Commentary

In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.¹

Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.

Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.

One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.

Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.

Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.

It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.

Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.

Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.

Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.

Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.

Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.

All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.

If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”

Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.

In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.¹

Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.

Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.

One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.

Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.

Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.

It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.

Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.

Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.

Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.

Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.

Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.

All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.

If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”

Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.

In dermatology and dermatopathology, some histologic diagnoses are incontrovertible and reveal features that are readily diagnostic; however, in many cases clinical correlation is essential, as many diseases have similar histologic reaction patterns and the correct diagnosis is based on additional clinical information. Accuracy of diagnosis has been shown to improve when cases were evaluated at a clinical conference where histology and clinical features were correlated or when digital clinical photographs were evaluated with histologic findings.¹

Because clinical features usually are not available to the dermatopathologist when evaluating histologic specimens, he/she must rely on the information provided by the referring clinician on the pathology requisition form. It is important for clinicians to include as much information as is reasonably possible on the form in a legible fashion. If the specimen is a pigmented lesion, it should be described by its diameter and any additional information that is available, such as dermoscopic findings. If the process is an eruption, the extent, distribution, color, duration, symptoms, and any other relevant information should be provided.

Clinicians should always avoid “cryptic” allusions. Occasionally, dermatopathologists receive biopsy specimens with no information other than to rule out leukemia cutis. There is obviously more to that story. Do not expect the dermatopathologist to be a mind reader. We appreciate a request when a clinician wants a special stain or a margin rather than assuming we know when those are desired. We also would prefer for margin requests not to be made in an automatic manner when it does not matter whether the process involves the margins, such as in inflammatory conditions.

One should not dilute the value of the clinical impression. For example, do not write “rule out melanoma” for all pigmented lesions or “neoplasm of uncertain behavior” for all cutaneous neoplasms. If there is a prior biopsy, submit the prior number and the diagnosis if possible. Fill out all demographic information (eg, sex, race, age) and other important information such as pregnancy status, medication history, underlying condition, or history of neoplasia, as they all have bearing on the diagnosis.

Inflammatory skin diseases can be challenging to diagnose, as classic examples described in textbooks usually are not sampled. Consider performing more than one biopsy from lesions at different stages of evolution or from different body sites. In difficult cases, bring the patient to a conference, send the patient for consultation, or submit a clinical photograph or digital image. It also may be beneficial to call and discuss the case with the dermatopathologist. If the diagnosis does not make sense, ask for recuts, special stains, or a second expert opinion.

Regarding the biopsy process itself, always harvest a good piece of tissue and place it into the proper medium for the appropriate test. Formalin solution 10% is used for routine specimens, while Michel’s transport medium and saline are used for immunofluorescence studies. Make sure the specimen is floating in the liquid, as specimens may adhere to the side of the bottle or the lid. Beware of specimens remaining on a scalpel blade or within the barrel of a punch before inadvertently submitting a bottle containing no material. Also be sure to fill out the information on the bottle label, as the bottle and requisition form may get separated. Do not write on the lid in case it happens to come off.

It also is important not to put more than 1 specimen in the same bottle, especially when dealing with multiple different neoplasms. A possible reasonable exception is multiple skin tags, but note in the chart that you are submitting representative specimens. Beware of throwing away tissue instead of submitting it for biopsy whenever something is removed from the skin.

Keep a biopsy logbook or other records and review all pathology reports systematically. Communicate with the laboratory to check on the status of a biopsy if results are not back as soon as expected to ensure that there is not an inadvertent problem. Legal action can result if the patient is not notified in a timely fashion or if treatment is delayed. If the patient does not follow-up in a timely fashion, a certified letter should be sent to the patient.

Extremely small specimens (ie, <1 mm in diameter) or friable specimens may not survive processing. Occasionally, a specimen gets lost, either on the way to the laboratory or otherwise. If there is still a neoplasm at the site or the patient has a widespread process, another biopsy can be performed. My laboratory has a policy of not charging the patient given the circumstances. If nothing is left at the site and it is a neoplasm that could possibly have been malignant, a reasonable approach would be to conservatively re-excise the area and document everything in the medical record.

Regarding biopsy technique, punches of broad neoplasms, especially possible melanoma, may give false-negative results, which includes sampling the darkest area, a practice thought to be more sensitive at detecting malignancy. In actuality, it may be an area of hemorrhage, an associated solar lentigo, or a seborrheic keratosis. Furthermore, this may produce the phenomenon of “biopsy sculpture,” turning a large asymmetrical neoplasm into a smaller sample that looks symmetrical and more benign than it actually is. If a punch biopsy is performed, it should be a broad punch (ie, >5 mm in diameter) or the entire lesion should be punched out, which represents an excision. Multiple small punches are not optimal, as a broad specimen that provides a panoramic view of the entire process is preferable. Although incision or excision specimens are excellent, they often are impractical; rather, a broad saucerization biopsy is an excellent method that provides a representative specimen in the majority of cases.

Shave specimens of inflammatory processes do not sample the lower dermis or subcutis and often are inadequate, leading to reports of “tissue insufficient for diagnosis” or “descriptive” rather than specific diagnoses. Inadequate biopsies increase expenses as well as patient inconvenience and anger. In my laboratory, we teach residents to treat the biopsy as a treasure. Some clinicians think that performing a biopsy is analogous to doing a blood test and that any tissue at all will be sufficient for a diagnosis to be rendered; however, small curettings or tiny fragments of tissue often are inadequate and place both the clinician and the pathologist at medicolegal risk.

Clinicians requesting margins on shave biopsies must understand that they are not equivalent to margins reported on elliptical excision specimens or those performed using Mohs micrographic surgery. The pathologist can only report that a neoplasm removed by shave technique “seems to be removed in these sections,” as it cannot be determined with certainty that the lesion has been completely removed using this technique.

All biopsies are prone to sampling error. Dermatopathologists often put a note on a report saying that if this specimen represents part of a larger lesion, clinical correlation is recommended to exclude sampling error, which should be known by clinicians. It is extremely risky to ask for margins on a melanoma biopsy, and one should never assume a shave biopsy of a melanoma is adequate treatment.

If a clinician is clinically concerned about a diagnosis, especially melanoma, and the histologic diagnosis is benign, it is recommended that the lesion be excised nonetheless. A final diagnosis depends on a number of clinical, histological, historical, and genetic elements and possibly others. In some cases, the clinical diagnosis is more important than the histologic diagnosis. Clinicians should always feel free to call their dermatopathologist, ask questions, and refute a diagnosis. The dermatopathologist seeks to arrive at the best diagnosis for the patient, not to be “right.”

Diagnoses should be simple and differential diagnoses few. The longer the report and the more stains that are performed, generally the less is known about the diagnosis. Diagnoses should be rendered in terms easily understood by clinical dermatologists. Get a consultant dermatopathologist that you know and trust.

Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.

As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.

Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.

Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.

With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.

These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.

While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.

Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.

A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.

For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.

Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.

Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.

As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.

Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.

Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.

With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.

These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.

While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.

Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.

A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.

For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.

Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.

Of the 3,363 physicians who have been certified by the American Board of Addiction Medicine (ABAM) in the subspecialty of addiction medicine, about 1% have listed pediatrics as their primary specialty. Given the potentially life-threatening substance abuse problems that we see in adolescents today, this is a troubling reality.

As pediatricians, we all understand the importance of disease prevention and early detection. We take comprehensive histories and perform exhaustive physical exams. We ensure that our patients are up to date on vaccinations, and provide anticipatory guidance about child development and safety. We offer an array of interventions to keep patients well and treat illness early.

Both biomedical research and epidemiology now show that we can significantly lessen the prevalence and impact of risky drug use and addiction in adults by focusing on prevention in youth. All physicians know that adolescence is a time of great vulnerability, but it is a particularly dangerous time for the disease of addiction. Equipping physicians with a skill set for recognition and educating them about treatment options are of vital importance to combating the epidemic of adolescent substance abuse.

Research in substance abuse has been extensive and has consistently shown that the adolescent brain is uniquely sensitive to the effects of nicotine, alcohol, and other drugs. Current studies shows that 90% or more of addicted adults began drug use between the ages of 12 and 21 years. It is clear that if drug use can be avoided in youth, the incidence of addiction and its consequences can be sharply reduced in the adult population.

With these facts in mind, the American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians be knowledgeable about the prevalence, patterns, cultural differences, and health consequences of substance use in their communities; incorporate substance use prevention into anticipatory guidance at office visits; be aware of the signs and symptoms of substance use and their association with other risky behaviors; and be able to screen for and evaluate the nature and extent of substance use among patients and their families. The AAP guidelines also recommend that pediatricians become knowledgeable about community services for evaluation, referral, and treatment of substance use disorders, and be available to provide aftercare for adolescent patients completing substance use treatment programs and assist in their reintegration into the community.

These are very well reasoned and laudable goals, yet how are pediatricians going to acquire the skills and knowledge to achieve them? Currently, relatively few physicians screen, intervene, or refer, because they have not been sufficiently educated about addiction medicine in medical school, nor trained in residencies. Until the establishment of ABAM, one barrier to this training was the lack of an addiction medicine subspecialty for primary care physicians. A subspecialty of addiction psychiatry exists within the field of psychiatry, although this does not provide the opportunity for addiction certification for physicians in other primary specialties. While there are excellent addiction psychiatry fellowships, there are no addiction medicine residencies for physicians pursuing primary care specialties among the 9,262 Accreditation Council for Graduate Medical Education (ACGME) accredited U.S. programs that are training 119,588 residents. The ABAM Foundation has worked to remedy this by certifying postresidency addiction medicine fellowship programs at leading medical schools across North America. The fellowships are based on the foundation’s national guidelines, Program Requirements for Graduate Medical Education in Addiction Medicine. These requirements are consistent with ACGME standards.

While addiction disorders account for a staggering amount of primary care visits in the United States, formal courses in addiction medicine are largely absent from most medical school curricula. I was fortunate during my own medical education at Tulane to volunteer at a local homeless shelter that served many patients with substance abuse problems. Following medical school, I completed an internship in internal medicine at Georgetown University Hospital, but I soon realized that my true love was pediatrics. I re-entered the residency match and completed my pediatrics residency at New York-Presbyterian Hospital/Weill Cornell Medical College.

Working with adolescents proved to be most enlightening and inspiring, and I felt myself drawn to the unique clinical crossroads of psychiatry, addiction, and pediatrics. I soon learned that there was a formal path for certification and for postgraduate training in addiction medicine. After finishing my residency, I completed a fellowship in addiction medicine at The Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals (then affiliated with the Columbia University College of Physicians & Surgeons; now affiliated with Mount Sinai’s Icahn School of Medicine). Following fellowship, I took the ABAM certification exam and became ABAM board certified in addiction medicine. While it is not necessary to complete an addiction medicine fellowship in order to qualify for or pass the ABAM examination, I certainly feel that my fellowship was a worthwhile endeavor. After my fellowship, I was hired as associate director, and I am now director of the Addiction Institute’s fellowship program.

A decade ago when I was in medical school, the opioid pandemic among American children represented a gathering storm. It has now become an all-encompassing and uniquely lethal deluge. Well over half of the substance use disorders that I see in my practice are opioid use disorders – with the typical progression being prescription opioid pills to heroin. As pediatricians, combating this pandemic is the calling of our time. We must educate ourselves about substance use disorders, particularly opioid use disorders. We must equip ourselves with screening techniques and become facile with evidence-based pharmacotherapies and psychosocial interventions. Undertaking ABAM fellowship training or becoming ABAM certified can be invaluable first steps.

For information on the ABAM certification exam, please visit www.abam.net. To learn more about ABAM Foundation fellowship programs, go to www.abamfoundation.org.

Dr. Brennan serves as an attending physician and director of the fellowship in addiction medicine at The Addiction Institute of New York – Mount Sinai Health System. He is board certified in pediatrics and addiction medicine. Dr. Brennan said he had no relevant financial disclosures.

It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.

It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.

Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).

On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.

So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.

While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.

I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.

None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.

Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”

It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.

It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.

Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).

On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.

So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.

While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.

I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.

None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.

Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”

It’s no secret that young adult North Americans, especially those in more privileged socioeconomic strata, are delaying childbearing. They struggle with the notion of committing to one another and then take even longer to arrive at the decision to have children. On the other hand, they seem to have much less trouble deciding to get a dog. One wonders if the canine commitment is a subconscious test balloon launched to assess their aptitude for parenting. Of course, any parent who has raised both children and dogs will tell you that the coefficient of correlation between the two adventures is approaching zero.

It is often assumed that upwardly mobile young adults are choosing canine husbandry over parenting because they want to make sure their careers are solidly on track before they commit to the financial responsibilities and emotional challenges of raising a child. However, it may be that some of them have read the same studies I have recently encountered that suggest if you want to stay fit, you are better off getting a dog than having a child.

Dog owners are 34% more likely to squeeze 150 minutes of walking into their weeks than are those who don’t own a dog. And having a dog increases leisure time physical activity by 69%. Not surprising, walking a puppy increases one’s walking speed by 28% over a solitary pace. Compare this to walking with a human companion that only increases one’s speed 4% (“Dog Ownership and Physical Activity: A Review of the Evidence” [J. Phys. Act. Health 2013;10:750-9]).

On the other hand, having a child can really do a number on the fitness habits of a parent (“How to Get Your Spouse to Exercise,” Gretchen Reynolds, New York Times, March 28, 2015). For a father, becoming a parent of a single child usually has little effect on the amount of moderate to vigorous exercise he gets. However, when a woman becomes a mother, she can expect to see a significant drop in the time she can spend exercising. Fathers eventually pay the price in reduced vigorous activity if they father more than one child. Not surprisingly, having a child under 6 years in the house decreases moderate activity for both parents, while it increases their light activity as they attempt to stay one step ahead of a toddler.

So, if a young adult wants to stay healthy by maintaining even a moderate exercise regimen and he or she runs the numbers, the answer is pretty clear: Forget the kids and get a dog.

While children can have a negative impact on their parents’ physical activity, it turns out that parents can create downward pressure on their child’s physical activity if they adopt one of several parenting styles (“Hyper-parenting is negatively associated with physical activity among 7- to 12-year olds” [Prev. Med. 2015;73:55-9]). In a recently reported Canadian survey of more than 700 parents, a researcher has found that the children of parents whose style of parenting could be categorized as hyper-parenting got significantly less physical activity than did the children of parents with low hyper-parenting scores.

I learned from reviewing the paper that behavior specialists now split hyper-parents into categories: overprotective, helicopter, tiger mom, little emperor, and concerted cultivation (overscheduling). Only the children of helicopter parents were spared the negative impact of their parents’ style. It may be that while hovering may be annoying, it does allow for enough distance between parent and child for the child to follow his own urge to be active.

None of these studies that I reviewed was very robust, and while their results may not stand the test of repetition, intuition suggests having children can make it challenging for parents who want to maintain a healthy level of physical activity. And you and I know that children need physical and emotional space from their parents in which to play freely and actively.

Obviously I don’t think we should be encouraging all young adults to choose dog ownership over parenthood, but we should be helping parents choose strategies and parenting styles that leave enough time and space for everyone in the family to get a healthy amount of physical activity.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years, and is the author of “Coping With a Picky Eater.”

To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?

For more, read our Storify page detailing the incident and the response from the mental health community:

To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?

For more, read our Storify page detailing the incident and the response from the mental health community:

To what extent were Andreas Lubitz’s reported ‘suicidal tendencies’ and depression factors in the catastrophe?

For more, read our Storify page detailing the incident and the response from the mental health community:

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.

Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.

Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.

The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.

A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.

As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.

Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.

Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

Problems with access to care at the Department of Veterans Affairs have been the source of front-page headlines for at least a year. Some of us are asked: Can the VA and military health care system do it all? My answer: Of course not.

More than 2.5 million American combat veterans have fought in longest war in our history, the wars in Afghanistan and Iraq. Thousands of physically and psychologically wounded active duty troops overflow military hospitals. The VHA (Veterans Health Administration), the medical arm of VA, is caring for millions of these recent veterans. But it also treats veterans from many other wars, including those from World War II, Korea, and Vietnam.

As those men and women age, their need for medical care will only increase. So just take into account the older veterans, and then add the recent combat veterans with posttraumatic stress disorder, traumatic brain injury, and physical injuries from the conflicts in Iraq and Afghanistan.

So, to me, “of course not” is an obvious answer to whether the military health care system and VA can do it all.

This should be no surprise. Back in 2007, my former boss, the Army surgeon general, was fired when Walter Reed National Military Medical Center got overwhelmed with the wounded. A consistent theme of overwhelmed military and veterans facilities has emerged.

Yet, I still get asked the question “Is the military and the VA doing enough to take care of wounded veterans?” whenever I do a media interview about PTSD and suicides in soldiers. The reporters tend to ask with a kind of “gotcha” attitude, as if the VA’s struggle to keep up is a secret.

My answer is “They are doing all they can. They are stretched very thin.”

I recently served on an Institute of Medicine committee looking at how well the Department of Defense and the VA delivered care for PTSD. The short answer? It varies. Some VA hospitals deliver stellar care, others not so much. Being swamped was a common theme.

Rather than ragging on the struggling VA, the more productive direction, it seems to me, is to ensure that the civilian health care system is capable of recognizing and treating the psychological injuries of war.

Why involve civilians? For many reasons. A lot of veterans choose not go to the VA, because they receive health care via their workplace or school insurance. Some veterans are too low a priority to be seen. Even for those eligible to receive treatment there, when too full, the VA refers many veterans to the civilian sector.

Fortunately, there have been a lot of efforts to teach psychiatrists about caring for the psychological wounds of war, including:

• The military track at the American Psychiatric Association meeting in Toronto, on its 5th year.

• Webinars and conferences developed by public and private organizations, such as the Substance Abuse and Mental Health Services Administration, and the Massachusetts General Hospital Home Base program.

• Many books and articles by experts in the area of veterans health, for example see Once a Warrior – Always a Warriorb y Col. (Ret.) Charles W. Hoge, M.D., (Guilford, Conn.: Lyons Press, 2010), or my forthcoming book, Women at War (Oxford University Press, 2015).

• Numerous websites, such as that of the National Center for PTSD,the Borden Institute,and the Center for Deployment Psychology.

• The developing medical school curriculum on veteran’s health, spurred by the White House’s Joining Forces initiative.

• An action paper to be presented at this year’s APA Assembly, recommending that all providers inquire about the military status of their patients.

Of course, there is lots of room for everybody – not just health care providers – to join in the mission. As we enter year 14th year of the long war, we all need to help.

Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

As of this writing, there is much speculation in the press regarding the Germanwings’ copilot’s mental illness, with the implications that taking antidepressants or being depressed should be sufficient reason for a pilot’s never being allowed to fly or get a license to fly.

There is evidence that the airline knew that the copilot, Andreas Lubitz, had a history of depression, and had “suicidal tendencies” in the past, but it is unclear whether that meant suicidal thoughts just crossed his mind or he was seriously contemplating a suicide plan.

(German prosecutors report that searches on suicide were conducted on his computer in the days before the crash, suggesting that he had been considering and likely planning suicide in the preceding days.) Being depressed alone though, without serious thoughts about suicide if he were thought to be well-controlled with antidepressants without excessive sedation, would not necessarily mean that he was unfit to fly. But there might be questions about the adequacy of monitoring his mental state by those able to assess such risks, though suicide cannot always be predicted, especially if patients hide such intent.

Preliminary reports indicate that Mr. Lubitz was seeing a psychotherapist and a physician in the time before the crash. We do not know what he told them. It is not clear whether he was seeing a psychiatrist. It also looks as if the airline was made aware of the copilot’s past psychiatric problems before hiring him. It does appear that he recently feared losing his job, and it is possible that that might have affected his actions.

Although someone currently suicidal or homicidal undoubtedly should not be allowed to fly, there is no evidence at this time that the pilot communicated to anybody his intent to fly a commercial plane with passengers into a mountain. No mental health professional can adequately assess the risk a patient poses without information from the patient or another reliable source.

Legitimate questions remain whether more could have been done to minimize the risk or whether there were warning signs that should have warranted further evaluation and risk assessment of the copilot. Questions also can arise about what kind of monitoring is needed of those with a history of mental illness working in high-risk jobs such as piloting planes. But currently, there is a serious risk in Germany and even in the United States now of an overreaction to this tragedy that can increase danger by discouraging those with mental illness from getting help.

It has been reported that Mr. Lubitz had a note in his home from his doctor excusing him from flying on the date he crashed the plane. It was not submitted to his employer and he flew anyway. We do not know what the basis for the letter was or what specifically he told his psychotherapist. But the incident nonetheless raises questions about a psychotherapist’s duty to protect in both Germany and the United States. It is important to know that the laws and responsibilities of psychotherapists and physicians in Germany are not the same as those in the United States. In addition, the laws governing the responsibilities of psychotherapists differ even in the United States from one state to another.

The Tarasoff case itself creating the duty to protect in the United States originated in California. The 1974 decision of the California Supreme Court created a duty to warn. But 2 years later in 1976, the duty was changed to a duty to protect potential victims with warning potential victims and notifying the police being solely ways to satisfy the duty to protect. The 1976 decision found potential liability if a psychotherapist knew or should have known that the patient was dangerous. Since the “should have known” language opened up liability for failure to have a crystal ball to accurately predict the future, laws were passed in California and in many other states limiting liability to situations in which a serious threat was made to an identifiable victim.

For some reason, despite the original Tarasoff duty in California being a duty to warn for only 2 years from 1974 to 1976, the Tarasoff duty often was still erroneously referred to as a duty to warn. The ambiguous immunity statute referred to a duty to warn and protect, and this phrase was interpreted to mean the warn part of the duty could be satisfied only by warning. As a result, legislation was passed clarifying that the duty is to protect in California and not to warn. Warning the victim and notifying the police does, however, confer immunity from liability.

Other states have duties to protect and even duties to warn. Some have permissive but not required duties to protect or warn. Some have no such duties at all. So there are tremendous variations in such duties across the country with some states having no such duty at all.

According to a March 30 article in the Washington Post, Germany, in part in reaction to its Nazi past and the Communist past in East Germany, tries especially hard to limit intrusion into personal privacy. Although doctors in Germany can violate confidentiality for protective reasons, they can face steep legal repercussions if the confidentiality violations are later thought unwarranted. “Violations of medical privacy can carry criminal sentences of up to five years in jail.” Of course we do not know what the copilot told his psychotherapist or physician, but it is possible that fear of such penalties could intimidate professionals from taking a risk of notifying authorities since they face no penalty for opting not to report such information.

In contrast, California now allows confidentiality violations for protective reasons even for dangers that do not meet the duty to protect. It does not want psychotherapists to fear liability for notifying authorities in order to protect the public. California civil code 56.10 (19) in referring to release of confidential medical information now reads that information may be disclosed “if the psychotherapist in good faith believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable victim or victims, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.”

Although we do not know what the copilot told his psychotherapist, it is important to keep in mind that the psychotherapist’s duty very much depends on the country and jurisdiction. Some legal changes might be necessary, and there might well be better monitoring of those with a serious mental illness in highly sensitive positions, but it is important not to overreact in ways that increase the dangers by increasing the stigma of mental illness unjustifiably. Stigma can discourage those with mental disorders from getting the help they need and cause people to hide any evidence of illness. Furthermore, overly frantic efforts to protect the public could discourage needed treatment and end up putting the public at even greater risk.

Dr. Weinstock is health sciences clinical professor of psychiatry, David Geffen School of Medicine, University of California, Los Angeles. He also is immediate past president of the American Academy of Psychiatry and the Law, and has coauthored or edited several textbooks about ethical practices in forensic psychiatry.

Dr. Darby is a current resident in the UCLA Semel Institute for Neuroscience and Human Behavior psychiatry residency program and a graduate of the Perelman School of Medicine at the University of Pennsylvania. He received his bachelor of arts degree from Swarthmore College in Pennsylvania with a special major in psychobiology.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Eighteenth-century French philosopher Voltaire – amongst his many other pithy and lasting axioms – notably wrote: “God gave us the gift of life; it is up to us to give ourselves the gift of living well.” Almost 300 years later, his observation seems more salient and timely than ever. In the 21st century, we find ourselves in an era of technology unimaginable by Voltaire – one that empowers individuals to live better than ever, with tools no longer limited to the intellectual or aristocratic elite.

Accordingly, this month we thought it would be refreshing to take a break from looking back at the trials and tribulation caused by Meaningful Use in 2014, and look forward to the advantages and challenges promised by the consumer-focused health care technology market of 2015 and beyond. After all, we need only walk into the local Wal-Mart to be confronted with devices aimed at improving everything from sleep to diabetes, and our patients are clearly starting to take notice. Much more disruptive than the Internet revolution of the past 20 years, emerging technology promises not only to educate, but also diagnose, leading to an entirely different definition of “informed patients.” Like it or not, this is the new generation of “connected health,” and it is poised to reshape health care delivery in the very near future. We’ll review some of the recent innovations here.

‘Steps’ to achieve better health

While you might be challenged to recall the introduction of the mechanical pedometer by Thomas Jefferson in the 1700s, you no doubt recall the digital pedometer revolution of the 1990s. Seemingly overnight, these small belt-worn novelties began showing up on waistbands everywhere, easily confused for small pagers. Initially, the goal of owning a pedometer was simple: get to 10,000 steps a day to achieve better health. But the pedometers of today are far from simple. Now, they are worn on the wrist, or embedded in our phones, and track everything from calories burned to hours and quality of sleep. What’s more, they are integrated with health and wellness smartphone apps and often form the center of diet and fitness plans.

It’s hard to argue with the value of devices such as Fitbits and FuelBands as they encourage our patients (and even ourselves) to engage in more healthful and active lifestyles, but these are really just the beginning of the connected movement. Things really become interesting for physicians when patients choose to advance to the next level of technology and move from wellness tracking to disease management and diagnosis.

Beyond the Fitbit: Personal diagnostic technology

All of us encourage patients to monitor their blood pressures and blood glucose levels at home, as this can provide multiple data points crucial for proper management and medication dosing. But patients are no longer limited to just taking measurements and recording them on a paper log. Like the modern pedometers described above, BP cuffs and glucometers can now fully integrate with smartphone apps, leading to a whole new world of data integration. What’s more, the software can help patients self-manage their conditions, make recommendations on lifestyle modifications, and even suggest treatment options.

But personal medical gadgets are not just limited to upgraded versions of time-honored devices. Advancement in sensor and cloud-based technologies have paved the way for entirely new categories of diagnostic equipment. One such device, the S+ by ResMed (a respected respiratory equipment manufacturer), is a small box that sits on a bedside table. It is billed as “the first non-contact sleep sensor,” and ResMed claims it will “track and better understand your sleeping patterns, and then create personalized feedback and suggestions to help improve your sleep.” Not surprisingly, the S+ integrates with your smartphone, and even includes multiple sensors, smart alarms, and other tools to improve your sleep experience.

Another device currently in clinical trials is the Scanadu Scout, described by creators as a “medical tricorder” (an intentional reference to Star Trek). Integrating a thermometer, blood pressure sensor, pulsometer, pulse oximeter, and 2-lead EKG into a device about half the size of a hockey puck, the Scout collects and communicates data to a smartphone via Bluetooth. This could make it easier than ever for patients to compile cardiovascular data to share with their physicians, especially as a growing number of ambulatory EMRs offer the ability to submit these readings directly into the medical record through a web portal.

On a final note, we would be remiss if we didn’t mention the growing range of home blood-testing kits that offer everything from hemoglobin A_1C measurements to complete genome sequencing. All of these innovations signal a shift away from the idea of the medical home being the physician’s office, while keeping the patient squarely at the center of care delivery.

Shifting the data paradigm

Try as we might to avoid it, it is difficult for us to discuss emerging trends in medicine without mentioning Meaningful Use. Thus we feel compelled to mention that the MU Stage III proposed rule (which we will be discussing at length in future columns) includes language about connected medical devices. Under the header of “Active Patient Engagement,” the rule requires that physicians incorporate health data from nonclinical settings for 15% of patients. This leads us to ponder several questions. First, how will we handle this new onslaught of health information? How should it affect our medical decision making? And finally, what is our role as patients embrace these new technologies to take increasing ownership of their own care. Returning to the words of Voltaire we find comfort in this: “The fine art of medicine consists of amusing the patient while nature cures the disease.” Perhaps the paradigm hasn’t changed much at all. Perhaps patients have simply found new ways to be amused.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.