Commentary

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

Clinician Reviews is celebrating its 25th year of publication in 2015. As the journal’s PA and NP Editors-in-Chief, we would like to be among the first to congratulate the publication on this milestone anniversary.

Paging through the inaugural issue (February 1991) today is an indication of how much has changed in 25 years (and, at the same time, how much hasn’t). In that issue, the editors acknowledged the service of military PAs and NPs who were deployed during Operation Desert Storm (at the time, a current conflict) and introduced an AIDS Update department because “the spread of human immunodeficiency virus (HIV) shows little sign of abating.”

Despite the passage of time, CR remains faithful to the editorial purpose established more than two decades ago. It was “designed to provide you with the information you need to keep abreast of the changes in medicine that occur on a daily basis.” And to the present day, the editorial staff and the editorial board have maintained their commitment to providing peer-reviewed, clinician-authored content that helps NPs and PAs provide the best possible patient care in an increasingly challenging environment. The journal has never lost its focus on primary care—the heart of health care in the United States—while acknowledging that primary care clinicians manage a wide variety of disease states and conditions.

The true strength of the journal has always been, and continues to be, the people affiliated with it. Special thanks to the dedicated editorial staff: Karen J. Clemments (Editor), Ann M. Hoppel (Managing Editor), Fran Hopkins (Senior Editor), and Kristen Garafano (Web Editor). This noteworthy anniversary would not be complete without extending special thanks to past Editors Robert E. De Donato, Jean Paternoster, and Maura Griffin, and longtime Senior Editor Christine Mooney Lukesh, who retired last year.

In addition, we acknowledge that no journal can be successful without the support and guidance of its editorial board. We have been especially blessed with colleagues from both the PA and NP professions—many of whom have been on the board for a decade or longer. Their names are listed here.

We, as Editors-in-Chief, would particularly like to thank you—our readers and colleagues—for your thoughtful feedback on our monthly editorials. It is rewarding to think that we have fostered discussion and fruitful debate on issues relevant to our professions—and we gain just as much perspective as we hope to impart. To those of you who have contributed manuscripts over the years, know that we are grateful for your professionalism, generosity with your time and expertise, and commitment to enhancing the knowledge of your fellow practitioners.

So, as CR marks its 25th anniversary, we invite our authors, peer reviewers, and readers to join us in celebrating. Thank you for your support for the past 25 years. Here’s to many more.

Clinician Reviews is celebrating its 25th year of publication in 2015. As the journal’s PA and NP Editors-in-Chief, we would like to be among the first to congratulate the publication on this milestone anniversary.

Paging through the inaugural issue (February 1991) today is an indication of how much has changed in 25 years (and, at the same time, how much hasn’t). In that issue, the editors acknowledged the service of military PAs and NPs who were deployed during Operation Desert Storm (at the time, a current conflict) and introduced an AIDS Update department because “the spread of human immunodeficiency virus (HIV) shows little sign of abating.”

Despite the passage of time, CR remains faithful to the editorial purpose established more than two decades ago. It was “designed to provide you with the information you need to keep abreast of the changes in medicine that occur on a daily basis.” And to the present day, the editorial staff and the editorial board have maintained their commitment to providing peer-reviewed, clinician-authored content that helps NPs and PAs provide the best possible patient care in an increasingly challenging environment. The journal has never lost its focus on primary care—the heart of health care in the United States—while acknowledging that primary care clinicians manage a wide variety of disease states and conditions.

The true strength of the journal has always been, and continues to be, the people affiliated with it. Special thanks to the dedicated editorial staff: Karen J. Clemments (Editor), Ann M. Hoppel (Managing Editor), Fran Hopkins (Senior Editor), and Kristen Garafano (Web Editor). This noteworthy anniversary would not be complete without extending special thanks to past Editors Robert E. De Donato, Jean Paternoster, and Maura Griffin, and longtime Senior Editor Christine Mooney Lukesh, who retired last year.

In addition, we acknowledge that no journal can be successful without the support and guidance of its editorial board. We have been especially blessed with colleagues from both the PA and NP professions—many of whom have been on the board for a decade or longer. Their names are listed here.

We, as Editors-in-Chief, would particularly like to thank you—our readers and colleagues—for your thoughtful feedback on our monthly editorials. It is rewarding to think that we have fostered discussion and fruitful debate on issues relevant to our professions—and we gain just as much perspective as we hope to impart. To those of you who have contributed manuscripts over the years, know that we are grateful for your professionalism, generosity with your time and expertise, and commitment to enhancing the knowledge of your fellow practitioners.

So, as CR marks its 25th anniversary, we invite our authors, peer reviewers, and readers to join us in celebrating. Thank you for your support for the past 25 years. Here’s to many more.

Clinician Reviews is celebrating its 25th year of publication in 2015. As the journal’s PA and NP Editors-in-Chief, we would like to be among the first to congratulate the publication on this milestone anniversary.

Paging through the inaugural issue (February 1991) today is an indication of how much has changed in 25 years (and, at the same time, how much hasn’t). In that issue, the editors acknowledged the service of military PAs and NPs who were deployed during Operation Desert Storm (at the time, a current conflict) and introduced an AIDS Update department because “the spread of human immunodeficiency virus (HIV) shows little sign of abating.”

Despite the passage of time, CR remains faithful to the editorial purpose established more than two decades ago. It was “designed to provide you with the information you need to keep abreast of the changes in medicine that occur on a daily basis.” And to the present day, the editorial staff and the editorial board have maintained their commitment to providing peer-reviewed, clinician-authored content that helps NPs and PAs provide the best possible patient care in an increasingly challenging environment. The journal has never lost its focus on primary care—the heart of health care in the United States—while acknowledging that primary care clinicians manage a wide variety of disease states and conditions.

The true strength of the journal has always been, and continues to be, the people affiliated with it. Special thanks to the dedicated editorial staff: Karen J. Clemments (Editor), Ann M. Hoppel (Managing Editor), Fran Hopkins (Senior Editor), and Kristen Garafano (Web Editor). This noteworthy anniversary would not be complete without extending special thanks to past Editors Robert E. De Donato, Jean Paternoster, and Maura Griffin, and longtime Senior Editor Christine Mooney Lukesh, who retired last year.

In addition, we acknowledge that no journal can be successful without the support and guidance of its editorial board. We have been especially blessed with colleagues from both the PA and NP professions—many of whom have been on the board for a decade or longer. Their names are listed here.

We, as Editors-in-Chief, would particularly like to thank you—our readers and colleagues—for your thoughtful feedback on our monthly editorials. It is rewarding to think that we have fostered discussion and fruitful debate on issues relevant to our professions—and we gain just as much perspective as we hope to impart. To those of you who have contributed manuscripts over the years, know that we are grateful for your professionalism, generosity with your time and expertise, and commitment to enhancing the knowledge of your fellow practitioners.

So, as CR marks its 25th anniversary, we invite our authors, peer reviewers, and readers to join us in celebrating. Thank you for your support for the past 25 years. Here’s to many more.

There are more than 60 websites that review physicians online, with the number growing each year. A staggering number of physician searches—in excess of 3 million—are done each day in the United States. They have increased 68% from 2013 to 2014.¹ All online physician review sites provide some type of structured doctor experience rating score, and many allow comments from patients. Some sites also provide information about physician education, board certification, and hospital affiliation. The quality of physician review sites varies, just like the quality of those reviewed.

Physician review sites have not been embraced by the medical community and are often regarded by physicians with apathy, if not antipathy. There are many reasons for this reaction. The information on the sites—often gathered from flawed public and payer databases—can be very inaccurate; the number of patient reviews for each physician—orthopedic surgeons have an average of 12—is too limited to accurately represent a practice; and a single scathing review—frequently anonymous—can damage a physician’s reputation. First Amendment free speech laws allow patients to place their reviews anonymously, and the Health Insurance Portability and Accountability Act (HIPAA) prevents a physician from answering a negative review in anything but general terms. Under the federal Communications Decency Act, website providers aren’t liable for the postings of those who comment. Legitimate rave reviews may be deemed fake by certain websites and removed, and customer service is often a charade, with no one to speak to but a website computer. Most importantly, the review sites rarely represent the full breadth of a physician’s practice and reduce the physician to a simple star or numerical rating.

Like it or not, physician review sites are here to stay. In part as a result of the insurance changes created by the Affordable Care Act, patients are searching for new doctors online in unprecedented numbers. According to the Pew Research Internet Project, 72% of Internet users say they go online for health information.² A 2014 study in the Journal of the American Medical Association reported that 59% of respondents indicated that physician rating sites were “somewhat or very important” when choosing a physician; 35% reported selection of a physician based on good ratings; and 37% reported avoidance of a physician based on bad ones.³ This is important information for an orthopedic surgeon to consider. Orthopedic surgery is the most frequently searched physician specialty on the Internet, and it is not uncommon for a busy orthopedist to have more than 1000 searches per year on just 1 review site. Consumer research data indicates that as many as 50% of patients who visit a review site call that physician for an appointment within 1 week.⁴ When a physician’s name is entered into a search engine such as Google, physician review sites are often listed above the physician’s own website.

Last year the California Orthopaedic Association (COA), responding to its members’ concerns, reviewed online physician review sites. As part of this initiative, the COA approached Healthgrades, a leader in online medical reporting of physicians, hospitals, and other health care providers. The goal was to understand Healthgrades’ perspective and to see if they were open to orthopedic input. The COA was concerned that review sites often had incomplete and inaccurate information about physicians’ practices, lacked orthopedic subspecialty designation, and precluded physicians from posting comprehensive information about their practices in their own words. Personalized practice information provided by the physician, the COA reasoned, especially if displayed prominently, would complement the patients’ 1- to 5-star physician rating.  Both prospective patients and physicians would benefit.

Three months ago, as a direct result of these collaborative efforts, Healthgrades made major changes to its review site. They increased the number of searchable orthopedic subspecialties, so that a patient with a specific problem is more likely to find an orthopedic surgeon with the right expertise. Physicians or their practice managers can now more easily update information about their practice, either online or by phone. Most importantly, Healthgrades added a featured section—“Your Voice”—prominently positioned next to their star rating, where a physician can describe who he/she is and what he/she does. This addition is not to be underestimated. No other major review site provides this opportunity to the physician.

Healthgrades should be applauded for their collaboration with the COA and the highly successful improvement of their physician review site. They have raised the bar and set an example that other review sites will hopefully follow.

References

1.    Leslie J. Patient use of online reviews: IndustryView 2014. Software Advice. http://www.softwareadvice.com/medical/industryview/online-reviews-report-2014. Published November 19, 2014. Accessed December 8, 2014.

2.    Fox S, Duggan M. Health online 2013. Pew Research Center’s Internet & American Life Project. http://www.pewinternet.org/2013/01/15/health-online-2013. Published January 15, 2013. Accessed December 8, 2014.

3.    Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735.

4.    Stax, Inc. Assessing Objectives & Actions Taken Among Users of Healthgrades. Unpublished data, April 2012.

There are more than 60 websites that review physicians online, with the number growing each year. A staggering number of physician searches—in excess of 3 million—are done each day in the United States. They have increased 68% from 2013 to 2014.¹ All online physician review sites provide some type of structured doctor experience rating score, and many allow comments from patients. Some sites also provide information about physician education, board certification, and hospital affiliation. The quality of physician review sites varies, just like the quality of those reviewed.

Physician review sites have not been embraced by the medical community and are often regarded by physicians with apathy, if not antipathy. There are many reasons for this reaction. The information on the sites—often gathered from flawed public and payer databases—can be very inaccurate; the number of patient reviews for each physician—orthopedic surgeons have an average of 12—is too limited to accurately represent a practice; and a single scathing review—frequently anonymous—can damage a physician’s reputation. First Amendment free speech laws allow patients to place their reviews anonymously, and the Health Insurance Portability and Accountability Act (HIPAA) prevents a physician from answering a negative review in anything but general terms. Under the federal Communications Decency Act, website providers aren’t liable for the postings of those who comment. Legitimate rave reviews may be deemed fake by certain websites and removed, and customer service is often a charade, with no one to speak to but a website computer. Most importantly, the review sites rarely represent the full breadth of a physician’s practice and reduce the physician to a simple star or numerical rating.

Like it or not, physician review sites are here to stay. In part as a result of the insurance changes created by the Affordable Care Act, patients are searching for new doctors online in unprecedented numbers. According to the Pew Research Internet Project, 72% of Internet users say they go online for health information.² A 2014 study in the Journal of the American Medical Association reported that 59% of respondents indicated that physician rating sites were “somewhat or very important” when choosing a physician; 35% reported selection of a physician based on good ratings; and 37% reported avoidance of a physician based on bad ones.³ This is important information for an orthopedic surgeon to consider. Orthopedic surgery is the most frequently searched physician specialty on the Internet, and it is not uncommon for a busy orthopedist to have more than 1000 searches per year on just 1 review site. Consumer research data indicates that as many as 50% of patients who visit a review site call that physician for an appointment within 1 week.⁴ When a physician’s name is entered into a search engine such as Google, physician review sites are often listed above the physician’s own website.

Last year the California Orthopaedic Association (COA), responding to its members’ concerns, reviewed online physician review sites. As part of this initiative, the COA approached Healthgrades, a leader in online medical reporting of physicians, hospitals, and other health care providers. The goal was to understand Healthgrades’ perspective and to see if they were open to orthopedic input. The COA was concerned that review sites often had incomplete and inaccurate information about physicians’ practices, lacked orthopedic subspecialty designation, and precluded physicians from posting comprehensive information about their practices in their own words. Personalized practice information provided by the physician, the COA reasoned, especially if displayed prominently, would complement the patients’ 1- to 5-star physician rating.  Both prospective patients and physicians would benefit.

Three months ago, as a direct result of these collaborative efforts, Healthgrades made major changes to its review site. They increased the number of searchable orthopedic subspecialties, so that a patient with a specific problem is more likely to find an orthopedic surgeon with the right expertise. Physicians or their practice managers can now more easily update information about their practice, either online or by phone. Most importantly, Healthgrades added a featured section—“Your Voice”—prominently positioned next to their star rating, where a physician can describe who he/she is and what he/she does. This addition is not to be underestimated. No other major review site provides this opportunity to the physician.

Healthgrades should be applauded for their collaboration with the COA and the highly successful improvement of their physician review site. They have raised the bar and set an example that other review sites will hopefully follow.

References

1.    Leslie J. Patient use of online reviews: IndustryView 2014. Software Advice. http://www.softwareadvice.com/medical/industryview/online-reviews-report-2014. Published November 19, 2014. Accessed December 8, 2014.

2.    Fox S, Duggan M. Health online 2013. Pew Research Center’s Internet & American Life Project. http://www.pewinternet.org/2013/01/15/health-online-2013. Published January 15, 2013. Accessed December 8, 2014.

3.    Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735.

4.    Stax, Inc. Assessing Objectives & Actions Taken Among Users of Healthgrades. Unpublished data, April 2012.

There are more than 60 websites that review physicians online, with the number growing each year. A staggering number of physician searches—in excess of 3 million—are done each day in the United States. They have increased 68% from 2013 to 2014.¹ All online physician review sites provide some type of structured doctor experience rating score, and many allow comments from patients. Some sites also provide information about physician education, board certification, and hospital affiliation. The quality of physician review sites varies, just like the quality of those reviewed.

Physician review sites have not been embraced by the medical community and are often regarded by physicians with apathy, if not antipathy. There are many reasons for this reaction. The information on the sites—often gathered from flawed public and payer databases—can be very inaccurate; the number of patient reviews for each physician—orthopedic surgeons have an average of 12—is too limited to accurately represent a practice; and a single scathing review—frequently anonymous—can damage a physician’s reputation. First Amendment free speech laws allow patients to place their reviews anonymously, and the Health Insurance Portability and Accountability Act (HIPAA) prevents a physician from answering a negative review in anything but general terms. Under the federal Communications Decency Act, website providers aren’t liable for the postings of those who comment. Legitimate rave reviews may be deemed fake by certain websites and removed, and customer service is often a charade, with no one to speak to but a website computer. Most importantly, the review sites rarely represent the full breadth of a physician’s practice and reduce the physician to a simple star or numerical rating.

Like it or not, physician review sites are here to stay. In part as a result of the insurance changes created by the Affordable Care Act, patients are searching for new doctors online in unprecedented numbers. According to the Pew Research Internet Project, 72% of Internet users say they go online for health information.² A 2014 study in the Journal of the American Medical Association reported that 59% of respondents indicated that physician rating sites were “somewhat or very important” when choosing a physician; 35% reported selection of a physician based on good ratings; and 37% reported avoidance of a physician based on bad ones.³ This is important information for an orthopedic surgeon to consider. Orthopedic surgery is the most frequently searched physician specialty on the Internet, and it is not uncommon for a busy orthopedist to have more than 1000 searches per year on just 1 review site. Consumer research data indicates that as many as 50% of patients who visit a review site call that physician for an appointment within 1 week.⁴ When a physician’s name is entered into a search engine such as Google, physician review sites are often listed above the physician’s own website.

Last year the California Orthopaedic Association (COA), responding to its members’ concerns, reviewed online physician review sites. As part of this initiative, the COA approached Healthgrades, a leader in online medical reporting of physicians, hospitals, and other health care providers. The goal was to understand Healthgrades’ perspective and to see if they were open to orthopedic input. The COA was concerned that review sites often had incomplete and inaccurate information about physicians’ practices, lacked orthopedic subspecialty designation, and precluded physicians from posting comprehensive information about their practices in their own words. Personalized practice information provided by the physician, the COA reasoned, especially if displayed prominently, would complement the patients’ 1- to 5-star physician rating.  Both prospective patients and physicians would benefit.

Three months ago, as a direct result of these collaborative efforts, Healthgrades made major changes to its review site. They increased the number of searchable orthopedic subspecialties, so that a patient with a specific problem is more likely to find an orthopedic surgeon with the right expertise. Physicians or their practice managers can now more easily update information about their practice, either online or by phone. Most importantly, Healthgrades added a featured section—“Your Voice”—prominently positioned next to their star rating, where a physician can describe who he/she is and what he/she does. This addition is not to be underestimated. No other major review site provides this opportunity to the physician.

Healthgrades should be applauded for their collaboration with the COA and the highly successful improvement of their physician review site. They have raised the bar and set an example that other review sites will hopefully follow.

References

1.    Leslie J. Patient use of online reviews: IndustryView 2014. Software Advice. http://www.softwareadvice.com/medical/industryview/online-reviews-report-2014. Published November 19, 2014. Accessed December 8, 2014.

2.    Fox S, Duggan M. Health online 2013. Pew Research Center’s Internet & American Life Project. http://www.pewinternet.org/2013/01/15/health-online-2013. Published January 15, 2013. Accessed December 8, 2014.

3.    Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734-735.

4.    Stax, Inc. Assessing Objectives & Actions Taken Among Users of Healthgrades. Unpublished data, April 2012.

We all dismiss patients who are noncompliant with treatment. The threshold varies between us, but all of us have fired (for example) an epilepsy patient who won’t take the meds and is in and out of the emergency department.

What about smokers? Do they count?

A recent article in Anesthesiology News (2014 September) featured a surgical group that won’t do elective hernia repairs on patients who don’t quit smoking. I can see their point. Smoking increases the risk of complications, which hurt the patient. So, having a good patient outcome depends on their condition, too. And, honestly, I don’t blame the surgeons for refusing to do nonurgent cases under these circumstances.

What about neurologists, though?

Smoking is a big one. The literature has no shortage of data on it worsening migraines and multiple sclerosis, increasing the risk of stroke and peripheral vascular disease, contributing to vascular dementia ... and many other things.

I always tell smokers that they should quit, but should I be going beyond that? Refuse to treat migraines until someone quits smoking? The other conditions I mentioned have enough serious health risks that I don’t think it’s ethical to withhold care over smoking.

At my first job, I had a partner who took this approach. She routinely told migraineurs who smoked that they couldn’t return to her until they’d quit. Her view was that then she could treat them to her best ability without tobacco as a confounding factor, or they’d simply not come back.

I can understand this approach, and, in a perfect world, would do it myself. I certainly don’t support tobacco use and wish I had a magic bullet to help them quit. But I don’t. I can preach it, explain why they should quit, review the risks, send them to their internist for cessation ... but I’m still not sure I’d flat out turn them away.

I’m trying to help them. Refusing to provide care, even in the name of quitting smoking, is only going to alienate them. They may get turned off to seeing doctors altogether and consequently develop other issues. I don’t want them to smoke, but none of us is without our vices, either.

I’m also not them, and don’t know what’s going on in their lives. Maybe they are taking care of a parent with a terminal condition, going through a divorce, have a terrible job, or a million other stressors and just don’t have the will right now to quit tobacco.

Migraines, in the grand scheme of medicine, are certainly a lower-risk issue than surgical complications. So, while I disapprove of tobacco and encourage smokers to stop, my door remains open to them. Part of caring for my patients is accepting them as they are and trying to work with them inside that framework.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We all dismiss patients who are noncompliant with treatment. The threshold varies between us, but all of us have fired (for example) an epilepsy patient who won’t take the meds and is in and out of the emergency department.

What about smokers? Do they count?

A recent article in Anesthesiology News (2014 September) featured a surgical group that won’t do elective hernia repairs on patients who don’t quit smoking. I can see their point. Smoking increases the risk of complications, which hurt the patient. So, having a good patient outcome depends on their condition, too. And, honestly, I don’t blame the surgeons for refusing to do nonurgent cases under these circumstances.

What about neurologists, though?

Smoking is a big one. The literature has no shortage of data on it worsening migraines and multiple sclerosis, increasing the risk of stroke and peripheral vascular disease, contributing to vascular dementia ... and many other things.

I always tell smokers that they should quit, but should I be going beyond that? Refuse to treat migraines until someone quits smoking? The other conditions I mentioned have enough serious health risks that I don’t think it’s ethical to withhold care over smoking.

At my first job, I had a partner who took this approach. She routinely told migraineurs who smoked that they couldn’t return to her until they’d quit. Her view was that then she could treat them to her best ability without tobacco as a confounding factor, or they’d simply not come back.

I can understand this approach, and, in a perfect world, would do it myself. I certainly don’t support tobacco use and wish I had a magic bullet to help them quit. But I don’t. I can preach it, explain why they should quit, review the risks, send them to their internist for cessation ... but I’m still not sure I’d flat out turn them away.

I’m trying to help them. Refusing to provide care, even in the name of quitting smoking, is only going to alienate them. They may get turned off to seeing doctors altogether and consequently develop other issues. I don’t want them to smoke, but none of us is without our vices, either.

I’m also not them, and don’t know what’s going on in their lives. Maybe they are taking care of a parent with a terminal condition, going through a divorce, have a terrible job, or a million other stressors and just don’t have the will right now to quit tobacco.

Migraines, in the grand scheme of medicine, are certainly a lower-risk issue than surgical complications. So, while I disapprove of tobacco and encourage smokers to stop, my door remains open to them. Part of caring for my patients is accepting them as they are and trying to work with them inside that framework.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We all dismiss patients who are noncompliant with treatment. The threshold varies between us, but all of us have fired (for example) an epilepsy patient who won’t take the meds and is in and out of the emergency department.

What about smokers? Do they count?

A recent article in Anesthesiology News (2014 September) featured a surgical group that won’t do elective hernia repairs on patients who don’t quit smoking. I can see their point. Smoking increases the risk of complications, which hurt the patient. So, having a good patient outcome depends on their condition, too. And, honestly, I don’t blame the surgeons for refusing to do nonurgent cases under these circumstances.

What about neurologists, though?

Smoking is a big one. The literature has no shortage of data on it worsening migraines and multiple sclerosis, increasing the risk of stroke and peripheral vascular disease, contributing to vascular dementia ... and many other things.

I always tell smokers that they should quit, but should I be going beyond that? Refuse to treat migraines until someone quits smoking? The other conditions I mentioned have enough serious health risks that I don’t think it’s ethical to withhold care over smoking.

At my first job, I had a partner who took this approach. She routinely told migraineurs who smoked that they couldn’t return to her until they’d quit. Her view was that then she could treat them to her best ability without tobacco as a confounding factor, or they’d simply not come back.

I can understand this approach, and, in a perfect world, would do it myself. I certainly don’t support tobacco use and wish I had a magic bullet to help them quit. But I don’t. I can preach it, explain why they should quit, review the risks, send them to their internist for cessation ... but I’m still not sure I’d flat out turn them away.

I’m trying to help them. Refusing to provide care, even in the name of quitting smoking, is only going to alienate them. They may get turned off to seeing doctors altogether and consequently develop other issues. I don’t want them to smoke, but none of us is without our vices, either.

I’m also not them, and don’t know what’s going on in their lives. Maybe they are taking care of a parent with a terminal condition, going through a divorce, have a terrible job, or a million other stressors and just don’t have the will right now to quit tobacco.

Migraines, in the grand scheme of medicine, are certainly a lower-risk issue than surgical complications. So, while I disapprove of tobacco and encourage smokers to stop, my door remains open to them. Part of caring for my patients is accepting them as they are and trying to work with them inside that framework.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The rate of change in health care is accelerating. There are several trends that are now apparent, and they have the potential to significantly change the way we deliver and consume health care. Here are five highlights and predictions for what’s next:

Telemedicine ascendant. Telemedicine is the use of technology to deliver health care services remotely. The concept and much of the technology are decades old, so much so that passionate advocates for telemedicine have seemed more doting than daring. We’ve heard for years that telemedicine will revolutionize how we practice, yet adoption for both providers and patients has been paltry. This year is different. The convergence of high-fidelity, affordable technology, changed consumer expectations, and now viable telemedicine business plans have created an environment for telemedicine to thrive. As payers look to reduce the costs of hospitalization and get patients home sooner and safer, the use of telemedicine video and remote monitoring has grown rapidly. According to the American Telemedicine Association, more than half of all U.S. hospitals use some form of telemedicine. Now that Medicare and other payers have opened their wallets to start reimbursing for some telemedicine services, providers are looking to capitalize. Our patients have changed as well. Patients/consumers have shown they are interested in using phone calls, photo sharing, and video conferencing as channels to get their care, particularly for common and routine medical problems. Telemedicine is as hot as social media for Silicon Valley entrepreneurs and venture capitalists.

Prediction: The AAD Telemedicine Committee will someday eclipse all others in popularity.

Wearable technology. According to a PriceWaterhouseCoopers 2014 report, Americans believe in the promise of wearable wellness devices: Fifty-six percent believe that the average life expectancy will grow by 10 years because of wearable-enabled monitoring of vital signs! Today, just one in five American adults owns a wearable, but that market is expected to grow rapidly as technology improves and entry costs drop. For health care, the potential impact is huge, but the barriers are equally large. For wearables to reach their full clinical potential, they need to provide more than just data. They will have to deliver on engagement for patients and insight for physicians. Both are headed our way.

Prediction: Medicine moves from helping sick people become well to helping well people become uber-healthy.

Increasing adoption of electronic medical records (EMRs). Whether you love (if one could actually love an EMR) or curse your EMR, chances are you have one. Soon we all will. Centers for Medicare and Medicaid Services stipends and promises of penalties have broken the inertia. Two studies from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology showed that almost half (48%) of all physicians had an EMR system with advanced technologies in 2013 (double the adoption rate of 2009). Similarly, 59% of hospitals had EMRs with advanced technologies (quadrupling their 2010 rate). Although expensive, flawed, and accompanied by trade-offs in patient interaction and physician work experience, EMRs have brought benefit to health care. Soon they will be ubiquitous and later no longer an interesting topic of discussion.

Prediction: Open notes (wherein patients can read their entire medical chart) are next.

The consumerization of health care. From retail health insurance stores to health care kiosks in malls, health care is moving toward consumerization; that is, health care as an industry is shifting from business-to-business (B2B) to business-to-consumer (B2C). As consumers pay more out of pocket for their services, they are experiencing health care in a different way and expect a higher value for their costs (they are more “price sensitive” as they say in economics). This has profound implications, such as more patients “shopping” for health care. Just as consumers have come to expect high-quality, customized experiences in retail and digital spaces, so too do they expect high-quality, personalized health care experiences.

Prediction: Online doctor reviews will become more relevant over time.

Retail health care clinics. Walk-in retail health clinics have been around since 2000, yet only recently have they gained momentum. CVS, Walgreen’s, Target, and Walmart are all entering this space. A 2014 report by Accenture predicts that retail health clinics will double in number this year. Three trends are driving this rapid growth: 1) Increased numbers of newly insured patients (as a result of an improved economy and the Affordable Care Act) with too few primary care physicians to care for them; 2) The ability of efficient retailers such as Walmart to drive down the cost of care delivery and consequently prices for patients; 3) Clinics using price transparency, another trend that is attractive to consumers. As with telemedicine, consumers are coming to accept the idea of getting health care while at the grocery store or the mall.

Prediction: Telemedicine plus retail will lead to opportunities for specialists to add value to retail settings. Buy diapers and have a remote dermatologist consult for your child’s rash all in one, low-cost visit.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

The rate of change in health care is accelerating. There are several trends that are now apparent, and they have the potential to significantly change the way we deliver and consume health care. Here are five highlights and predictions for what’s next:

Telemedicine ascendant. Telemedicine is the use of technology to deliver health care services remotely. The concept and much of the technology are decades old, so much so that passionate advocates for telemedicine have seemed more doting than daring. We’ve heard for years that telemedicine will revolutionize how we practice, yet adoption for both providers and patients has been paltry. This year is different. The convergence of high-fidelity, affordable technology, changed consumer expectations, and now viable telemedicine business plans have created an environment for telemedicine to thrive. As payers look to reduce the costs of hospitalization and get patients home sooner and safer, the use of telemedicine video and remote monitoring has grown rapidly. According to the American Telemedicine Association, more than half of all U.S. hospitals use some form of telemedicine. Now that Medicare and other payers have opened their wallets to start reimbursing for some telemedicine services, providers are looking to capitalize. Our patients have changed as well. Patients/consumers have shown they are interested in using phone calls, photo sharing, and video conferencing as channels to get their care, particularly for common and routine medical problems. Telemedicine is as hot as social media for Silicon Valley entrepreneurs and venture capitalists.

Prediction: The AAD Telemedicine Committee will someday eclipse all others in popularity.

Wearable technology. According to a PriceWaterhouseCoopers 2014 report, Americans believe in the promise of wearable wellness devices: Fifty-six percent believe that the average life expectancy will grow by 10 years because of wearable-enabled monitoring of vital signs! Today, just one in five American adults owns a wearable, but that market is expected to grow rapidly as technology improves and entry costs drop. For health care, the potential impact is huge, but the barriers are equally large. For wearables to reach their full clinical potential, they need to provide more than just data. They will have to deliver on engagement for patients and insight for physicians. Both are headed our way.

Prediction: Medicine moves from helping sick people become well to helping well people become uber-healthy.

Increasing adoption of electronic medical records (EMRs). Whether you love (if one could actually love an EMR) or curse your EMR, chances are you have one. Soon we all will. Centers for Medicare and Medicaid Services stipends and promises of penalties have broken the inertia. Two studies from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology showed that almost half (48%) of all physicians had an EMR system with advanced technologies in 2013 (double the adoption rate of 2009). Similarly, 59% of hospitals had EMRs with advanced technologies (quadrupling their 2010 rate). Although expensive, flawed, and accompanied by trade-offs in patient interaction and physician work experience, EMRs have brought benefit to health care. Soon they will be ubiquitous and later no longer an interesting topic of discussion.

Prediction: Open notes (wherein patients can read their entire medical chart) are next.

The consumerization of health care. From retail health insurance stores to health care kiosks in malls, health care is moving toward consumerization; that is, health care as an industry is shifting from business-to-business (B2B) to business-to-consumer (B2C). As consumers pay more out of pocket for their services, they are experiencing health care in a different way and expect a higher value for their costs (they are more “price sensitive” as they say in economics). This has profound implications, such as more patients “shopping” for health care. Just as consumers have come to expect high-quality, customized experiences in retail and digital spaces, so too do they expect high-quality, personalized health care experiences.

Prediction: Online doctor reviews will become more relevant over time.

Retail health care clinics. Walk-in retail health clinics have been around since 2000, yet only recently have they gained momentum. CVS, Walgreen’s, Target, and Walmart are all entering this space. A 2014 report by Accenture predicts that retail health clinics will double in number this year. Three trends are driving this rapid growth: 1) Increased numbers of newly insured patients (as a result of an improved economy and the Affordable Care Act) with too few primary care physicians to care for them; 2) The ability of efficient retailers such as Walmart to drive down the cost of care delivery and consequently prices for patients; 3) Clinics using price transparency, another trend that is attractive to consumers. As with telemedicine, consumers are coming to accept the idea of getting health care while at the grocery store or the mall.

Prediction: Telemedicine plus retail will lead to opportunities for specialists to add value to retail settings. Buy diapers and have a remote dermatologist consult for your child’s rash all in one, low-cost visit.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

The rate of change in health care is accelerating. There are several trends that are now apparent, and they have the potential to significantly change the way we deliver and consume health care. Here are five highlights and predictions for what’s next:

Telemedicine ascendant. Telemedicine is the use of technology to deliver health care services remotely. The concept and much of the technology are decades old, so much so that passionate advocates for telemedicine have seemed more doting than daring. We’ve heard for years that telemedicine will revolutionize how we practice, yet adoption for both providers and patients has been paltry. This year is different. The convergence of high-fidelity, affordable technology, changed consumer expectations, and now viable telemedicine business plans have created an environment for telemedicine to thrive. As payers look to reduce the costs of hospitalization and get patients home sooner and safer, the use of telemedicine video and remote monitoring has grown rapidly. According to the American Telemedicine Association, more than half of all U.S. hospitals use some form of telemedicine. Now that Medicare and other payers have opened their wallets to start reimbursing for some telemedicine services, providers are looking to capitalize. Our patients have changed as well. Patients/consumers have shown they are interested in using phone calls, photo sharing, and video conferencing as channels to get their care, particularly for common and routine medical problems. Telemedicine is as hot as social media for Silicon Valley entrepreneurs and venture capitalists.

Prediction: The AAD Telemedicine Committee will someday eclipse all others in popularity.

Wearable technology. According to a PriceWaterhouseCoopers 2014 report, Americans believe in the promise of wearable wellness devices: Fifty-six percent believe that the average life expectancy will grow by 10 years because of wearable-enabled monitoring of vital signs! Today, just one in five American adults owns a wearable, but that market is expected to grow rapidly as technology improves and entry costs drop. For health care, the potential impact is huge, but the barriers are equally large. For wearables to reach their full clinical potential, they need to provide more than just data. They will have to deliver on engagement for patients and insight for physicians. Both are headed our way.

Prediction: Medicine moves from helping sick people become well to helping well people become uber-healthy.

Increasing adoption of electronic medical records (EMRs). Whether you love (if one could actually love an EMR) or curse your EMR, chances are you have one. Soon we all will. Centers for Medicare and Medicaid Services stipends and promises of penalties have broken the inertia. Two studies from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology showed that almost half (48%) of all physicians had an EMR system with advanced technologies in 2013 (double the adoption rate of 2009). Similarly, 59% of hospitals had EMRs with advanced technologies (quadrupling their 2010 rate). Although expensive, flawed, and accompanied by trade-offs in patient interaction and physician work experience, EMRs have brought benefit to health care. Soon they will be ubiquitous and later no longer an interesting topic of discussion.

Prediction: Open notes (wherein patients can read their entire medical chart) are next.

The consumerization of health care. From retail health insurance stores to health care kiosks in malls, health care is moving toward consumerization; that is, health care as an industry is shifting from business-to-business (B2B) to business-to-consumer (B2C). As consumers pay more out of pocket for their services, they are experiencing health care in a different way and expect a higher value for their costs (they are more “price sensitive” as they say in economics). This has profound implications, such as more patients “shopping” for health care. Just as consumers have come to expect high-quality, customized experiences in retail and digital spaces, so too do they expect high-quality, personalized health care experiences.

Prediction: Online doctor reviews will become more relevant over time.

Retail health care clinics. Walk-in retail health clinics have been around since 2000, yet only recently have they gained momentum. CVS, Walgreen’s, Target, and Walmart are all entering this space. A 2014 report by Accenture predicts that retail health clinics will double in number this year. Three trends are driving this rapid growth: 1) Increased numbers of newly insured patients (as a result of an improved economy and the Affordable Care Act) with too few primary care physicians to care for them; 2) The ability of efficient retailers such as Walmart to drive down the cost of care delivery and consequently prices for patients; 3) Clinics using price transparency, another trend that is attractive to consumers. As with telemedicine, consumers are coming to accept the idea of getting health care while at the grocery store or the mall.

Prediction: Telemedicine plus retail will lead to opportunities for specialists to add value to retail settings. Buy diapers and have a remote dermatologist consult for your child’s rash all in one, low-cost visit.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Christine is a 29-year-old white female with a history of alcohol use disorder, generalized anxiety disorder, and depressive disorder NOS. Christine was admitted to the hospital for detoxification following 5 days of binge drinking alone in her apartment after a breakup with her fiancé. On the third day of her detoxification, the patient felt sad, hopeless, guilty, and worthless because of her life circumstances. She denied any suicidal ideation but wasn’t sure her life could improve. She has a history of two previous detoxes and one 30-day rehab stay, but quickly relapsed within 3 weeks of discharge. Christine is ambivalent about going back to a rehab at this time.

Patients completing detoxification programs are at a crossroads and face difficult decisions about next steps in treatment. Patients can a feel myriad of emotions such as fear, sadness, relief, worry, guilt, shame, anxiety, and anger. It is critical to provide support, build trust, and optimize communication with patients in order to help them gather the strength to maintain movement in the direction of recovery.

Recovery is a process that can take on different meanings to different people, and there is no agreed-upon definition among scientists and clinicians.

Although recovery might require total abstinence from substances, many argue that this is not necessary. More broadly, recovery from a substance use disorder (SUD) can be thought of as developing mindfulness, awareness, and adaptive skills. The individual in recovery must learn to act in more reflective and less reactive ways. Recovery involves acceptance of one’s particular set of strengths and vulnerabilities while moving toward mental, emotional, physical, and spiritual balance.

Discussion with patients offers a way of being with them that can help promote positive behavioral change. During that discussion, we should:

1. Provide psychoeducation about the nature of a substance use disorder as a medical condition. The clinician should explain to the patient that a substance use disorder is not a moral defect but rather a medical condition that needs to be treated like every other chronic medical condition. A person who is suffering from diabetes who needs to be admitted to the hospital is no different from a person suffering from an SUD who has a setback and requires detox. Patients should be provided information regarding the high prevalence of co-occurring mental health conditions present in the context of an SUD such as anxiety, depression, attention-deficit/hyperactivity disorder, or trauma. When these other conditions are treated, overall treatment outcomes are improved.

2. Embrace a nonjudgmental and empathic stance. Empathy is a key component to delivering the highest level of care to patients. It is our job to have the willingness to listen and to understand patients in the fullest way possible, which on a concrete level means using active listening skills as a deliberate and meaningful part of the clinical experience. Providing information, for instance, has a much greater chance of enhancing someone’s motivation when it is specifically tied to the personal attributes and statements of the patient in front of you. Suspending judgment can serve to build the therapeutic bond and allow the clinician to connect with the part of the patient that seeks change.

3. Avoid stigmatizing language. It is key to pay attention to the words we use in our clinical practice in order to have the most effective conversations about behavioral change. Words such as enabling, denial, addict, alcoholic, and codependency should be removed from our lexicon, as they often carry negative meanings, can promote discord between clinician and patient, and can be more confusing than clarifying. If the patient uses these words, then it can be helpful to ask the patient to clarify and explore the meaning of the word to him or her so the underpinnings and individualized meaning for this patient can be understood and explored.

4. Explore ambivalence. Show patients that we understand their perspective and acknowledge the difficulty and various emotions elicited with the dilemma of change. Ambivalence is normal, and one of the key dilemmas we all face when considering health behavior change. The value of acknowledging the function of the substance use for the patient can both help the patient feel heard and understood but also identify an important area in need of change so that the particular function can be replaced with healthier behaviors.

5. Lend hope and optimism to patients. Patients completing detox may feel that there is no hope in getting to a better place. Clinicians should emphasize the importance of patients not judging themselves too harshly. Instead, patients should focus on self-care and minimizing negative self-talk that fuels negative feelings and emotions. Reassure patients by explaining that dysphoria and anxiety can be attributed to protracted withdrawal lasting weeks to months, and that their feelings are normal given the current situation. It also can be affirming and fuel optimism to acknowledge the important and courageous first step taken by engaging in the detoxification process itself, with as much specificity to their current situation as possible.

6. Find the strengths in our patients, and use affirmations judiciously.
Affirmations should only be offered when sincere, genuine, and specific. Eliciting strengths from patients may serve to build the therapeutic bond and help patients have a more accurate self-image. Affirmations must be individualized, and can be verbal or nonverbal. While some appreciate enthusiasm, others may appreciate more subtle acknowledgments.

Dr. Ascher serves as a clinical associate in psychiatry at the University of Pennsylvania, Philadelphia. He is coeditor of “The Behavioral Addictions” (Washington: American Psychiatric Publishing, 2015). Dr. Kosanke is the director of family services at the Center for Motivation and Change in New York City and a coauthor of “Beyond Addiction: How Science and Kindness Help People Change” (New York: Scribner, 2014).

Christine is a 29-year-old white female with a history of alcohol use disorder, generalized anxiety disorder, and depressive disorder NOS. Christine was admitted to the hospital for detoxification following 5 days of binge drinking alone in her apartment after a breakup with her fiancé. On the third day of her detoxification, the patient felt sad, hopeless, guilty, and worthless because of her life circumstances. She denied any suicidal ideation but wasn’t sure her life could improve. She has a history of two previous detoxes and one 30-day rehab stay, but quickly relapsed within 3 weeks of discharge. Christine is ambivalent about going back to a rehab at this time.

Patients completing detoxification programs are at a crossroads and face difficult decisions about next steps in treatment. Patients can a feel myriad of emotions such as fear, sadness, relief, worry, guilt, shame, anxiety, and anger. It is critical to provide support, build trust, and optimize communication with patients in order to help them gather the strength to maintain movement in the direction of recovery.

Recovery is a process that can take on different meanings to different people, and there is no agreed-upon definition among scientists and clinicians.

Although recovery might require total abstinence from substances, many argue that this is not necessary. More broadly, recovery from a substance use disorder (SUD) can be thought of as developing mindfulness, awareness, and adaptive skills. The individual in recovery must learn to act in more reflective and less reactive ways. Recovery involves acceptance of one’s particular set of strengths and vulnerabilities while moving toward mental, emotional, physical, and spiritual balance.

Discussion with patients offers a way of being with them that can help promote positive behavioral change. During that discussion, we should:

1. Provide psychoeducation about the nature of a substance use disorder as a medical condition. The clinician should explain to the patient that a substance use disorder is not a moral defect but rather a medical condition that needs to be treated like every other chronic medical condition. A person who is suffering from diabetes who needs to be admitted to the hospital is no different from a person suffering from an SUD who has a setback and requires detox. Patients should be provided information regarding the high prevalence of co-occurring mental health conditions present in the context of an SUD such as anxiety, depression, attention-deficit/hyperactivity disorder, or trauma. When these other conditions are treated, overall treatment outcomes are improved.

2. Embrace a nonjudgmental and empathic stance. Empathy is a key component to delivering the highest level of care to patients. It is our job to have the willingness to listen and to understand patients in the fullest way possible, which on a concrete level means using active listening skills as a deliberate and meaningful part of the clinical experience. Providing information, for instance, has a much greater chance of enhancing someone’s motivation when it is specifically tied to the personal attributes and statements of the patient in front of you. Suspending judgment can serve to build the therapeutic bond and allow the clinician to connect with the part of the patient that seeks change.

3. Avoid stigmatizing language. It is key to pay attention to the words we use in our clinical practice in order to have the most effective conversations about behavioral change. Words such as enabling, denial, addict, alcoholic, and codependency should be removed from our lexicon, as they often carry negative meanings, can promote discord between clinician and patient, and can be more confusing than clarifying. If the patient uses these words, then it can be helpful to ask the patient to clarify and explore the meaning of the word to him or her so the underpinnings and individualized meaning for this patient can be understood and explored.

4. Explore ambivalence. Show patients that we understand their perspective and acknowledge the difficulty and various emotions elicited with the dilemma of change. Ambivalence is normal, and one of the key dilemmas we all face when considering health behavior change. The value of acknowledging the function of the substance use for the patient can both help the patient feel heard and understood but also identify an important area in need of change so that the particular function can be replaced with healthier behaviors.

5. Lend hope and optimism to patients. Patients completing detox may feel that there is no hope in getting to a better place. Clinicians should emphasize the importance of patients not judging themselves too harshly. Instead, patients should focus on self-care and minimizing negative self-talk that fuels negative feelings and emotions. Reassure patients by explaining that dysphoria and anxiety can be attributed to protracted withdrawal lasting weeks to months, and that their feelings are normal given the current situation. It also can be affirming and fuel optimism to acknowledge the important and courageous first step taken by engaging in the detoxification process itself, with as much specificity to their current situation as possible.

6. Find the strengths in our patients, and use affirmations judiciously.
Affirmations should only be offered when sincere, genuine, and specific. Eliciting strengths from patients may serve to build the therapeutic bond and help patients have a more accurate self-image. Affirmations must be individualized, and can be verbal or nonverbal. While some appreciate enthusiasm, others may appreciate more subtle acknowledgments.

Dr. Ascher serves as a clinical associate in psychiatry at the University of Pennsylvania, Philadelphia. He is coeditor of “The Behavioral Addictions” (Washington: American Psychiatric Publishing, 2015). Dr. Kosanke is the director of family services at the Center for Motivation and Change in New York City and a coauthor of “Beyond Addiction: How Science and Kindness Help People Change” (New York: Scribner, 2014).

Christine is a 29-year-old white female with a history of alcohol use disorder, generalized anxiety disorder, and depressive disorder NOS. Christine was admitted to the hospital for detoxification following 5 days of binge drinking alone in her apartment after a breakup with her fiancé. On the third day of her detoxification, the patient felt sad, hopeless, guilty, and worthless because of her life circumstances. She denied any suicidal ideation but wasn’t sure her life could improve. She has a history of two previous detoxes and one 30-day rehab stay, but quickly relapsed within 3 weeks of discharge. Christine is ambivalent about going back to a rehab at this time.

Patients completing detoxification programs are at a crossroads and face difficult decisions about next steps in treatment. Patients can a feel myriad of emotions such as fear, sadness, relief, worry, guilt, shame, anxiety, and anger. It is critical to provide support, build trust, and optimize communication with patients in order to help them gather the strength to maintain movement in the direction of recovery.

Recovery is a process that can take on different meanings to different people, and there is no agreed-upon definition among scientists and clinicians.

Although recovery might require total abstinence from substances, many argue that this is not necessary. More broadly, recovery from a substance use disorder (SUD) can be thought of as developing mindfulness, awareness, and adaptive skills. The individual in recovery must learn to act in more reflective and less reactive ways. Recovery involves acceptance of one’s particular set of strengths and vulnerabilities while moving toward mental, emotional, physical, and spiritual balance.

Discussion with patients offers a way of being with them that can help promote positive behavioral change. During that discussion, we should:

1. Provide psychoeducation about the nature of a substance use disorder as a medical condition. The clinician should explain to the patient that a substance use disorder is not a moral defect but rather a medical condition that needs to be treated like every other chronic medical condition. A person who is suffering from diabetes who needs to be admitted to the hospital is no different from a person suffering from an SUD who has a setback and requires detox. Patients should be provided information regarding the high prevalence of co-occurring mental health conditions present in the context of an SUD such as anxiety, depression, attention-deficit/hyperactivity disorder, or trauma. When these other conditions are treated, overall treatment outcomes are improved.

2. Embrace a nonjudgmental and empathic stance. Empathy is a key component to delivering the highest level of care to patients. It is our job to have the willingness to listen and to understand patients in the fullest way possible, which on a concrete level means using active listening skills as a deliberate and meaningful part of the clinical experience. Providing information, for instance, has a much greater chance of enhancing someone’s motivation when it is specifically tied to the personal attributes and statements of the patient in front of you. Suspending judgment can serve to build the therapeutic bond and allow the clinician to connect with the part of the patient that seeks change.

3. Avoid stigmatizing language. It is key to pay attention to the words we use in our clinical practice in order to have the most effective conversations about behavioral change. Words such as enabling, denial, addict, alcoholic, and codependency should be removed from our lexicon, as they often carry negative meanings, can promote discord between clinician and patient, and can be more confusing than clarifying. If the patient uses these words, then it can be helpful to ask the patient to clarify and explore the meaning of the word to him or her so the underpinnings and individualized meaning for this patient can be understood and explored.

4. Explore ambivalence. Show patients that we understand their perspective and acknowledge the difficulty and various emotions elicited with the dilemma of change. Ambivalence is normal, and one of the key dilemmas we all face when considering health behavior change. The value of acknowledging the function of the substance use for the patient can both help the patient feel heard and understood but also identify an important area in need of change so that the particular function can be replaced with healthier behaviors.

5. Lend hope and optimism to patients. Patients completing detox may feel that there is no hope in getting to a better place. Clinicians should emphasize the importance of patients not judging themselves too harshly. Instead, patients should focus on self-care and minimizing negative self-talk that fuels negative feelings and emotions. Reassure patients by explaining that dysphoria and anxiety can be attributed to protracted withdrawal lasting weeks to months, and that their feelings are normal given the current situation. It also can be affirming and fuel optimism to acknowledge the important and courageous first step taken by engaging in the detoxification process itself, with as much specificity to their current situation as possible.

6. Find the strengths in our patients, and use affirmations judiciously.
Affirmations should only be offered when sincere, genuine, and specific. Eliciting strengths from patients may serve to build the therapeutic bond and help patients have a more accurate self-image. Affirmations must be individualized, and can be verbal or nonverbal. While some appreciate enthusiasm, others may appreciate more subtle acknowledgments.

Dr. Ascher serves as a clinical associate in psychiatry at the University of Pennsylvania, Philadelphia. He is coeditor of “The Behavioral Addictions” (Washington: American Psychiatric Publishing, 2015). Dr. Kosanke is the director of family services at the Center for Motivation and Change in New York City and a coauthor of “Beyond Addiction: How Science and Kindness Help People Change” (New York: Scribner, 2014).