in the Philippines in 2014, and it has now been identified in 14 other countries.
Most U.S. measles cases occur in unvaccinated travelers who become ill after their return and spread the disease to susceptible individuals. Do you have patients who are unimmunized? Another point to consider when speaking with these parents about travel is the potential loss of the herd immunity afforded their children while living in the United States. This benefit may not exist when they are visiting and/or relocating to countries with lower immunization rates. Measles outbreaks are occurring in multiple countries and are not limited to underdeveloped countries. For the most up-to-date travel health-related information from the CDC, click here.
Travelers’ diarrhea (TD) occurs in up to 70 % of travelers to developing countries. The World Health Organization defines it as passage of at least three loose stools in a 24-hour period. Most often it is self-limited, with symptoms lasting a median of 3-4 days. Although TD can be caused by bacteria, protozoa, and viruses, bacteria are usually the etiology, with enterotoxigenic Escherichia coli being the most common pathogens. Other bacterial etiologies include Shigella and Campylobacter species. Two antimicrobials are frequently prescribed to travelers for self-treatment of TD: ciprofloxacin and azithromycin. Most young children are prescribed the latter; however, in older children, ciprofloxacin may be prescribed off label, as its use in persons younger than 18 years is not approved by the Food and Drug Administration.
In December 2014, PulseNet, the national molecular subtyping network for food-borne disease, detected a multistate cluster of ciprofloxacin-resistant Shigella sonnei. Between May 2014 and February 2015, 157 cases including 37 children were detected in 32 states and Puerto Rico. Nine of the cases identified by PulseNet, and an additional 76 cases, were associated with an outbreak of ciprofloxacin-resistant S. sonnei in San Francisco. Antibiotic susceptibility was available for 126 isolates, of which 109 (87%) were not ciprofloxacin susceptible. Travel history was available for 75 patients not associated with the San Francisco outbreak, and slightly more than half (40) were associated with international travel. The island of Hispaniola (Dominican Republic = 22 cases and Haiti = 4 cases) was the most common destination, followed by India (8 cases) and Morocco (3 cases). The remaining destinations were Asia and Europe (MMWR 2015;64:318-20) Travel history was available and positive for 23 of the 37 children (62%).
Why such a concern? International travelers are at risk of becoming colonized with drug-resistant bacteria and have the potential to spread them domestically. It has already begun. In 2012, the National Antimicrobial Resistance Monitoring System (NARMS) revealed that isolates of S. sonnei had the following resistance pattern: trimethoprim/sulfamethoxazole, 42%; ampicillin, 18%; and ciprofloxacin, 2.1%. During this outbreak, 19 of the 126 isolates were tested by NARMS with the following resistance patterns noted: trimethoprim/sulfamethoxazole, 84%; ampicillin, 5%; and ciprofloxacin, 32%.
More judicious use of antibiotics is necessary. As pediatricians, we are not immune to this issue. The challenge is when, if at all, antibiotics should be prescribed for TD, and under what conditions should patients be instructed to use them. I’m rethinking my own practice. TD is one of the most common illnesses travelers acquire and is easily treated, but at what cost? The one expression I keep hearing myself say is, First do no harm.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures.
Graduation season is rapidly approaching, with high school graduations, followed by summer vacations. While searching for that unique gift and /or summer experience, many of your patients may choose an international destination. Not to be forgotten are those who might travel to resource-limited areas to visit relatives, volunteer, or have extended stays because of parental job relocation. More U.S. high school graduates are participating in gap year programs, many of which involve extensive travel while providing the participant the opportunity to immerse and to actively participate in other cultures. For many, it may be their first experience in a country with poor hygiene. This week alone, I’ve helped prepare travelers, including adolescents and children, for a safari and one for 4 weeks of volunteerism in Tanzania. Another young traveler’s destinations were Rwanda, Uganda, and Kenya, and a fourth is planning to explore and trek regions in the high elevations of Bolivia and Peru. The question is, Will you be ready to help prepare young travelers to stay healthy and return home without any unwanted souvenirs?
For many, health concerns often are not the top priority when they are planning vacations. However, the primary care physician will most likely will be their initial call and resource once they realize their potential to be exposed to diseases and/or conditions not routinely encountered in the United States. Even if you receive the call late, there are still interventions you can provide.
To avoid that last-minute call, develop strategies to identify international travelers in your practice. Many practices send out reminders yearly for influenza and well visits, so consider developing one for international travel. Text-message reminders have been shown to improve influenza vaccine administration rates and are another form of communication that can be considered. Frequently remind families that if planning international travel, they should seek pretravel advice in a timely manner: Ideally advice should be obtained 4-6 weeks in advance, and definitely at least 2 weeks prior to departure. Remind them that adequate time is needed for the vaccine to become effective. In addition, depending on the patients’ destination, trip duration, and type of activity, two vaccines (rabies and Japanese encephalitis) may be recommended and are administered over a 28-day period. Yellow fever vaccine, which is recommended or required for entry into some countries, can be obtained only at centers designated by each state health department. It should be administered at least 10 days prior to travel.
Vaccine interventions are based on the potential risk for disease exposure/acquisition. Factors to consider include the age of the travelers, their health and immunization status, in addition to their destination, duration of stay, accommodations, activities, and reason for travel (such as business or visiting friends and relatives). If you have a child with a chronic disorder or who is immunocompromised, comparable medical care may not be available at all international destinations. In addition, not everyone may be a candidate to receive some recommended or required vaccines. Involvement with a health professional prior to booking the trip would be advisable.
Identify a travel health specialist in your area as a local resource who can provide the most up-to-date information and recommendations. Ensure that individual is willing to see children of all ages.
Make sure routine immunizations are up to date for age. Measles is the one exception. I know you have heard it before, but outbreaks persist, even in the United States. Travelers 6- to 11-months-old should receive one MMR dose prior to international travel. This dose will not count, so these children should receive two additional doses of vaccine once they are at least 1 year old. Many children travel with adults. All travelers at least 12 months of age and born after 1956 should have two documented doses of MMR prior to international travel unless they have serologic evidence of immunity. The second dose can be given as early as 4 weeks after the first. If two doses at least 4 weeks apart are administered when a child is at least 12 months of age, no additional doses are necessary.
In 2014, there were 668 cases of measles from 27 states in the United States. The United States is still experiencing a multistate outbreak of measles at press time, which began December 2014. As of April 24, 2015, 166 cases have been reported from 19 states. The Centers for Disease Control and Prevention analyzed the virus type (B3). It is identical to the one responsible for the outbreak in the Philippines in 2014, and it has now been identified in 14 other countries.
Most U.S. measles cases occur in unvaccinated travelers who become ill after their return and spread the disease to susceptible individuals. Do you have patients who are unimmunized? Another point to consider when speaking with these parents about travel is the potential loss of the herd immunity afforded their children while living in the United States. This benefit may not exist when they are visiting and/or relocating to countries with lower immunization rates. Measles outbreaks are occurring in multiple countries and are not limited to underdeveloped countries. For the most up-to-date travel health-related information from the CDC, click here.
Travelers’ diarrhea (TD) occurs in up to 70 % of travelers to developing countries. The World Health Organization defines it as passage of at least three loose stools in a 24-hour period. Most often it is self-limited, with symptoms lasting a median of 3-4 days. Although TD can be caused by bacteria, protozoa, and viruses, bacteria are usually the etiology, with enterotoxigenic Escherichia coli being the most common pathogens. Other bacterial etiologies include Shigella and Campylobacter species. Two antimicrobials are frequently prescribed to travelers for self-treatment of TD: ciprofloxacin and azithromycin. Most young children are prescribed the latter; however, in older children, ciprofloxacin may be prescribed off label, as its use in persons younger than 18 years is not approved by the Food and Drug Administration.
In December 2014, PulseNet, the national molecular subtyping network for food-borne disease, detected a multistate cluster of ciprofloxacin-resistant Shigella sonnei. Between May 2014 and February 2015, 157 cases including 37 children were detected in 32 states and Puerto Rico. Nine of the cases identified by PulseNet, and an additional 76 cases, were associated with an outbreak of ciprofloxacin-resistant S. sonnei in San Francisco. Antibiotic susceptibility was available for 126 isolates, of which 109 (87%) were not ciprofloxacin susceptible. Travel history was available for 75 patients not associated with the San Francisco outbreak, and slightly more than half (40) were associated with international travel. The island of Hispaniola (Dominican Republic = 22 cases and Haiti = 4 cases) was the most common destination, followed by India (8 cases) and Morocco (3 cases). The remaining destinations were Asia and Europe (MMWR 2015;64:318-20) Travel history was available and positive for 23 of the 37 children (62%).
Why such a concern? International travelers are at risk of becoming colonized with drug-resistant bacteria and have the potential to spread them domestically. It has already begun. In 2012, the National Antimicrobial Resistance Monitoring System (NARMS) revealed that isolates of S. sonnei had the following resistance pattern: trimethoprim/sulfamethoxazole, 42%; ampicillin, 18%; and ciprofloxacin, 2.1%. During this outbreak, 19 of the 126 isolates were tested by NARMS with the following resistance patterns noted: trimethoprim/sulfamethoxazole, 84%; ampicillin, 5%; and ciprofloxacin, 32%.
More judicious use of antibiotics is necessary. As pediatricians, we are not immune to this issue. The challenge is when, if at all, antibiotics should be prescribed for TD, and under what conditions should patients be instructed to use them. I’m rethinking my own practice. TD is one of the most common illnesses travelers acquire and is easily treated, but at what cost? The one expression I keep hearing myself say is, First do no harm.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures.
Graduation season is rapidly approaching, with high school graduations, followed by summer vacations. While searching for that unique gift and /or summer experience, many of your patients may choose an international destination. Not to be forgotten are those who might travel to resource-limited areas to visit relatives, volunteer, or have extended stays because of parental job relocation. More U.S. high school graduates are participating in gap year programs, many of which involve extensive travel while providing the participant the opportunity to immerse and to actively participate in other cultures. For many, it may be their first experience in a country with poor hygiene. This week alone, I’ve helped prepare travelers, including adolescents and children, for a safari and one for 4 weeks of volunteerism in Tanzania. Another young traveler’s destinations were Rwanda, Uganda, and Kenya, and a fourth is planning to explore and trek regions in the high elevations of Bolivia and Peru. The question is, Will you be ready to help prepare young travelers to stay healthy and return home without any unwanted souvenirs?
For many, health concerns often are not the top priority when they are planning vacations. However, the primary care physician will most likely will be their initial call and resource once they realize their potential to be exposed to diseases and/or conditions not routinely encountered in the United States. Even if you receive the call late, there are still interventions you can provide.
To avoid that last-minute call, develop strategies to identify international travelers in your practice. Many practices send out reminders yearly for influenza and well visits, so consider developing one for international travel. Text-message reminders have been shown to improve influenza vaccine administration rates and are another form of communication that can be considered. Frequently remind families that if planning international travel, they should seek pretravel advice in a timely manner: Ideally advice should be obtained 4-6 weeks in advance, and definitely at least 2 weeks prior to departure. Remind them that adequate time is needed for the vaccine to become effective. In addition, depending on the patients’ destination, trip duration, and type of activity, two vaccines (rabies and Japanese encephalitis) may be recommended and are administered over a 28-day period. Yellow fever vaccine, which is recommended or required for entry into some countries, can be obtained only at centers designated by each state health department. It should be administered at least 10 days prior to travel.
Vaccine interventions are based on the potential risk for disease exposure/acquisition. Factors to consider include the age of the travelers, their health and immunization status, in addition to their destination, duration of stay, accommodations, activities, and reason for travel (such as business or visiting friends and relatives). If you have a child with a chronic disorder or who is immunocompromised, comparable medical care may not be available at all international destinations. In addition, not everyone may be a candidate to receive some recommended or required vaccines. Involvement with a health professional prior to booking the trip would be advisable.
Identify a travel health specialist in your area as a local resource who can provide the most up-to-date information and recommendations. Ensure that individual is willing to see children of all ages.
Make sure routine immunizations are up to date for age. Measles is the one exception. I know you have heard it before, but outbreaks persist, even in the United States. Travelers 6- to 11-months-old should receive one MMR dose prior to international travel. This dose will not count, so these children should receive two additional doses of vaccine once they are at least 1 year old. Many children travel with adults. All travelers at least 12 months of age and born after 1956 should have two documented doses of MMR prior to international travel unless they have serologic evidence of immunity. The second dose can be given as early as 4 weeks after the first. If two doses at least 4 weeks apart are administered when a child is at least 12 months of age, no additional doses are necessary.
In 2014, there were 668 cases of measles from 27 states in the United States. The United States is still experiencing a multistate outbreak of measles at press time, which began December 2014. As of April 24, 2015, 166 cases have been reported from 19 states. The Centers for Disease Control and Prevention analyzed the virus type (B3). It is identical to the one responsible for the outbreak in the Philippines in 2014, and it has now been identified in 14 other countries.
Most U.S. measles cases occur in unvaccinated travelers who become ill after their return and spread the disease to susceptible individuals. Do you have patients who are unimmunized? Another point to consider when speaking with these parents about travel is the potential loss of the herd immunity afforded their children while living in the United States. This benefit may not exist when they are visiting and/or relocating to countries with lower immunization rates. Measles outbreaks are occurring in multiple countries and are not limited to underdeveloped countries. For the most up-to-date travel health-related information from the CDC, click here.
Travelers’ diarrhea (TD) occurs in up to 70 % of travelers to developing countries. The World Health Organization defines it as passage of at least three loose stools in a 24-hour period. Most often it is self-limited, with symptoms lasting a median of 3-4 days. Although TD can be caused by bacteria, protozoa, and viruses, bacteria are usually the etiology, with enterotoxigenic Escherichia coli being the most common pathogens. Other bacterial etiologies include Shigella and Campylobacter species. Two antimicrobials are frequently prescribed to travelers for self-treatment of TD: ciprofloxacin and azithromycin. Most young children are prescribed the latter; however, in older children, ciprofloxacin may be prescribed off label, as its use in persons younger than 18 years is not approved by the Food and Drug Administration.
In December 2014, PulseNet, the national molecular subtyping network for food-borne disease, detected a multistate cluster of ciprofloxacin-resistant Shigella sonnei. Between May 2014 and February 2015, 157 cases including 37 children were detected in 32 states and Puerto Rico. Nine of the cases identified by PulseNet, and an additional 76 cases, were associated with an outbreak of ciprofloxacin-resistant S. sonnei in San Francisco. Antibiotic susceptibility was available for 126 isolates, of which 109 (87%) were not ciprofloxacin susceptible. Travel history was available for 75 patients not associated with the San Francisco outbreak, and slightly more than half (40) were associated with international travel. The island of Hispaniola (Dominican Republic = 22 cases and Haiti = 4 cases) was the most common destination, followed by India (8 cases) and Morocco (3 cases). The remaining destinations were Asia and Europe (MMWR 2015;64:318-20) Travel history was available and positive for 23 of the 37 children (62%).
Why such a concern? International travelers are at risk of becoming colonized with drug-resistant bacteria and have the potential to spread them domestically. It has already begun. In 2012, the National Antimicrobial Resistance Monitoring System (NARMS) revealed that isolates of S. sonnei had the following resistance pattern: trimethoprim/sulfamethoxazole, 42%; ampicillin, 18%; and ciprofloxacin, 2.1%. During this outbreak, 19 of the 126 isolates were tested by NARMS with the following resistance patterns noted: trimethoprim/sulfamethoxazole, 84%; ampicillin, 5%; and ciprofloxacin, 32%.
More judicious use of antibiotics is necessary. As pediatricians, we are not immune to this issue. The challenge is when, if at all, antibiotics should be prescribed for TD, and under what conditions should patients be instructed to use them. I’m rethinking my own practice. TD is one of the most common illnesses travelers acquire and is easily treated, but at what cost? The one expression I keep hearing myself say is, First do no harm.
Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures.
Using cervical length screening to predict preterm birth
One of the key indicators of a nation’s health is how well it can care for its young. Despite many advances in medical care and improvements in access to care, infant mortality remains a significant concern worldwide. According to the World Health Organization, the leading cause of death among children under age 5 is preterm birth complications. With an estimated 15 million babies born prematurely (prior to 37 weeks’ gestation) globally each year, it is vital for ob.gyns. to uncover ways to predict, diagnose early, and treat the causes of preterm birth.
While the challenges to infant health could be considered more of an issue in developing countries, here in the United States, the Centers for Disease Control and Prevention estimates that 1 in 9 babies is born prematurely. Preterm birth-related causes of death (i.e., breathing and feeding problems and disabilities) accounted for 35% of all infant deaths in 2010.
The World Health Organization (WHO) lists the United States as one of the top 10 countries with the greatest number of preterm births, despite the fact that we spend approximately 17.1% of our gross domestic product in total health care expenditures – the highest rate among our peer nations.
In the April 2014 edition of Master Class, we discussed one of the primary causes of preterm birth, bacterial infections, and specifically the need for ob.gyns. to rigorously screen patients for asymptomatic bacteriuria, which can lead to pyelonephritis. This month, we examine another biologic marker of preterm birth, cervical length.
Seminal studies of transvaginal sonography to measure cervical length during pregnancy and predict premature birth were published more than 2 decades ago. This work showed that a short cervix at 24 and 28 weeks’ gestation predicted preterm birth. Since then, clinical studies have demonstrated the utility of cervical length screening in women with prior preterm pregnancies. In the last decade, three large, randomized human trials have examined the usefulness of universal cervical length screening (Am. J. Obstet. Gynecol. 2012;207:101-6). However, the results of these trials have given practitioners a confusing picture of the predictability of this biologic marker.
Given the complexity of the “to screen or not to screen” issue, we have devoted this Master Class to a discussion on the role of cervical length screening and the prediction of preterm birth. Our guest author this month is Dr. Erika Werner, an assistant professor in ob.gyn (maternal-fetal medicine) in the department of obstetrics and gynecology at Brown University, in Providence, R.I., and an expert in the area of preterm birth.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
One of the key indicators of a nation’s health is how well it can care for its young. Despite many advances in medical care and improvements in access to care, infant mortality remains a significant concern worldwide. According to the World Health Organization, the leading cause of death among children under age 5 is preterm birth complications. With an estimated 15 million babies born prematurely (prior to 37 weeks’ gestation) globally each year, it is vital for ob.gyns. to uncover ways to predict, diagnose early, and treat the causes of preterm birth.
While the challenges to infant health could be considered more of an issue in developing countries, here in the United States, the Centers for Disease Control and Prevention estimates that 1 in 9 babies is born prematurely. Preterm birth-related causes of death (i.e., breathing and feeding problems and disabilities) accounted for 35% of all infant deaths in 2010.
The World Health Organization (WHO) lists the United States as one of the top 10 countries with the greatest number of preterm births, despite the fact that we spend approximately 17.1% of our gross domestic product in total health care expenditures – the highest rate among our peer nations.
In the April 2014 edition of Master Class, we discussed one of the primary causes of preterm birth, bacterial infections, and specifically the need for ob.gyns. to rigorously screen patients for asymptomatic bacteriuria, which can lead to pyelonephritis. This month, we examine another biologic marker of preterm birth, cervical length.
Seminal studies of transvaginal sonography to measure cervical length during pregnancy and predict premature birth were published more than 2 decades ago. This work showed that a short cervix at 24 and 28 weeks’ gestation predicted preterm birth. Since then, clinical studies have demonstrated the utility of cervical length screening in women with prior preterm pregnancies. In the last decade, three large, randomized human trials have examined the usefulness of universal cervical length screening (Am. J. Obstet. Gynecol. 2012;207:101-6). However, the results of these trials have given practitioners a confusing picture of the predictability of this biologic marker.
Given the complexity of the “to screen or not to screen” issue, we have devoted this Master Class to a discussion on the role of cervical length screening and the prediction of preterm birth. Our guest author this month is Dr. Erika Werner, an assistant professor in ob.gyn (maternal-fetal medicine) in the department of obstetrics and gynecology at Brown University, in Providence, R.I., and an expert in the area of preterm birth.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
One of the key indicators of a nation’s health is how well it can care for its young. Despite many advances in medical care and improvements in access to care, infant mortality remains a significant concern worldwide. According to the World Health Organization, the leading cause of death among children under age 5 is preterm birth complications. With an estimated 15 million babies born prematurely (prior to 37 weeks’ gestation) globally each year, it is vital for ob.gyns. to uncover ways to predict, diagnose early, and treat the causes of preterm birth.
While the challenges to infant health could be considered more of an issue in developing countries, here in the United States, the Centers for Disease Control and Prevention estimates that 1 in 9 babies is born prematurely. Preterm birth-related causes of death (i.e., breathing and feeding problems and disabilities) accounted for 35% of all infant deaths in 2010.
The World Health Organization (WHO) lists the United States as one of the top 10 countries with the greatest number of preterm births, despite the fact that we spend approximately 17.1% of our gross domestic product in total health care expenditures – the highest rate among our peer nations.
In the April 2014 edition of Master Class, we discussed one of the primary causes of preterm birth, bacterial infections, and specifically the need for ob.gyns. to rigorously screen patients for asymptomatic bacteriuria, which can lead to pyelonephritis. This month, we examine another biologic marker of preterm birth, cervical length.
Seminal studies of transvaginal sonography to measure cervical length during pregnancy and predict premature birth were published more than 2 decades ago. This work showed that a short cervix at 24 and 28 weeks’ gestation predicted preterm birth. Since then, clinical studies have demonstrated the utility of cervical length screening in women with prior preterm pregnancies. In the last decade, three large, randomized human trials have examined the usefulness of universal cervical length screening (Am. J. Obstet. Gynecol. 2012;207:101-6). However, the results of these trials have given practitioners a confusing picture of the predictability of this biologic marker.
Given the complexity of the “to screen or not to screen” issue, we have devoted this Master Class to a discussion on the role of cervical length screening and the prediction of preterm birth. Our guest author this month is Dr. Erika Werner, an assistant professor in ob.gyn (maternal-fetal medicine) in the department of obstetrics and gynecology at Brown University, in Providence, R.I., and an expert in the area of preterm birth.
Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].
The benefits, costs of universal cervical length screening
Rates of preterm birth in the United States have been falling since 2006, but the rates of early preterm birth in singletons (those under 34 weeks’ gestation), specifically, have not trended downward as dramatically as have late preterm birth in singletons (34-36 weeks). According to 2015 data from the National Vital Statistics Reports, the rate of early preterm births is still 3.4% in all pregnancies and 2.7% among singletons.
While the number of neonates born before 37 weeks of gestation remains high – approximately 11% in 2013 – and signifies a continuing public health problem, the rate of early preterm birth is particularly concerning because early preterm birth is more significantly associated with neonatal mortality, long-term morbidity and extended neonatal intensive care unit stays, all leading to increased health care expenditures.
Finding predictors for preterm birth that are stronger than traditional clinical factors has long been a goal of ob.gyns. because the vast majority of all spontaneous preterm births occur to women without known risk factors (i.e., multiple gestations or prior preterm birth).
Cervical length in the midtrimester is now a well-verified predictor of preterm birth, for both low- and high-risk women. Furthermore, vaginal progesterone has been shown to be a safe and beneficial intervention for women with no known risk factors who are diagnosed with a shortened cervical length (< 2 cm), and cervical cerclage has been suggested to reduce the risk of preterm birth for women with a history of prior preterm birth who also have a shortened cervical length.
Some are now advocating universal cervical length screening for women with singleton gestations, but before universal screening is mandated, the downstream effect of such a change in practice must be considered.
Backdrop to screening
Cervical length measurement was first investigated more than 25 years ago as a possible predictor of preterm birth. In 1996, a prospective multicenter study of almost 3,000 women with singleton pregnancies showed that the risk of preterm delivery is inversely and directly related to the length of the cervix, as measured with vaginal ultrasonography (N. Engl. J. Med. 1996;334:567-72).
In fact, at 24 weeks’ gestation, every 1 mm of additional cervical length equates to a significant decrease in preterm birth risk (odds ratio, 0.91). Several other studies, in addition to the landmark 1996 study, have similarly demonstrated this inverse relationship between preterm birth risk and cervical length between 18 and 24 weeks’ gestation.
However, the use of cervical measurement did not achieve widespread use until more than a decade later, when researchers began to identify interventions that could prolong pregnancy if a short cervix was diagnosed in the second trimester.
For example, Dr. E.B. Fonseca’s study of almost 25,000 asymptomatic pregnant women, demonstrated that daily vaginal progesterone reduced the risk of spontaneous delivery before 34 weeks by approximately 44% in women identified with a cervical length of 1.5 cm or less (N. Engl. J. Med. 2007;357:462-9). The vast majority of the women in this study had singleton pregnancies.
Shortly thereafter, Dr. S.S. Hassan and her colleagues completed a similar trial in women with singleton gestations and transvaginal cervical lengths between 1.0 and 2.0 cm at 20-23 weeks’ gestation. In this trial, nightly progesterone gel (with 90 mg progesterone per application) was associated with a 45% reduction in preterm birth before 33 weeks and a 38% reduction in preterm birth before 35 weeks (Ultrasound. Obstet. Gynecol. 2011;38:18-31).
A meta-analysis led by Dr. Roberto Romero, which included the Fonseca and Hassan trials, looked specifically at 775 women with a midtrimester cervical length of 2.5 cm or less. Women with a singleton gestation who had no history of preterm birth had a 40% reduction in the rate of early preterm birth when they were treated with vaginal progesterone (Am. J. Obstet. Gynecol. 2012;206:124-e1-19).
The benefits of identifying a short cervix likely extend to women with a history of prior preterm birth. A patient-level meta-analysis published in 2011 demonstrated that cervical cerclage placement was associated with a significant reduction in preterm birth before 35 weeks’ gestation in women with singleton gestations, previous spontaneous preterm birth, and cervical length less than 2.5 cm before 24 weeks’ gestation (Obstet. Gynecol. 2011;117:663-71).
The possible benefits of diagnosing and intervening for a shortened cervix have tipped many experts and clinicians toward the practice of universal cervical length screening of all singleton pregnancies. Research has shown that we can accurately obtain a cervical-length measurement before 24 weeks, and that we have effective and safe interventions for cases of short cervix: cerclage in women with a history of preterm birth who are already receiving progesterone, and vaginal progesterone in women without such a history.
Screening certainties and doubts
In 2011, my colleagues and I compared the cost effectiveness of two approaches to preterm birth prevention in low-risk pregnancies: no screening versus a single transvaginal ultrasound cervical-length measurement in all asymptomatic, low-risk singleton pregnant individuals between 18 and 24 weeks’ gestation.
In our model, women identified as having a cervical length less than 1.5 cm would be offered vaginal progesterone. Based on published data, we assumed there would be a 92% adherence rate, and a 45% reduction in deliveries before 34 weeks with progesterone treatment.
We found that in low-risk pregnancies, universal transvaginal cervical-length ultrasound screening and progesterone intervention would be cost effective and in many cases cost saving. We estimated that screening would prevent 248 early preterm births – as well as 22 neonatal deaths or neonates with long-term neurologic deficits – per 100,000 deliveries.
Our sensitivity analyses showed that screening remained cost saving under a range of clinical scenarios, including varied preterm birth rates and predictive values of a shortened cervix. Screening was not cost saving, but remained cost effective, when the expense of a transvaginal ultrasound scan exceeds $187 or when vaginal progesterone is assumed to reduce the risk of early preterm delivery by less than 20% (Ultrasound Obstet. Gynecol. 2011;38;32-37).
Neither the American College of Obstetricians and Gynecologists nor the Society for Maternal-Fetal Medicine support mandated universal transvaginal ultrasound cervical length screening. Both organizations state, however, that the approach may be considered in women with singleton gestations without prior spontaneous preterm birth.
Interestingly, Thomas Jefferson University in Philadelphia, which uses a universal screening program for singleton gestations without prior preterm birth, has recently published data that complicate the growing trend toward universal cervical length screening.
The Philadelphia clinicians followed a strategy whereby women with a transvaginal cervical length of 2 cm or less were prescribed vaginal progesterone (90 mg vaginal progesterone gel, or 200 mg micronized progesterone gel capsules). Those with a cervical length between approximately 2 cm and 2.5 cm were asked to return for a follow-up cervical length measurement before 24 weeks’ gestation.
What they found in this cohort was surprising: a rate of short cervix that is significantly lower than what previous research has shown.
Among those screened, 0.8% of women had a cervical length of 2 cm or less on an initial transvaginal ultrasonogram. Previously, a prevalence of 1%-2% for an even shorter cervical length (less than 1.5 cm) was fairly consistent in the literature.
As Dr. Kelly M. Orzechowski and her colleagues point out, the low incidence of short cervix “raises questions regarding whether universal transvaginal ultrasonogram cervical length screening in low-risk asymptomatic women is beneficial” (Obstet. Gynecol. 2014;124:520-5).
In our 2011 cost-effectiveness analysis, we found that screening was no longer a cost-saving practice when the incidence of cervical length less than 1.5 cm falls below 0.8%. Screening remained cost effective, however.
Recently, we found that if the Philadelphia protocol is followed and the U.S. population has an incidence of shortened cervix similar to that described by Dr. Orzechowski and her colleagues, universal cervical length screening in low-risk singleton pregnancies is cost effective but not cost saving. Furthermore, we found several additional plausible situations in this unpublished analysis in which universal screening ceased to be cost effective.
Thus, before we move to a strategy of mandated universal screening, we need better population-based estimates of the incidence of short cervix in a truly low-risk population.
We also must consider the future costs of progesterone. It is possible that costs may increase significantly if vaginal progesterone wins approval from the Food and Drug Administration for this indication.
Finally, if universal cervical length screening is to become the standard of care, we need policies in place to prevent misuse of the screening technology that would inevitably drive up costs without improving outcomes. For example, we must ensure that one cervical length measurement does not transition into serial cervical length measurements over the course of pregnancy, since measurement after 24 weeks has limited clinical utility. Similarly, progesterone use for a cervical length less than or equal to 2.0 cm cannot progress to progesterone for anyone approaching 2.0 cm (i.e. 2.5 cm or even 3 cm) as there is no evidence to suggest a benefit for women with longer cervixes.
Over time, it would be beneficial to have additional data on how best to manage patients who have a cervical length of 2 cm-2.5 cm before 24 weeks’ gestation. Many of us ask these women to return for a follow-up measurement and some may prescribe progesterone. However, we lack evidence for either approach; while a cervical length measurement less than 2.5 cm is clearly associated with an increased risk of preterm birth, the benefit of treatment has been demonstrated only with a cervical length of 2 cm or less.
Today and the future
For women with a history of preterm birth, cervical length screening is now routine. For low-risk pregnant women – those without a history of previous spontaneous preterm delivery – various approaches are currently taken. Most physicians recommend assessing the cervical length transabdominally at the time of the 18-20-week ultrasound, and proceeding to transvaginal ultrasonography if the cervical length is less than 3 cm or 3.5 cm.
To reliably image the cervix with transabdominal ultrasound, it should be performed with a full bladder and with the understanding that the cervix appears longer (6 mm longer, on average) when the bladder is full (Aust. N. Z. J. Obstet. Gynaecol. 2014;54:250-55).
Transvaginal ultrasound has been widely recognized as a sensitive and reproducible method for detecting shortened cervical length. Overall, this tool has several advantages over the transabdominal approach. However, the lack of universal access to transvaginal ultrasound and to consistently reliable cervical length measurements have been valid concerns of those who oppose universal transvaginal ultrasound cervical length screening.
Such concerns likely will lessen over time as transvaginal ultrasound continues to become more pervasive. Several years ago, the Perinatal Quality Foundation set standards for measuring the cervix and launched the Cervical Length Education and Review (CLEAR) program. When sonographers and physicians obtain training and credentialing, there appears to be only a 5%-10% intraobserver variability in cervical length measurement. (The PQF’s initial focus in 2005 was the Nuchal Translucency Quality Review program.)
Increasingly, I believe, transvaginal ultrasound cervical length measurement will be utilized to identify women at high risk for early preterm birth so that low-risk women can receive progesterone and high-risk women (those with a history of preterm birth) can be considered as candidates for cerclage placement. In the process, the quality of clinical care as well as the quality of our research data will improve. Whether and when such screening will become universal, however, is still uncertain.
Dr. Werner reported that she has no financial disclosures relevant to this Master Class.
Rates of preterm birth in the United States have been falling since 2006, but the rates of early preterm birth in singletons (those under 34 weeks’ gestation), specifically, have not trended downward as dramatically as have late preterm birth in singletons (34-36 weeks). According to 2015 data from the National Vital Statistics Reports, the rate of early preterm births is still 3.4% in all pregnancies and 2.7% among singletons.
While the number of neonates born before 37 weeks of gestation remains high – approximately 11% in 2013 – and signifies a continuing public health problem, the rate of early preterm birth is particularly concerning because early preterm birth is more significantly associated with neonatal mortality, long-term morbidity and extended neonatal intensive care unit stays, all leading to increased health care expenditures.
Finding predictors for preterm birth that are stronger than traditional clinical factors has long been a goal of ob.gyns. because the vast majority of all spontaneous preterm births occur to women without known risk factors (i.e., multiple gestations or prior preterm birth).
Cervical length in the midtrimester is now a well-verified predictor of preterm birth, for both low- and high-risk women. Furthermore, vaginal progesterone has been shown to be a safe and beneficial intervention for women with no known risk factors who are diagnosed with a shortened cervical length (< 2 cm), and cervical cerclage has been suggested to reduce the risk of preterm birth for women with a history of prior preterm birth who also have a shortened cervical length.
Some are now advocating universal cervical length screening for women with singleton gestations, but before universal screening is mandated, the downstream effect of such a change in practice must be considered.
Backdrop to screening
Cervical length measurement was first investigated more than 25 years ago as a possible predictor of preterm birth. In 1996, a prospective multicenter study of almost 3,000 women with singleton pregnancies showed that the risk of preterm delivery is inversely and directly related to the length of the cervix, as measured with vaginal ultrasonography (N. Engl. J. Med. 1996;334:567-72).
In fact, at 24 weeks’ gestation, every 1 mm of additional cervical length equates to a significant decrease in preterm birth risk (odds ratio, 0.91). Several other studies, in addition to the landmark 1996 study, have similarly demonstrated this inverse relationship between preterm birth risk and cervical length between 18 and 24 weeks’ gestation.
However, the use of cervical measurement did not achieve widespread use until more than a decade later, when researchers began to identify interventions that could prolong pregnancy if a short cervix was diagnosed in the second trimester.
For example, Dr. E.B. Fonseca’s study of almost 25,000 asymptomatic pregnant women, demonstrated that daily vaginal progesterone reduced the risk of spontaneous delivery before 34 weeks by approximately 44% in women identified with a cervical length of 1.5 cm or less (N. Engl. J. Med. 2007;357:462-9). The vast majority of the women in this study had singleton pregnancies.
Shortly thereafter, Dr. S.S. Hassan and her colleagues completed a similar trial in women with singleton gestations and transvaginal cervical lengths between 1.0 and 2.0 cm at 20-23 weeks’ gestation. In this trial, nightly progesterone gel (with 90 mg progesterone per application) was associated with a 45% reduction in preterm birth before 33 weeks and a 38% reduction in preterm birth before 35 weeks (Ultrasound. Obstet. Gynecol. 2011;38:18-31).
A meta-analysis led by Dr. Roberto Romero, which included the Fonseca and Hassan trials, looked specifically at 775 women with a midtrimester cervical length of 2.5 cm or less. Women with a singleton gestation who had no history of preterm birth had a 40% reduction in the rate of early preterm birth when they were treated with vaginal progesterone (Am. J. Obstet. Gynecol. 2012;206:124-e1-19).
The benefits of identifying a short cervix likely extend to women with a history of prior preterm birth. A patient-level meta-analysis published in 2011 demonstrated that cervical cerclage placement was associated with a significant reduction in preterm birth before 35 weeks’ gestation in women with singleton gestations, previous spontaneous preterm birth, and cervical length less than 2.5 cm before 24 weeks’ gestation (Obstet. Gynecol. 2011;117:663-71).
The possible benefits of diagnosing and intervening for a shortened cervix have tipped many experts and clinicians toward the practice of universal cervical length screening of all singleton pregnancies. Research has shown that we can accurately obtain a cervical-length measurement before 24 weeks, and that we have effective and safe interventions for cases of short cervix: cerclage in women with a history of preterm birth who are already receiving progesterone, and vaginal progesterone in women without such a history.
Screening certainties and doubts
In 2011, my colleagues and I compared the cost effectiveness of two approaches to preterm birth prevention in low-risk pregnancies: no screening versus a single transvaginal ultrasound cervical-length measurement in all asymptomatic, low-risk singleton pregnant individuals between 18 and 24 weeks’ gestation.
In our model, women identified as having a cervical length less than 1.5 cm would be offered vaginal progesterone. Based on published data, we assumed there would be a 92% adherence rate, and a 45% reduction in deliveries before 34 weeks with progesterone treatment.
We found that in low-risk pregnancies, universal transvaginal cervical-length ultrasound screening and progesterone intervention would be cost effective and in many cases cost saving. We estimated that screening would prevent 248 early preterm births – as well as 22 neonatal deaths or neonates with long-term neurologic deficits – per 100,000 deliveries.
Our sensitivity analyses showed that screening remained cost saving under a range of clinical scenarios, including varied preterm birth rates and predictive values of a shortened cervix. Screening was not cost saving, but remained cost effective, when the expense of a transvaginal ultrasound scan exceeds $187 or when vaginal progesterone is assumed to reduce the risk of early preterm delivery by less than 20% (Ultrasound Obstet. Gynecol. 2011;38;32-37).
Neither the American College of Obstetricians and Gynecologists nor the Society for Maternal-Fetal Medicine support mandated universal transvaginal ultrasound cervical length screening. Both organizations state, however, that the approach may be considered in women with singleton gestations without prior spontaneous preterm birth.
Interestingly, Thomas Jefferson University in Philadelphia, which uses a universal screening program for singleton gestations without prior preterm birth, has recently published data that complicate the growing trend toward universal cervical length screening.
The Philadelphia clinicians followed a strategy whereby women with a transvaginal cervical length of 2 cm or less were prescribed vaginal progesterone (90 mg vaginal progesterone gel, or 200 mg micronized progesterone gel capsules). Those with a cervical length between approximately 2 cm and 2.5 cm were asked to return for a follow-up cervical length measurement before 24 weeks’ gestation.
What they found in this cohort was surprising: a rate of short cervix that is significantly lower than what previous research has shown.
Among those screened, 0.8% of women had a cervical length of 2 cm or less on an initial transvaginal ultrasonogram. Previously, a prevalence of 1%-2% for an even shorter cervical length (less than 1.5 cm) was fairly consistent in the literature.
As Dr. Kelly M. Orzechowski and her colleagues point out, the low incidence of short cervix “raises questions regarding whether universal transvaginal ultrasonogram cervical length screening in low-risk asymptomatic women is beneficial” (Obstet. Gynecol. 2014;124:520-5).
In our 2011 cost-effectiveness analysis, we found that screening was no longer a cost-saving practice when the incidence of cervical length less than 1.5 cm falls below 0.8%. Screening remained cost effective, however.
Recently, we found that if the Philadelphia protocol is followed and the U.S. population has an incidence of shortened cervix similar to that described by Dr. Orzechowski and her colleagues, universal cervical length screening in low-risk singleton pregnancies is cost effective but not cost saving. Furthermore, we found several additional plausible situations in this unpublished analysis in which universal screening ceased to be cost effective.
Thus, before we move to a strategy of mandated universal screening, we need better population-based estimates of the incidence of short cervix in a truly low-risk population.
We also must consider the future costs of progesterone. It is possible that costs may increase significantly if vaginal progesterone wins approval from the Food and Drug Administration for this indication.
Finally, if universal cervical length screening is to become the standard of care, we need policies in place to prevent misuse of the screening technology that would inevitably drive up costs without improving outcomes. For example, we must ensure that one cervical length measurement does not transition into serial cervical length measurements over the course of pregnancy, since measurement after 24 weeks has limited clinical utility. Similarly, progesterone use for a cervical length less than or equal to 2.0 cm cannot progress to progesterone for anyone approaching 2.0 cm (i.e. 2.5 cm or even 3 cm) as there is no evidence to suggest a benefit for women with longer cervixes.
Over time, it would be beneficial to have additional data on how best to manage patients who have a cervical length of 2 cm-2.5 cm before 24 weeks’ gestation. Many of us ask these women to return for a follow-up measurement and some may prescribe progesterone. However, we lack evidence for either approach; while a cervical length measurement less than 2.5 cm is clearly associated with an increased risk of preterm birth, the benefit of treatment has been demonstrated only with a cervical length of 2 cm or less.
Today and the future
For women with a history of preterm birth, cervical length screening is now routine. For low-risk pregnant women – those without a history of previous spontaneous preterm delivery – various approaches are currently taken. Most physicians recommend assessing the cervical length transabdominally at the time of the 18-20-week ultrasound, and proceeding to transvaginal ultrasonography if the cervical length is less than 3 cm or 3.5 cm.
To reliably image the cervix with transabdominal ultrasound, it should be performed with a full bladder and with the understanding that the cervix appears longer (6 mm longer, on average) when the bladder is full (Aust. N. Z. J. Obstet. Gynaecol. 2014;54:250-55).
Transvaginal ultrasound has been widely recognized as a sensitive and reproducible method for detecting shortened cervical length. Overall, this tool has several advantages over the transabdominal approach. However, the lack of universal access to transvaginal ultrasound and to consistently reliable cervical length measurements have been valid concerns of those who oppose universal transvaginal ultrasound cervical length screening.
Such concerns likely will lessen over time as transvaginal ultrasound continues to become more pervasive. Several years ago, the Perinatal Quality Foundation set standards for measuring the cervix and launched the Cervical Length Education and Review (CLEAR) program. When sonographers and physicians obtain training and credentialing, there appears to be only a 5%-10% intraobserver variability in cervical length measurement. (The PQF’s initial focus in 2005 was the Nuchal Translucency Quality Review program.)
Increasingly, I believe, transvaginal ultrasound cervical length measurement will be utilized to identify women at high risk for early preterm birth so that low-risk women can receive progesterone and high-risk women (those with a history of preterm birth) can be considered as candidates for cerclage placement. In the process, the quality of clinical care as well as the quality of our research data will improve. Whether and when such screening will become universal, however, is still uncertain.
Dr. Werner reported that she has no financial disclosures relevant to this Master Class.
Rates of preterm birth in the United States have been falling since 2006, but the rates of early preterm birth in singletons (those under 34 weeks’ gestation), specifically, have not trended downward as dramatically as have late preterm birth in singletons (34-36 weeks). According to 2015 data from the National Vital Statistics Reports, the rate of early preterm births is still 3.4% in all pregnancies and 2.7% among singletons.
While the number of neonates born before 37 weeks of gestation remains high – approximately 11% in 2013 – and signifies a continuing public health problem, the rate of early preterm birth is particularly concerning because early preterm birth is more significantly associated with neonatal mortality, long-term morbidity and extended neonatal intensive care unit stays, all leading to increased health care expenditures.
Finding predictors for preterm birth that are stronger than traditional clinical factors has long been a goal of ob.gyns. because the vast majority of all spontaneous preterm births occur to women without known risk factors (i.e., multiple gestations or prior preterm birth).
Cervical length in the midtrimester is now a well-verified predictor of preterm birth, for both low- and high-risk women. Furthermore, vaginal progesterone has been shown to be a safe and beneficial intervention for women with no known risk factors who are diagnosed with a shortened cervical length (< 2 cm), and cervical cerclage has been suggested to reduce the risk of preterm birth for women with a history of prior preterm birth who also have a shortened cervical length.
Some are now advocating universal cervical length screening for women with singleton gestations, but before universal screening is mandated, the downstream effect of such a change in practice must be considered.
Backdrop to screening
Cervical length measurement was first investigated more than 25 years ago as a possible predictor of preterm birth. In 1996, a prospective multicenter study of almost 3,000 women with singleton pregnancies showed that the risk of preterm delivery is inversely and directly related to the length of the cervix, as measured with vaginal ultrasonography (N. Engl. J. Med. 1996;334:567-72).
In fact, at 24 weeks’ gestation, every 1 mm of additional cervical length equates to a significant decrease in preterm birth risk (odds ratio, 0.91). Several other studies, in addition to the landmark 1996 study, have similarly demonstrated this inverse relationship between preterm birth risk and cervical length between 18 and 24 weeks’ gestation.
However, the use of cervical measurement did not achieve widespread use until more than a decade later, when researchers began to identify interventions that could prolong pregnancy if a short cervix was diagnosed in the second trimester.
For example, Dr. E.B. Fonseca’s study of almost 25,000 asymptomatic pregnant women, demonstrated that daily vaginal progesterone reduced the risk of spontaneous delivery before 34 weeks by approximately 44% in women identified with a cervical length of 1.5 cm or less (N. Engl. J. Med. 2007;357:462-9). The vast majority of the women in this study had singleton pregnancies.
Shortly thereafter, Dr. S.S. Hassan and her colleagues completed a similar trial in women with singleton gestations and transvaginal cervical lengths between 1.0 and 2.0 cm at 20-23 weeks’ gestation. In this trial, nightly progesterone gel (with 90 mg progesterone per application) was associated with a 45% reduction in preterm birth before 33 weeks and a 38% reduction in preterm birth before 35 weeks (Ultrasound. Obstet. Gynecol. 2011;38:18-31).
A meta-analysis led by Dr. Roberto Romero, which included the Fonseca and Hassan trials, looked specifically at 775 women with a midtrimester cervical length of 2.5 cm or less. Women with a singleton gestation who had no history of preterm birth had a 40% reduction in the rate of early preterm birth when they were treated with vaginal progesterone (Am. J. Obstet. Gynecol. 2012;206:124-e1-19).
The benefits of identifying a short cervix likely extend to women with a history of prior preterm birth. A patient-level meta-analysis published in 2011 demonstrated that cervical cerclage placement was associated with a significant reduction in preterm birth before 35 weeks’ gestation in women with singleton gestations, previous spontaneous preterm birth, and cervical length less than 2.5 cm before 24 weeks’ gestation (Obstet. Gynecol. 2011;117:663-71).
The possible benefits of diagnosing and intervening for a shortened cervix have tipped many experts and clinicians toward the practice of universal cervical length screening of all singleton pregnancies. Research has shown that we can accurately obtain a cervical-length measurement before 24 weeks, and that we have effective and safe interventions for cases of short cervix: cerclage in women with a history of preterm birth who are already receiving progesterone, and vaginal progesterone in women without such a history.
Screening certainties and doubts
In 2011, my colleagues and I compared the cost effectiveness of two approaches to preterm birth prevention in low-risk pregnancies: no screening versus a single transvaginal ultrasound cervical-length measurement in all asymptomatic, low-risk singleton pregnant individuals between 18 and 24 weeks’ gestation.
In our model, women identified as having a cervical length less than 1.5 cm would be offered vaginal progesterone. Based on published data, we assumed there would be a 92% adherence rate, and a 45% reduction in deliveries before 34 weeks with progesterone treatment.
We found that in low-risk pregnancies, universal transvaginal cervical-length ultrasound screening and progesterone intervention would be cost effective and in many cases cost saving. We estimated that screening would prevent 248 early preterm births – as well as 22 neonatal deaths or neonates with long-term neurologic deficits – per 100,000 deliveries.
Our sensitivity analyses showed that screening remained cost saving under a range of clinical scenarios, including varied preterm birth rates and predictive values of a shortened cervix. Screening was not cost saving, but remained cost effective, when the expense of a transvaginal ultrasound scan exceeds $187 or when vaginal progesterone is assumed to reduce the risk of early preterm delivery by less than 20% (Ultrasound Obstet. Gynecol. 2011;38;32-37).
Neither the American College of Obstetricians and Gynecologists nor the Society for Maternal-Fetal Medicine support mandated universal transvaginal ultrasound cervical length screening. Both organizations state, however, that the approach may be considered in women with singleton gestations without prior spontaneous preterm birth.
Interestingly, Thomas Jefferson University in Philadelphia, which uses a universal screening program for singleton gestations without prior preterm birth, has recently published data that complicate the growing trend toward universal cervical length screening.
The Philadelphia clinicians followed a strategy whereby women with a transvaginal cervical length of 2 cm or less were prescribed vaginal progesterone (90 mg vaginal progesterone gel, or 200 mg micronized progesterone gel capsules). Those with a cervical length between approximately 2 cm and 2.5 cm were asked to return for a follow-up cervical length measurement before 24 weeks’ gestation.
What they found in this cohort was surprising: a rate of short cervix that is significantly lower than what previous research has shown.
Among those screened, 0.8% of women had a cervical length of 2 cm or less on an initial transvaginal ultrasonogram. Previously, a prevalence of 1%-2% for an even shorter cervical length (less than 1.5 cm) was fairly consistent in the literature.
As Dr. Kelly M. Orzechowski and her colleagues point out, the low incidence of short cervix “raises questions regarding whether universal transvaginal ultrasonogram cervical length screening in low-risk asymptomatic women is beneficial” (Obstet. Gynecol. 2014;124:520-5).
In our 2011 cost-effectiveness analysis, we found that screening was no longer a cost-saving practice when the incidence of cervical length less than 1.5 cm falls below 0.8%. Screening remained cost effective, however.
Recently, we found that if the Philadelphia protocol is followed and the U.S. population has an incidence of shortened cervix similar to that described by Dr. Orzechowski and her colleagues, universal cervical length screening in low-risk singleton pregnancies is cost effective but not cost saving. Furthermore, we found several additional plausible situations in this unpublished analysis in which universal screening ceased to be cost effective.
Thus, before we move to a strategy of mandated universal screening, we need better population-based estimates of the incidence of short cervix in a truly low-risk population.
We also must consider the future costs of progesterone. It is possible that costs may increase significantly if vaginal progesterone wins approval from the Food and Drug Administration for this indication.
Finally, if universal cervical length screening is to become the standard of care, we need policies in place to prevent misuse of the screening technology that would inevitably drive up costs without improving outcomes. For example, we must ensure that one cervical length measurement does not transition into serial cervical length measurements over the course of pregnancy, since measurement after 24 weeks has limited clinical utility. Similarly, progesterone use for a cervical length less than or equal to 2.0 cm cannot progress to progesterone for anyone approaching 2.0 cm (i.e. 2.5 cm or even 3 cm) as there is no evidence to suggest a benefit for women with longer cervixes.
Over time, it would be beneficial to have additional data on how best to manage patients who have a cervical length of 2 cm-2.5 cm before 24 weeks’ gestation. Many of us ask these women to return for a follow-up measurement and some may prescribe progesterone. However, we lack evidence for either approach; while a cervical length measurement less than 2.5 cm is clearly associated with an increased risk of preterm birth, the benefit of treatment has been demonstrated only with a cervical length of 2 cm or less.
Today and the future
For women with a history of preterm birth, cervical length screening is now routine. For low-risk pregnant women – those without a history of previous spontaneous preterm delivery – various approaches are currently taken. Most physicians recommend assessing the cervical length transabdominally at the time of the 18-20-week ultrasound, and proceeding to transvaginal ultrasonography if the cervical length is less than 3 cm or 3.5 cm.
To reliably image the cervix with transabdominal ultrasound, it should be performed with a full bladder and with the understanding that the cervix appears longer (6 mm longer, on average) when the bladder is full (Aust. N. Z. J. Obstet. Gynaecol. 2014;54:250-55).
Transvaginal ultrasound has been widely recognized as a sensitive and reproducible method for detecting shortened cervical length. Overall, this tool has several advantages over the transabdominal approach. However, the lack of universal access to transvaginal ultrasound and to consistently reliable cervical length measurements have been valid concerns of those who oppose universal transvaginal ultrasound cervical length screening.
Such concerns likely will lessen over time as transvaginal ultrasound continues to become more pervasive. Several years ago, the Perinatal Quality Foundation set standards for measuring the cervix and launched the Cervical Length Education and Review (CLEAR) program. When sonographers and physicians obtain training and credentialing, there appears to be only a 5%-10% intraobserver variability in cervical length measurement. (The PQF’s initial focus in 2005 was the Nuchal Translucency Quality Review program.)
Increasingly, I believe, transvaginal ultrasound cervical length measurement will be utilized to identify women at high risk for early preterm birth so that low-risk women can receive progesterone and high-risk women (those with a history of preterm birth) can be considered as candidates for cerclage placement. In the process, the quality of clinical care as well as the quality of our research data will improve. Whether and when such screening will become universal, however, is still uncertain.
Dr. Werner reported that she has no financial disclosures relevant to this Master Class.
Helmets needed for female lacrosse players
On April 8, the sports section in my local N.J. paper showed a picture of three female lacrosse players with their sticks up high in the air all reaching for a flying ball. Male players wear a full helmet and face mask, but these players wore only goggles and mouth guards. As a pediatrician who has had a lot of experience in treating head injuries in high school and college athletes, my question is this: Why we don’t protect the girls as well as the boys?
Yes, it is true the boys’ game is more aggressive, but anyone who knows these athletes realizes there is not much difference between them in their enthusiasm and commitment to win. The excuse put forth by U.S. Lacrosse is that if helmets are required the game will become more aggressive. That is not only a sexist viewpoint, it is like saying our children will ride their bikes in a safer way if we don’t have them wear bike helmets. I have seen many lacrosse injuries from not only sticks to the head, but impacts of the ball, too. It is a significant source of morbidity to female athletes.
In 2007, Randall Dick and associates, reviewing 16 years of NCAA injury data, found that 56% of above-the-neck injuries in women’s lacrosse resulted from contact with a stick and 20% from contact with a ball (J. Athl. Train. 2007;42:173-82). A 3-year prospective study by Dr. Richard Y. Hinton and his associates found that female players had higher rates of overall head injuries than their male counterparts, mostly involving contact with sticks and balls (Am. J. Sports Med. 2005;33:1305-14).
In 2001, a 10-year analysis of the National Electronic Injury Surveillance System by P.T. Diamond and S.D. Gale showed that the head and face were the most common areas injured, being significantly more prevalent in females (30%) than males (18%) (Brain. Inj. 2001;15:537-44). Their recommendation: “Women and children lacrosse players are at risk of serious injury to the head and face region. The use of protective head/face gear should be encouraged.”
Perhaps the most compelling study, by Andrew E. Lincoln, Sc.D., and associates, found that high school girls’ head, face, and eye injuries (0.54/1,000 athletic exposures) were significantly higher than for boys (0.38/1,000), and while concussions were higher in boys, girls sustained significantly more facial injuries, primarily resulting from stick or ball contact (Am. J. Sports Med. 2007;35:207-15).
In the early sixties, hockey players wore no helmets and goalies no masks. It does not seem that the addition of these pieces of safety equipment has ruined the game at all. Even though there is no checking in the girls’ lacrosse games, this does not prevent the inevitable accidents that occur in any sporting event. The above referenced articles support this. Many of these injuries are not only game injuries, but may carry lifelong consequences. Although the situation in professional sports is well known, my colleagues and I are seeing an increasing number of head injuries in all amateur sports, with women’s lacrosse making up a significant proportion of these incidents. When the governing bodies will not act, those of us who care for these athletes must speak up. Isn’t it time we protect the girls as well as the boys?
Patrick A. Caruso, M.D.
clinical associate professor of pediatrics
Mount Sinai School of Medicine
Morristown, N.J.
On April 8, the sports section in my local N.J. paper showed a picture of three female lacrosse players with their sticks up high in the air all reaching for a flying ball. Male players wear a full helmet and face mask, but these players wore only goggles and mouth guards. As a pediatrician who has had a lot of experience in treating head injuries in high school and college athletes, my question is this: Why we don’t protect the girls as well as the boys?
Yes, it is true the boys’ game is more aggressive, but anyone who knows these athletes realizes there is not much difference between them in their enthusiasm and commitment to win. The excuse put forth by U.S. Lacrosse is that if helmets are required the game will become more aggressive. That is not only a sexist viewpoint, it is like saying our children will ride their bikes in a safer way if we don’t have them wear bike helmets. I have seen many lacrosse injuries from not only sticks to the head, but impacts of the ball, too. It is a significant source of morbidity to female athletes.
In 2007, Randall Dick and associates, reviewing 16 years of NCAA injury data, found that 56% of above-the-neck injuries in women’s lacrosse resulted from contact with a stick and 20% from contact with a ball (J. Athl. Train. 2007;42:173-82). A 3-year prospective study by Dr. Richard Y. Hinton and his associates found that female players had higher rates of overall head injuries than their male counterparts, mostly involving contact with sticks and balls (Am. J. Sports Med. 2005;33:1305-14).
In 2001, a 10-year analysis of the National Electronic Injury Surveillance System by P.T. Diamond and S.D. Gale showed that the head and face were the most common areas injured, being significantly more prevalent in females (30%) than males (18%) (Brain. Inj. 2001;15:537-44). Their recommendation: “Women and children lacrosse players are at risk of serious injury to the head and face region. The use of protective head/face gear should be encouraged.”
Perhaps the most compelling study, by Andrew E. Lincoln, Sc.D., and associates, found that high school girls’ head, face, and eye injuries (0.54/1,000 athletic exposures) were significantly higher than for boys (0.38/1,000), and while concussions were higher in boys, girls sustained significantly more facial injuries, primarily resulting from stick or ball contact (Am. J. Sports Med. 2007;35:207-15).
In the early sixties, hockey players wore no helmets and goalies no masks. It does not seem that the addition of these pieces of safety equipment has ruined the game at all. Even though there is no checking in the girls’ lacrosse games, this does not prevent the inevitable accidents that occur in any sporting event. The above referenced articles support this. Many of these injuries are not only game injuries, but may carry lifelong consequences. Although the situation in professional sports is well known, my colleagues and I are seeing an increasing number of head injuries in all amateur sports, with women’s lacrosse making up a significant proportion of these incidents. When the governing bodies will not act, those of us who care for these athletes must speak up. Isn’t it time we protect the girls as well as the boys?
Patrick A. Caruso, M.D.
clinical associate professor of pediatrics
Mount Sinai School of Medicine
Morristown, N.J.
On April 8, the sports section in my local N.J. paper showed a picture of three female lacrosse players with their sticks up high in the air all reaching for a flying ball. Male players wear a full helmet and face mask, but these players wore only goggles and mouth guards. As a pediatrician who has had a lot of experience in treating head injuries in high school and college athletes, my question is this: Why we don’t protect the girls as well as the boys?
Yes, it is true the boys’ game is more aggressive, but anyone who knows these athletes realizes there is not much difference between them in their enthusiasm and commitment to win. The excuse put forth by U.S. Lacrosse is that if helmets are required the game will become more aggressive. That is not only a sexist viewpoint, it is like saying our children will ride their bikes in a safer way if we don’t have them wear bike helmets. I have seen many lacrosse injuries from not only sticks to the head, but impacts of the ball, too. It is a significant source of morbidity to female athletes.
In 2007, Randall Dick and associates, reviewing 16 years of NCAA injury data, found that 56% of above-the-neck injuries in women’s lacrosse resulted from contact with a stick and 20% from contact with a ball (J. Athl. Train. 2007;42:173-82). A 3-year prospective study by Dr. Richard Y. Hinton and his associates found that female players had higher rates of overall head injuries than their male counterparts, mostly involving contact with sticks and balls (Am. J. Sports Med. 2005;33:1305-14).
In 2001, a 10-year analysis of the National Electronic Injury Surveillance System by P.T. Diamond and S.D. Gale showed that the head and face were the most common areas injured, being significantly more prevalent in females (30%) than males (18%) (Brain. Inj. 2001;15:537-44). Their recommendation: “Women and children lacrosse players are at risk of serious injury to the head and face region. The use of protective head/face gear should be encouraged.”
Perhaps the most compelling study, by Andrew E. Lincoln, Sc.D., and associates, found that high school girls’ head, face, and eye injuries (0.54/1,000 athletic exposures) were significantly higher than for boys (0.38/1,000), and while concussions were higher in boys, girls sustained significantly more facial injuries, primarily resulting from stick or ball contact (Am. J. Sports Med. 2007;35:207-15).
In the early sixties, hockey players wore no helmets and goalies no masks. It does not seem that the addition of these pieces of safety equipment has ruined the game at all. Even though there is no checking in the girls’ lacrosse games, this does not prevent the inevitable accidents that occur in any sporting event. The above referenced articles support this. Many of these injuries are not only game injuries, but may carry lifelong consequences. Although the situation in professional sports is well known, my colleagues and I are seeing an increasing number of head injuries in all amateur sports, with women’s lacrosse making up a significant proportion of these incidents. When the governing bodies will not act, those of us who care for these athletes must speak up. Isn’t it time we protect the girls as well as the boys?
Patrick A. Caruso, M.D.
clinical associate professor of pediatrics
Mount Sinai School of Medicine
Morristown, N.J.
Are we taught enough about behavior?
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
If you ask a primary care pediatrician who has been practicing for more than 2 decades, she will tell you that her practice has tilted steeply toward complaints with a more developmental and behavioral flavor. In the lead article of the April 2015 Pediatrics (“Are We on the Right Track? Examining the Role of Developmental Behavioral Pediatrics”) Dr. Ruth E.K. Stein, a recent recipient of the C. Anderson Aldrich Award given by the American Academy of Pediatrics section on children with developmental and behavioral pediatrics, questions whether we, both general pediatricians and specialists in developmental and behavioral pediatrics, are on the right path in addressing this shifting mix in our patient populations.
Dr. Stein observes that while she and other pioneers in the creation of her specialty began as general pediatricians, today physicians typically enter developmental and behavioral fellowship programs without the benefit of practicing the runny nose–earache–diaper rash kind of pediatrics that many of us enjoy. She worries that from this early branching point in training, developmental and behavioral specialists have become “sequestered and siloed – increasingly seen only as people who take care of children who have special needs.” The problem is that, as Dr. Stein wisely observes, developmental and behavioral issues “are the core constructs of pediatrics and its backbone and that they must be incorporated into every primary care and specialty encounter and included in every educational experience.”
Dr. Stein continues her essay by proposing a handful of strategies for bridging the gap between developmental and behavioral specialists and general pediatricians, and strengthening the training of house officers, which currently requires only a pitifully inadequate month devoted to developmental and behavioral issues. While it is hard to argue with Dr. Stein’s suggestions, they only nibble around the edges of the real problem.
If one really believes as she and I do, that behavior and development must be considered in every patient encounter and educational experience, then the solution lies in changing how we teach medicine from the very beginning instead of waiting until postgraduate education. Everyone mouths the importance of the mind-body connection, but it is often just so much hot air. The relationship between behavior and development, and what Dr. Stein refers to as “biomedical” conditions, exists in every patient. It is often said it is the fact that our patients are growing and developing that keeps pediatrics apart from the rest of medicine. But the same process of change over time occurs in adults as well; we call it aging instead of development. Understanding where our patients are positioned on this trajectory from birth to death is critical in helping us understand what is troubling them, and how best to help them manage their concerns.
For pediatricians, our preverbal patients’ behavior is often the only way we have of knowing there is a problem. Behavior can be their unspoken chief complaint. The failure by a physician to interpret her patient’s behavior as either a result or the cause of the problem can lead to an unfortunate outcome.
This means, as we teach aspiring doctors the art of medicine, we must make it clear that the patient’s behavior and stage of development must be considered equally with the more traditional biomedical etiologies, not as an afterthought. For example, any discussion of nonacute recurrent abdominal pain in children that fails to acknowledge from the outset that most of these patients will not have an abnormality detectable by lab work and imaging studies is doing the young physician and his patients a disservice. I am suggesting that we adopt a more patient-centered rather than a disease-centered approach to training all physicians.
While every patient must be viewed in the proper behavioral and developmental context, there are those in whom a behavior problem dominates. Given the patient mix that the new millennium pediatrician is going to face, 1 month in postgraduate training is clearly insufficient. One cannot begin to learn even the rudiments of managing common problems such as attention-deficit/hyperactivity disorder, disordered sleep, temper tantrums, and school refusal in 30 days. Finding room in a training program to give behavioral and developmental problems more than a quick nod is going to require some rethinking of how we train pediatricians. It may be that training programs will need to selectively trim back some programs that may be of only limited long-term use to most general office-based pediatricians and offer them as electives. For example, how many of us still practice the kind of neonatology we were exposed to in the special care nursery? These are not easy decisions, but as Dr. Reid has suggested, we need to reconsider whether we are on the right track.
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.” E-mail him at [email protected].
Finally, an end to the SGR game of chicken
Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.
For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.
For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.
The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.
So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.
I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.
It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.
I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.
But I’m not optimistic.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.
For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.
For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.
The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.
So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.
I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.
It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.
I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.
But I’m not optimistic.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Well, in a remarkable moment in what is likely the most dysfunctional American government on record, all sides agreed to repeal the sustainable growth rate formula and change the way Medicare payments are done.
For the foreseeable future, this eliminates the annual game of chicken that political parties play at our expense.
For more than 10 years now, the cuts have come up, the medical journals decry them, doctors threaten to stop seeing Medicare patients, and eventually the politicians reach an agreement to stop the cuts that had grown to a high of 27.4% in 2012 ... until the next year. The classic game of political kick the can.
The dysfunctional waltz had been going on for so long that only the medical press and doctors seemed to care.
So, after years of wrapping duct tape around a leaking pipe, they called a plumber and replaced the pipe. The cost is far higher than it would have been if they’d actually addressed the problem when it started in 2003.
I’m sure the new law will have its own issues, but it stops – for now – the nightmare scenario where the cuts are allowed to go through. That would have left many of us in the difficult situation of turning away new Medicare patients. None of us wants to do that.
It’s nice to have seen the government function in the way it’s supposed to – with negotiations and compromise – rather than more threats, vitriolic posturing, and finger-pointing that have been the recent norm. Members of Congress, regrettably, don’t have their health care affected by their decisions. Regardless of age, the majority aren’t on Medicare. They’re all covered through the Federal Employees Health Benefits Program, which uses private plans. So it doesn’t directly affect them if a doctor’s office is shuttered or sick constituents can’t find someone to help them. They figure by the next election cycle they’ll be able to distract voters with some other topic.
I’m glad that reason and concern for the health care of ordinary citizens prevailed. It’s easy to play chicken when someone else’s life and livelihood are involved, and not yours. I hope this leads to greater cooperation and willingness to work together between the two sides in the future.
But I’m not optimistic.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Bath salts – the new designer high
“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.
Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.
Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.
Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.
Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).
MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.
Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.
In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.
The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.
Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.
It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.
Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.
Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.
Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.
Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).
MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.
Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.
In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.
The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.
Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.
It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
“Bath salts” is a dangerous illicit drug that teens may be using. It hit the U.S. scene in 2010 after being a big hit in Europe. It’s called “bath salts” because it resembled Epsom salt, but shares no chemical properties with it.
Because it was called bath salts, it initially evaded the Food and Drug Administration, and was sold at gas stations and clubs marked “not for human consumption,” which earned it its name as the “legal high.” Bath salts are creatively packaged in containers that are colorful and attractive, and have aliases such as “plant food,” “Ivory Wave,” “Purple Wave,” “Bloom,” “Cloud Nine,” or “Vanilla Sky,” according to the National Institute on Drug Abuse.
Shortly after the drug’s debut, emergency departments were seeing several hundreds of people with amphetamine-like intoxication and “naked rages.” In 2012, when it became known that these substances were being use as illicit drugs, they were made illegal, but the problem now is there are many derivatives of this drug and their use is becoming more widespread.
Mephedrone is one of the possible active ingredients, and it is derived from the synthetic cathinone, similar to cathinone found naturally in the khat plant (Catha edulis). It stimulates the adrenergic receptors to release dopamine and norepinephrine, and block their reuptake, which makes them act like a stimulant on the nervous system. The result is agitation, hyperalertness, hypertension, tachycardia, diaphoresis, and elevated temperatures to 106<scaps>˚ </scaps>F. The term “naked rage” came into use because users would become overheated and angry, and would rip off their clothes as they raged.
Other synthetic canthinones being used as drugs of abuse include butylone, dimethylcathinone, ethcathinone, ethylone, 3- and 4-fluoromethcathinone, mephedrone, methedrone, methylenedioxypyrovalerone (MDPV), methylone, and pyrovalerone (J. Med. Toxicol. 2012;8:33-42).
MDPV raises dopamine levels in the brain as does cocaine, but is at least 10 times as potent, according to the National Institute on Drug Abuse.
Bath salts can be administered by snorting, ingesting, smoking, or injecting. Necrotizing fasciitis has been associated with its use. Most patients present with elevated temperatures, hypertension, palpitations, and delirium. Hydration and sedation are usually required, and patients usually need to be restrained to prevent them from hurting themselves further. Psychiatric symptoms may include paranoia, hallucinations, and panic attacks. Several deaths have been reported in association with its use.
In the time since this drug was made illegal, several other designer drugs have presented, which are just modifications of the mephedrone. “Flakka” and “jewelry cleaner” are examples of the modified synthetic cathinone. They all cause amphetamine-like reactions and the risk of overdose is great.
The cost to manufacture the drug is about $8 per unit, but its retail price is $20-$40. Though it takes only 3-5 mg to be effective, packages are sold with 500 mg, making the risk for overdose even greater. It usually takes about 1.5 hours to reach peak rush and the entire experience can last 6-8 hours. There is little difference between the euphoric level and intoxication level, which is what makes the drug so dangerous.
Synthetic drugs are a great danger to all age groups, including toddlers, because of the misleading packaging. But they are especially dangerous because the ingredients vary, and overdose occurs quickly.
It is imperative that parents and teens are made aware of the dangers associated with these drugs and their street names; www.streetdrugs.org is a website designed to educate teachers, parents and students about these drugs and their dangers.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
