Commentary

At some point in medical school, you might have come across the psychological theory of depressive realism, developed by Lauren Alloy, Ph.D., and Lyn Yvonne Abramson, Ph.D. The theory challenges traditional views of depression and suggests that an individual can become so entrenched in the reality of his status that it becomes overwhelmingly sad-depressive. This theory overturns the traditional view that nondepressed individuals are normal.

What happens when a large mass of individuals stops the delusion of their safe reality and dares to face, head on, their actual reality? Denying themselves rose-colored glasses? The answer is the birth of an entire community of people who dare to change the structure that ensures their depression is real. The product of this new birth are warriors, brave, intellectual, fearless activists who stand with mirrors to our societal made-up face with one hand, while snatching away the rose-tinted glasses with the other. Activists have made some uncomfortable because of the seed planted in the belly of their consciousness: an undeniable urge to do something. It makes us uncomfortable because we know that a national tragedy of this magnitude makes the need for psychiatric and psychological services undeniable and begs us each to answer the question: “What am I doing?”

As the current president for the St. Louis Association of Black Psychologists (STL ABPsi), I have seen face-to-face the devastation of what happens to a region plagued by depression, trauma, and generalized anxiety for 100 days with little to no focus on mental health. Regardless of your opinion of what occurred Aug. 9 between Michael “Mike Mike” Brown and Officer Darren Wilson of Ferguson, Mo., what we each should have an opinion of is the need to address the mental health of a community that has been forever changed following the interaction of those two individuals.

As of this writing, St. Louis County prosecuting attorney Robert McCullough has announced that the grand jury tasked with looking at all of the evidence in the case has decided not to indict Officer Wilson, and we are awaiting the results of the U.S. Justice Department investigation. The community is responding to the no indictment announcement in ways described by the St. Louis Post-Dispatch as "much worse than August."

As mental health providers, we must not wait for what happens next. We must be concerned right now that children are having nightmares; some parents are so hypervigilant that any dropped objects are striking a startle response; and many of our young boys and girls are walking in fear of seeing militarized police officers jump out of bushes.

When STL ABPsi entered the Canfield Apartment Complex, now referred to (by residents) as “ground zero,” we were unsure of what to expect. We simply understood that a community was grieving, and entire families were devastated by witnessing one of their community members lying in the street, face down, in his own blood, littered with bullets for more than 4 hours. Detailed visions of what they saw were at the start of every conversation for weeks and months to come.

As we provided crisis intervention services, we listened to parents with concern about their potty-trained children wetting the bed. Fathers disclosed feeling a sense of numbness. Mothers discussed their frustration with poor concentration, their own nightmares, and numbness. This might sound like a description of a war zone in a third-world country, but I am sad to report these are the symptoms suffered by American citizens not only in Ferguson but in other parts of the St. Louis metropolitan area.

It is my hope that behavioral health providers across the country also will be moved to do something to address the pain that plagues our region. Psychiatrists nationwide can choose to stand on the right side of history by supporting a local organization, volunteering medical services, or making a donation to organizations focused on supporting the mental health needs of St. Louis. It is my hope that the profession I have chosen to make my career is not left out of the recorded history of this historic moment. While many will agree, the time for justice is always right now. I urge my psychiatric community to boldly stand in our truth, that the movement for healing our children and families is certainly right now. What will you do?

Dr. Robinson is a licensed clinical psychologist in private practice in St. Louis.

At some point in medical school, you might have come across the psychological theory of depressive realism, developed by Lauren Alloy, Ph.D., and Lyn Yvonne Abramson, Ph.D. The theory challenges traditional views of depression and suggests that an individual can become so entrenched in the reality of his status that it becomes overwhelmingly sad-depressive. This theory overturns the traditional view that nondepressed individuals are normal.

What happens when a large mass of individuals stops the delusion of their safe reality and dares to face, head on, their actual reality? Denying themselves rose-colored glasses? The answer is the birth of an entire community of people who dare to change the structure that ensures their depression is real. The product of this new birth are warriors, brave, intellectual, fearless activists who stand with mirrors to our societal made-up face with one hand, while snatching away the rose-tinted glasses with the other. Activists have made some uncomfortable because of the seed planted in the belly of their consciousness: an undeniable urge to do something. It makes us uncomfortable because we know that a national tragedy of this magnitude makes the need for psychiatric and psychological services undeniable and begs us each to answer the question: “What am I doing?”

As the current president for the St. Louis Association of Black Psychologists (STL ABPsi), I have seen face-to-face the devastation of what happens to a region plagued by depression, trauma, and generalized anxiety for 100 days with little to no focus on mental health. Regardless of your opinion of what occurred Aug. 9 between Michael “Mike Mike” Brown and Officer Darren Wilson of Ferguson, Mo., what we each should have an opinion of is the need to address the mental health of a community that has been forever changed following the interaction of those two individuals.

As of this writing, St. Louis County prosecuting attorney Robert McCullough has announced that the grand jury tasked with looking at all of the evidence in the case has decided not to indict Officer Wilson, and we are awaiting the results of the U.S. Justice Department investigation. The community is responding to the no indictment announcement in ways described by the St. Louis Post-Dispatch as "much worse than August."

As mental health providers, we must not wait for what happens next. We must be concerned right now that children are having nightmares; some parents are so hypervigilant that any dropped objects are striking a startle response; and many of our young boys and girls are walking in fear of seeing militarized police officers jump out of bushes.

When STL ABPsi entered the Canfield Apartment Complex, now referred to (by residents) as “ground zero,” we were unsure of what to expect. We simply understood that a community was grieving, and entire families were devastated by witnessing one of their community members lying in the street, face down, in his own blood, littered with bullets for more than 4 hours. Detailed visions of what they saw were at the start of every conversation for weeks and months to come.

As we provided crisis intervention services, we listened to parents with concern about their potty-trained children wetting the bed. Fathers disclosed feeling a sense of numbness. Mothers discussed their frustration with poor concentration, their own nightmares, and numbness. This might sound like a description of a war zone in a third-world country, but I am sad to report these are the symptoms suffered by American citizens not only in Ferguson but in other parts of the St. Louis metropolitan area.

It is my hope that behavioral health providers across the country also will be moved to do something to address the pain that plagues our region. Psychiatrists nationwide can choose to stand on the right side of history by supporting a local organization, volunteering medical services, or making a donation to organizations focused on supporting the mental health needs of St. Louis. It is my hope that the profession I have chosen to make my career is not left out of the recorded history of this historic moment. While many will agree, the time for justice is always right now. I urge my psychiatric community to boldly stand in our truth, that the movement for healing our children and families is certainly right now. What will you do?

Dr. Robinson is a licensed clinical psychologist in private practice in St. Louis.

At some point in medical school, you might have come across the psychological theory of depressive realism, developed by Lauren Alloy, Ph.D., and Lyn Yvonne Abramson, Ph.D. The theory challenges traditional views of depression and suggests that an individual can become so entrenched in the reality of his status that it becomes overwhelmingly sad-depressive. This theory overturns the traditional view that nondepressed individuals are normal.

What happens when a large mass of individuals stops the delusion of their safe reality and dares to face, head on, their actual reality? Denying themselves rose-colored glasses? The answer is the birth of an entire community of people who dare to change the structure that ensures their depression is real. The product of this new birth are warriors, brave, intellectual, fearless activists who stand with mirrors to our societal made-up face with one hand, while snatching away the rose-tinted glasses with the other. Activists have made some uncomfortable because of the seed planted in the belly of their consciousness: an undeniable urge to do something. It makes us uncomfortable because we know that a national tragedy of this magnitude makes the need for psychiatric and psychological services undeniable and begs us each to answer the question: “What am I doing?”

As the current president for the St. Louis Association of Black Psychologists (STL ABPsi), I have seen face-to-face the devastation of what happens to a region plagued by depression, trauma, and generalized anxiety for 100 days with little to no focus on mental health. Regardless of your opinion of what occurred Aug. 9 between Michael “Mike Mike” Brown and Officer Darren Wilson of Ferguson, Mo., what we each should have an opinion of is the need to address the mental health of a community that has been forever changed following the interaction of those two individuals.

As of this writing, St. Louis County prosecuting attorney Robert McCullough has announced that the grand jury tasked with looking at all of the evidence in the case has decided not to indict Officer Wilson, and we are awaiting the results of the U.S. Justice Department investigation. The community is responding to the no indictment announcement in ways described by the St. Louis Post-Dispatch as "much worse than August."

As mental health providers, we must not wait for what happens next. We must be concerned right now that children are having nightmares; some parents are so hypervigilant that any dropped objects are striking a startle response; and many of our young boys and girls are walking in fear of seeing militarized police officers jump out of bushes.

When STL ABPsi entered the Canfield Apartment Complex, now referred to (by residents) as “ground zero,” we were unsure of what to expect. We simply understood that a community was grieving, and entire families were devastated by witnessing one of their community members lying in the street, face down, in his own blood, littered with bullets for more than 4 hours. Detailed visions of what they saw were at the start of every conversation for weeks and months to come.

As we provided crisis intervention services, we listened to parents with concern about their potty-trained children wetting the bed. Fathers disclosed feeling a sense of numbness. Mothers discussed their frustration with poor concentration, their own nightmares, and numbness. This might sound like a description of a war zone in a third-world country, but I am sad to report these are the symptoms suffered by American citizens not only in Ferguson but in other parts of the St. Louis metropolitan area.

It is my hope that behavioral health providers across the country also will be moved to do something to address the pain that plagues our region. Psychiatrists nationwide can choose to stand on the right side of history by supporting a local organization, volunteering medical services, or making a donation to organizations focused on supporting the mental health needs of St. Louis. It is my hope that the profession I have chosen to make my career is not left out of the recorded history of this historic moment. While many will agree, the time for justice is always right now. I urge my psychiatric community to boldly stand in our truth, that the movement for healing our children and families is certainly right now. What will you do?

Dr. Robinson is a licensed clinical psychologist in private practice in St. Louis.

My computer flashes a message that Lisa checked in, so I go to the waiting area of the college counseling center where I work. At first I do not see her, but then I notice a short, thin woman sitting in the corner, her head bowed with long, wavy blond hair covering her face.

Lisa came in for an appointment at the beginning of the semester and then missed the next appointment. After a few e-mails and phone calls on my part, I get her in for a follow-up visit. I do not always pursue a patient, but I am worried about Lisa. She was hospitalized a few months earlier after becoming paranoid and hitting her mother.

We walk into my office, and she sits and looks at me, pushing her hair from her face so I can see her blue eyes. She starts by telling me: “I ran out of medication, but I know I need to restart it.” I ask her to tell me how she knows.

“Since I stopped taking medication, my friends are getting annoyed with me for talking too much and keeping them awake when I call late at night. My professor spoke with me after class and told me I was being disruptive with all my questions. I think I am too revved up, and it is getting hard to concentrate on my school work.”

I feel a deep sense of relief that Lisa has insight into how her behavior affects others and that medication can help her. This is a major step for her, and I am hopeful that she will continue treatment that helps her achieve her goals. I praise Lisa for listening to feedback from others.

Lisa’s insight has been limited in the past. Her first hospitalization was 1 year ago, her second 2 months ago, both for psychotic episodes following escalating marijuana use. She had been a regular cannabis smoker since coming to college. Did the marijuana cause psychosis, or did she increase use to self-medicate psychosis? This will be debated until the end of time, but I don’t believe marijuana benefits her. She has been in college for 7 years.

I started to see Lisa after her first hospitalization. I was relieved that she subsequently stopped using marijuana and took an antipsychotic. Her mind cleared, and she successfully completed the semester. After 4 months of treatment, she told me she was going to taper her medication and would not need to see me anymore. I was sad, but not surprised, when she returned to my care after the second hospitalization.

Lisa still doubts she has bipolar disorder, a diagnosis she was given in the hospital. Whatever her diagnosis is, I ask her to consider using antipsychotic medication as a tool, along with therapy, friendship, exercise, and healthy eating, to accomplish her goal, graduating from college, which she will do at the end of the semester.

With Lisa, I see more trust with each visit. I also see a rocky road ahead for her, as she still uses marijuana, although not on a daily basis. I have tried to convince her of the benefits of abstinence, without success. I believe the antipsychotic is helping her, so I prescribe it. I schedule a follow-up appointment.

Sitting with patients like Lisa, believing you are slowly making steps toward wellness, is deeply rewarding. My job in a college counseling center allows me to spend 30-45 minutes in follow-up with my patients and meet as often as I need to. Lisa would be lucky in the public health sector to see someone every 3 months for 15 minutes.

I truly feel we as college mental health psychiatrists are often in the role of in loco parentis, and we make a difference. The doctor-patient relationship is the key element in our treatment, enabling patients to trust our recommendations, whether it is for medication, therapy, or exercise. Sometimes, with patients like Lisa, the trust has to be built up over time.

The importance of the doctor-patient relationship has not changed in the last 21 years since I completed my training. Sometimes, it is a battle to maintain this relationship, as I spend an increasing amount of time bent over my computer typing and tapping information into the electronic medical record. My notes have gone from short stories to novellas, as I fill in information to meet insurance, risk management, and psychiatry board requirements. I fear I will soon have a closer relationship with my computer than with my patients. Sometimes I feel like the astronaut in “2001: A Space Odyssey,” and Hal the computer has taken over my life.

Patients like Lisa literally bring me down to earth and help me remember why I became a psychiatrist. As I puzzle over how to strengthen the doctor-patient bond, I try to plant the seeds that will allow Lisa to forego marijuana and other drugs for good. I encourage her to connect with others in her shoes by going to a support group, acknowledging my own deficits in knowing her experience but my desire to understand it as best I can. The connections I form with patients, especially the more challenging ones like Lisa, cannot be measured, and don’t have a reimbursement code, but they are priceless.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

My computer flashes a message that Lisa checked in, so I go to the waiting area of the college counseling center where I work. At first I do not see her, but then I notice a short, thin woman sitting in the corner, her head bowed with long, wavy blond hair covering her face.

Lisa came in for an appointment at the beginning of the semester and then missed the next appointment. After a few e-mails and phone calls on my part, I get her in for a follow-up visit. I do not always pursue a patient, but I am worried about Lisa. She was hospitalized a few months earlier after becoming paranoid and hitting her mother.

We walk into my office, and she sits and looks at me, pushing her hair from her face so I can see her blue eyes. She starts by telling me: “I ran out of medication, but I know I need to restart it.” I ask her to tell me how she knows.

“Since I stopped taking medication, my friends are getting annoyed with me for talking too much and keeping them awake when I call late at night. My professor spoke with me after class and told me I was being disruptive with all my questions. I think I am too revved up, and it is getting hard to concentrate on my school work.”

I feel a deep sense of relief that Lisa has insight into how her behavior affects others and that medication can help her. This is a major step for her, and I am hopeful that she will continue treatment that helps her achieve her goals. I praise Lisa for listening to feedback from others.

Lisa’s insight has been limited in the past. Her first hospitalization was 1 year ago, her second 2 months ago, both for psychotic episodes following escalating marijuana use. She had been a regular cannabis smoker since coming to college. Did the marijuana cause psychosis, or did she increase use to self-medicate psychosis? This will be debated until the end of time, but I don’t believe marijuana benefits her. She has been in college for 7 years.

I started to see Lisa after her first hospitalization. I was relieved that she subsequently stopped using marijuana and took an antipsychotic. Her mind cleared, and she successfully completed the semester. After 4 months of treatment, she told me she was going to taper her medication and would not need to see me anymore. I was sad, but not surprised, when she returned to my care after the second hospitalization.

Lisa still doubts she has bipolar disorder, a diagnosis she was given in the hospital. Whatever her diagnosis is, I ask her to consider using antipsychotic medication as a tool, along with therapy, friendship, exercise, and healthy eating, to accomplish her goal, graduating from college, which she will do at the end of the semester.

With Lisa, I see more trust with each visit. I also see a rocky road ahead for her, as she still uses marijuana, although not on a daily basis. I have tried to convince her of the benefits of abstinence, without success. I believe the antipsychotic is helping her, so I prescribe it. I schedule a follow-up appointment.

Sitting with patients like Lisa, believing you are slowly making steps toward wellness, is deeply rewarding. My job in a college counseling center allows me to spend 30-45 minutes in follow-up with my patients and meet as often as I need to. Lisa would be lucky in the public health sector to see someone every 3 months for 15 minutes.

I truly feel we as college mental health psychiatrists are often in the role of in loco parentis, and we make a difference. The doctor-patient relationship is the key element in our treatment, enabling patients to trust our recommendations, whether it is for medication, therapy, or exercise. Sometimes, with patients like Lisa, the trust has to be built up over time.

The importance of the doctor-patient relationship has not changed in the last 21 years since I completed my training. Sometimes, it is a battle to maintain this relationship, as I spend an increasing amount of time bent over my computer typing and tapping information into the electronic medical record. My notes have gone from short stories to novellas, as I fill in information to meet insurance, risk management, and psychiatry board requirements. I fear I will soon have a closer relationship with my computer than with my patients. Sometimes I feel like the astronaut in “2001: A Space Odyssey,” and Hal the computer has taken over my life.

Patients like Lisa literally bring me down to earth and help me remember why I became a psychiatrist. As I puzzle over how to strengthen the doctor-patient bond, I try to plant the seeds that will allow Lisa to forego marijuana and other drugs for good. I encourage her to connect with others in her shoes by going to a support group, acknowledging my own deficits in knowing her experience but my desire to understand it as best I can. The connections I form with patients, especially the more challenging ones like Lisa, cannot be measured, and don’t have a reimbursement code, but they are priceless.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

My computer flashes a message that Lisa checked in, so I go to the waiting area of the college counseling center where I work. At first I do not see her, but then I notice a short, thin woman sitting in the corner, her head bowed with long, wavy blond hair covering her face.

Lisa came in for an appointment at the beginning of the semester and then missed the next appointment. After a few e-mails and phone calls on my part, I get her in for a follow-up visit. I do not always pursue a patient, but I am worried about Lisa. She was hospitalized a few months earlier after becoming paranoid and hitting her mother.

We walk into my office, and she sits and looks at me, pushing her hair from her face so I can see her blue eyes. She starts by telling me: “I ran out of medication, but I know I need to restart it.” I ask her to tell me how she knows.

“Since I stopped taking medication, my friends are getting annoyed with me for talking too much and keeping them awake when I call late at night. My professor spoke with me after class and told me I was being disruptive with all my questions. I think I am too revved up, and it is getting hard to concentrate on my school work.”

I feel a deep sense of relief that Lisa has insight into how her behavior affects others and that medication can help her. This is a major step for her, and I am hopeful that she will continue treatment that helps her achieve her goals. I praise Lisa for listening to feedback from others.

Lisa’s insight has been limited in the past. Her first hospitalization was 1 year ago, her second 2 months ago, both for psychotic episodes following escalating marijuana use. She had been a regular cannabis smoker since coming to college. Did the marijuana cause psychosis, or did she increase use to self-medicate psychosis? This will be debated until the end of time, but I don’t believe marijuana benefits her. She has been in college for 7 years.

I started to see Lisa after her first hospitalization. I was relieved that she subsequently stopped using marijuana and took an antipsychotic. Her mind cleared, and she successfully completed the semester. After 4 months of treatment, she told me she was going to taper her medication and would not need to see me anymore. I was sad, but not surprised, when she returned to my care after the second hospitalization.

Lisa still doubts she has bipolar disorder, a diagnosis she was given in the hospital. Whatever her diagnosis is, I ask her to consider using antipsychotic medication as a tool, along with therapy, friendship, exercise, and healthy eating, to accomplish her goal, graduating from college, which she will do at the end of the semester.

With Lisa, I see more trust with each visit. I also see a rocky road ahead for her, as she still uses marijuana, although not on a daily basis. I have tried to convince her of the benefits of abstinence, without success. I believe the antipsychotic is helping her, so I prescribe it. I schedule a follow-up appointment.

Sitting with patients like Lisa, believing you are slowly making steps toward wellness, is deeply rewarding. My job in a college counseling center allows me to spend 30-45 minutes in follow-up with my patients and meet as often as I need to. Lisa would be lucky in the public health sector to see someone every 3 months for 15 minutes.

I truly feel we as college mental health psychiatrists are often in the role of in loco parentis, and we make a difference. The doctor-patient relationship is the key element in our treatment, enabling patients to trust our recommendations, whether it is for medication, therapy, or exercise. Sometimes, with patients like Lisa, the trust has to be built up over time.

The importance of the doctor-patient relationship has not changed in the last 21 years since I completed my training. Sometimes, it is a battle to maintain this relationship, as I spend an increasing amount of time bent over my computer typing and tapping information into the electronic medical record. My notes have gone from short stories to novellas, as I fill in information to meet insurance, risk management, and psychiatry board requirements. I fear I will soon have a closer relationship with my computer than with my patients. Sometimes I feel like the astronaut in “2001: A Space Odyssey,” and Hal the computer has taken over my life.

Patients like Lisa literally bring me down to earth and help me remember why I became a psychiatrist. As I puzzle over how to strengthen the doctor-patient bond, I try to plant the seeds that will allow Lisa to forego marijuana and other drugs for good. I encourage her to connect with others in her shoes by going to a support group, acknowledging my own deficits in knowing her experience but my desire to understand it as best I can. The connections I form with patients, especially the more challenging ones like Lisa, cannot be measured, and don’t have a reimbursement code, but they are priceless.

Dr. Morris is a psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville and has provided clinical care to University of Florida students for the last 20 years. Her areas of specialty include depression, eating disorders, and anxiety disorders.

At Motherisk, we receive increasing numbers of queries from women and clinicians about the use of topiramate during pregnancy, mostly related to its use for migraine or seizures.Topiramate is approved for treatment of seizures and for migraine prevention, and in 2012, the Food and Drug Administration approved the combination of extended-release topiramate with the stimulant phentermine (Qsymia) as a chronic treatment for weight management.

When topiramate was initially approved in 1996, human reproductive data were scarce, but animal data suggested that a high dose of topiramate in rats and rabbits may induce some congenital malformations. Since that time, quite a few studies – but not all – have suggested that topiramate may be associated with an increased risk of oral clefts (cleft lip and cleft palate). Studies that have found an increased risk associated with first trimester exposure to topiramate include the North American AED Pregnancy Registry, which found a rate of 14 cases per 1,000 – more than tenfold greater than the rate in the general population.

For seizures and migraines, the FDA has labeled topiramate a pregnancy category D drug (there is evidence of human fetal risk, but “the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.” ) For Qsymia, however, topiramate is contraindicated in pregnancy and is a pregnancy category X, because its use “can cause fetal harm and weight loss offers no potential benefit to a pregnant woman,” the labeling states.

Based on arecent analysis of six controlled studies in the literature of more than 3,000 pregnancies exposed during the first trimester, we determinedthat the risk of oral clefts associated with first trimester exposure was increased by sixfold over controls. To put this into context, in the general population, oral clefts occur in less than 1% (0.07%), whereas in the studies, the rate was 0.36%, about a fivefold increase.

Until the approval of the weight loss indication, women of reproductive age with epilepsy or migraines prescribed topiramate were a relatively small group. But because obesity is so common, we are now in a situation where a drug that is likely a human teratogen, based on strong evidence, will be used by far more women of childbearing age, and an increase in unintended pregnancies exposed to the drug probably will occur. In phase III clinical trials of Qsymia, quite a few women got pregnant, which is not surprising since women who are obese may have more difficulty knowing they are pregnant, for hormonal and other reasons.

Clinicians and women who take the drug for weight loss need to be aware of this risk. It is important to counsel women of childbearing age who are on this medication about the need for contraception during treatment, and to have a pregnancy test before treatment, and every month during treatment. An important factor to keep in mind is that the maximum topiramate dose for weight loss is 92 mg a day, while the typical epilepsy dose is 200-400 mg a day, and for migraines, is 100 mg a day. It may turn out that the same risk may not be evident with the lower dose.

As the labeling states, women who become pregnant while on this drug should stop taking it immediately, and clinicians should counsel them about the possible risks to the fetus. Health care providers and patients should report pregnancies exposed to Qsymia to the Qsymia Pregnancy Surveillance Program, which is monitoring maternal-fetal outcomes of exposed pregnancies, at 888-998-4887, or the FDA’s MedWatch program at 800-332-1088.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He was a consultant to Vivus, the manufacturer of Qsymia. E-mail him at [email protected].

At Motherisk, we receive increasing numbers of queries from women and clinicians about the use of topiramate during pregnancy, mostly related to its use for migraine or seizures.Topiramate is approved for treatment of seizures and for migraine prevention, and in 2012, the Food and Drug Administration approved the combination of extended-release topiramate with the stimulant phentermine (Qsymia) as a chronic treatment for weight management.

When topiramate was initially approved in 1996, human reproductive data were scarce, but animal data suggested that a high dose of topiramate in rats and rabbits may induce some congenital malformations. Since that time, quite a few studies – but not all – have suggested that topiramate may be associated with an increased risk of oral clefts (cleft lip and cleft palate). Studies that have found an increased risk associated with first trimester exposure to topiramate include the North American AED Pregnancy Registry, which found a rate of 14 cases per 1,000 – more than tenfold greater than the rate in the general population.

For seizures and migraines, the FDA has labeled topiramate a pregnancy category D drug (there is evidence of human fetal risk, but “the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.” ) For Qsymia, however, topiramate is contraindicated in pregnancy and is a pregnancy category X, because its use “can cause fetal harm and weight loss offers no potential benefit to a pregnant woman,” the labeling states.

Based on arecent analysis of six controlled studies in the literature of more than 3,000 pregnancies exposed during the first trimester, we determinedthat the risk of oral clefts associated with first trimester exposure was increased by sixfold over controls. To put this into context, in the general population, oral clefts occur in less than 1% (0.07%), whereas in the studies, the rate was 0.36%, about a fivefold increase.

Until the approval of the weight loss indication, women of reproductive age with epilepsy or migraines prescribed topiramate were a relatively small group. But because obesity is so common, we are now in a situation where a drug that is likely a human teratogen, based on strong evidence, will be used by far more women of childbearing age, and an increase in unintended pregnancies exposed to the drug probably will occur. In phase III clinical trials of Qsymia, quite a few women got pregnant, which is not surprising since women who are obese may have more difficulty knowing they are pregnant, for hormonal and other reasons.

Clinicians and women who take the drug for weight loss need to be aware of this risk. It is important to counsel women of childbearing age who are on this medication about the need for contraception during treatment, and to have a pregnancy test before treatment, and every month during treatment. An important factor to keep in mind is that the maximum topiramate dose for weight loss is 92 mg a day, while the typical epilepsy dose is 200-400 mg a day, and for migraines, is 100 mg a day. It may turn out that the same risk may not be evident with the lower dose.

As the labeling states, women who become pregnant while on this drug should stop taking it immediately, and clinicians should counsel them about the possible risks to the fetus. Health care providers and patients should report pregnancies exposed to Qsymia to the Qsymia Pregnancy Surveillance Program, which is monitoring maternal-fetal outcomes of exposed pregnancies, at 888-998-4887, or the FDA’s MedWatch program at 800-332-1088.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He was a consultant to Vivus, the manufacturer of Qsymia. E-mail him at [email protected].

At Motherisk, we receive increasing numbers of queries from women and clinicians about the use of topiramate during pregnancy, mostly related to its use for migraine or seizures.Topiramate is approved for treatment of seizures and for migraine prevention, and in 2012, the Food and Drug Administration approved the combination of extended-release topiramate with the stimulant phentermine (Qsymia) as a chronic treatment for weight management.

When topiramate was initially approved in 1996, human reproductive data were scarce, but animal data suggested that a high dose of topiramate in rats and rabbits may induce some congenital malformations. Since that time, quite a few studies – but not all – have suggested that topiramate may be associated with an increased risk of oral clefts (cleft lip and cleft palate). Studies that have found an increased risk associated with first trimester exposure to topiramate include the North American AED Pregnancy Registry, which found a rate of 14 cases per 1,000 – more than tenfold greater than the rate in the general population.

For seizures and migraines, the FDA has labeled topiramate a pregnancy category D drug (there is evidence of human fetal risk, but “the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.” ) For Qsymia, however, topiramate is contraindicated in pregnancy and is a pregnancy category X, because its use “can cause fetal harm and weight loss offers no potential benefit to a pregnant woman,” the labeling states.

Based on arecent analysis of six controlled studies in the literature of more than 3,000 pregnancies exposed during the first trimester, we determinedthat the risk of oral clefts associated with first trimester exposure was increased by sixfold over controls. To put this into context, in the general population, oral clefts occur in less than 1% (0.07%), whereas in the studies, the rate was 0.36%, about a fivefold increase.

Until the approval of the weight loss indication, women of reproductive age with epilepsy or migraines prescribed topiramate were a relatively small group. But because obesity is so common, we are now in a situation where a drug that is likely a human teratogen, based on strong evidence, will be used by far more women of childbearing age, and an increase in unintended pregnancies exposed to the drug probably will occur. In phase III clinical trials of Qsymia, quite a few women got pregnant, which is not surprising since women who are obese may have more difficulty knowing they are pregnant, for hormonal and other reasons.

Clinicians and women who take the drug for weight loss need to be aware of this risk. It is important to counsel women of childbearing age who are on this medication about the need for contraception during treatment, and to have a pregnancy test before treatment, and every month during treatment. An important factor to keep in mind is that the maximum topiramate dose for weight loss is 92 mg a day, while the typical epilepsy dose is 200-400 mg a day, and for migraines, is 100 mg a day. It may turn out that the same risk may not be evident with the lower dose.

As the labeling states, women who become pregnant while on this drug should stop taking it immediately, and clinicians should counsel them about the possible risks to the fetus. Health care providers and patients should report pregnancies exposed to Qsymia to the Qsymia Pregnancy Surveillance Program, which is monitoring maternal-fetal outcomes of exposed pregnancies, at 888-998-4887, or the FDA’s MedWatch program at 800-332-1088.

Dr. Koren is professor of pediatrics, pharmacology, pharmacy, medicine, and medical genetics at the University of Toronto. He heads the Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation at the Hospital for Sick Children, Toronto, where he is director of the Motherisk Program. He was a consultant to Vivus, the manufacturer of Qsymia. E-mail him at [email protected].

Rarely do I post online as a knee-jerk reaction! But recently, a topic hit me right in the middle of the forehead. I received an email from a colleague who asked:

“Is there any study looking at how long a PA or NP needs after completing his/her training to be fully competent? I’m at a hospital board meeting and one member is suggesting ‘midlevels’ need three more years of training, at the expense of the institution hiring them.”

I must admit that I was at a loss as to how to respond! (Not least because I dislike the term midlevel.) Lately, competency has been a hot topic as hospitals and large health care organizations hire more new graduates and want to know how long it will take for them to get up to speed within the institution. Competence is thus defined as how long it takes these PAs/NPs to become fully functional in a particular setting. It’s a narrow, specific question rather than a broad, philosophical one—but it begs the competency question, does it not?

Let’s start with the definition of competency. I had to laugh when I consulted Merriam-Webster, which says competency is “the quality or state of being functionally adequate.” Now, that is what I strive to be … “adequate”!  

I prefer Norman’s definition of professional competence: “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”¹

He goes on to say that competence has multiple functions: cognitive (using acquired knowledge to solve real-life problems); integrative (using biomedical and psychosocial data in clinical reasoning); relational (communicating effectively with patients and colleagues); and affective/moral (the willingness, patience, and emotional awareness to use these skills judiciously and humanely). I was particularly struck by a final comment that competence is “developmental, impermanent, and context-dependent.”¹ Competence is certainly developmental in the context of lifelong learning. If it is indeed impermanent (temporary, transient, transitory, passing, fleeting), then it must be evaluated frequently. There is no argument that it is context-dependent, whether by level of care, specialty knowledge required, or institution.

Clearly, competence is complex. While the PA and NP professions have developed and published clinical competencies in the past decade (which mirror and parallel those of our physician colleagues), how do we actually demonstrate them?

Continue for competency definitions >>

Patricia Benner developed one of the best-known competency definitions in 1982 with her Novice to Expert model, which applied the Dreyfus Model of Skill Acquisition to nursing. It has been widely used as a tool to determine “expertise.”^2,3 Her model describes the five levels of expertise as
• Novice: A beginner with little to no experience. Novices face the inability to use discretionary judgment and require significant supervision.
• Advanced beginner: Able to demonstrate marginally acceptable performance based on some real-life experience.
• Competent: Has usually been on the job for two to three years. At this level, the clinician has a sense of mastery and the ability to cope with and manage many aspects of patient care.
• Proficient: Able to grasp clinical solutions quicker and able to hone in on accurate regions of the problem faster.
• Expert: No longer relies on analytics to connect to understanding of the problem but has an intuitive grasp and is able to zero in on all aspects of the problem at hand without any wasteful or unfruitful possibilities.³

Benner maintains that knowledge accrues over time in clinical practice and is developed through dialogue in relationship and situational contexts.⁴ Of note, clinical experience is not the mere passage of time or longevity within a clinical experience but rather the actual level of clinical interaction. The clinician, therefore, may move forward or backward, depending on the situation.

In 2011, Chuck defined six levels of competency, postulating that for each we find ways to scale the learning curve. It is where we are on the curve that determines our competence in a skill set. His six levels include
• Naïve/Newcomer: Exhibits little observable knowledge, skill, or sincere interest
• Intermediate: Has received minimal but not sufficient training to exhibit a core set of knowledge, skills, or ­interest
• Proficient: Has completed sufficient training (usually through a set of required classes) to reliably reproduce a core set of knowledge and skills, but requires further training when confronted with situations in which it needs to be applied
• Confident: Has above-average knowledge and skills and demonstrates appropriate confidence in adapting to new situations that challenge those skills
• Master: Demonstrates consistent excellence in knowledge and skills and can appropriately seek affirmation and criticism to independently develop additional skills
• Expert: Has received external validation of superior quality knowledge and skills and is considered an innovator, leader, or authority in a specific area.⁵

In the Chuck model, levels 1 and 2 would be prematriculants and students. You can see variations of this learning curve in different situations, whether it is a new clinician in the emergency department (ED) or an experienced clinician moving to a new practice.

So when is a clinician (specifically, a PA or NP) fully competent to see patients? This question is undoubtedly being asked more than we realize, and both professions should develop a serious answer to it. Are we doing enough research to make an objective argument in response? No matter how we answer, I think it is important to note that our respective professions have excellent patient care outcomes, even when taking into account the particular clinician level (novice through expert).

This is a challenging topic because what we do requires factual knowledge and the consistent, appropriate application of that knowledge. We know how to measure factual knowledge, more or less, but assuredly we don’t know how to measure the latter (possibly the more important part). In my opinion, we need a pragmatic approach to determine whether a clinician is competent and continues to be so.

One method is to do what is known as a 360 survey. Here’s how it might work: All coworkers of a particular clinician would be surveyed on the perceived elements of clinical competence, including knowledge, application of knowledge, efficiency, ability to make decisions, and attitude toward patients. Every person in the department—say, the ED—could anonymously complete the survey. (This would include nurses, techs, other PAs/NPs, housekeeping, on-call members of the medical staff—literally everybody, although not all of them will be capable of making some of these determinations.) Then the ED director would let the clinician review and discuss the feedback. Everyone in the department would know he or she would be similarly evaluated.⁶

This is the most brutal, yet fair and efficient, way to assess competency in its broadest sense. Will all opinions be factually substantiated? No! But what better technique do we have, at least for now?

But wait! Perhaps competence is not the end game. Perhaps competence is really a minimum standard. Competence (albeit novice) is measured by completion of the PA or NP curricula (meeting the course objectives) and passage of board/licensure exams, just as, essentially, physician competence is.

Most, if not all, would agree that mastery is achieved by the acquisition of knowledge coupled with sound practice and experience. Mastery or expertise, some say, is what we should focus on, the achievement of which is quite individual. All clinicians can move toward mastery, but not all will actually achieve it. Therefore, how can we mandate a minimum standard, beyond competence, for PAs and NPs but not for other providers?

So, after all the rhetorical ranting about when a PA or NP becomes fully competent, the answer is … It depends! There are too many moving parts. I would suggest that competency is the starting point and mastery (expertise) is a journey.

What do you think? Share your thoughts with me via [email protected].

REFERENCES
1. Norman GR. Defining competence: a methodological review. In: Neufeld VR, Norman GR, eds. Assessing Clinical Competence. New York, NY: Springer; 1985:15-35.

2. Gentile DL. Applying the novice-to-expert model to infusion nursing. J Infus Nurs. 2012;35(2):101-107.

3. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407.

4. Brykczynski KA. Patricia Benner: caring, clinical wisdom, and ethics in nursing practice. In: Alligood MR, ed. Nursing Theorists and Their Work. 8th ed. St Louis, MO: Elsevier. 2014; 120-146.

5. Chuck E. The competency manifesto: part 3. The Student Doctor Network. www.student doctor.net/2011/04/the-competency-mani festo-part-3. Accessed November 11, 2014.

6. Lepsinger R, Luca AD. The Art and Science of 360-Degree Feedback. 2nd ed. San Francisco, CA: Jossey-Bass; 2009. 

Rarely do I post online as a knee-jerk reaction! But recently, a topic hit me right in the middle of the forehead. I received an email from a colleague who asked:

“Is there any study looking at how long a PA or NP needs after completing his/her training to be fully competent? I’m at a hospital board meeting and one member is suggesting ‘midlevels’ need three more years of training, at the expense of the institution hiring them.”

I must admit that I was at a loss as to how to respond! (Not least because I dislike the term midlevel.) Lately, competency has been a hot topic as hospitals and large health care organizations hire more new graduates and want to know how long it will take for them to get up to speed within the institution. Competence is thus defined as how long it takes these PAs/NPs to become fully functional in a particular setting. It’s a narrow, specific question rather than a broad, philosophical one—but it begs the competency question, does it not?

Let’s start with the definition of competency. I had to laugh when I consulted Merriam-Webster, which says competency is “the quality or state of being functionally adequate.” Now, that is what I strive to be … “adequate”!  

I prefer Norman’s definition of professional competence: “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”¹

He goes on to say that competence has multiple functions: cognitive (using acquired knowledge to solve real-life problems); integrative (using biomedical and psychosocial data in clinical reasoning); relational (communicating effectively with patients and colleagues); and affective/moral (the willingness, patience, and emotional awareness to use these skills judiciously and humanely). I was particularly struck by a final comment that competence is “developmental, impermanent, and context-dependent.”¹ Competence is certainly developmental in the context of lifelong learning. If it is indeed impermanent (temporary, transient, transitory, passing, fleeting), then it must be evaluated frequently. There is no argument that it is context-dependent, whether by level of care, specialty knowledge required, or institution.

Clearly, competence is complex. While the PA and NP professions have developed and published clinical competencies in the past decade (which mirror and parallel those of our physician colleagues), how do we actually demonstrate them?

Continue for competency definitions >>

Patricia Benner developed one of the best-known competency definitions in 1982 with her Novice to Expert model, which applied the Dreyfus Model of Skill Acquisition to nursing. It has been widely used as a tool to determine “expertise.”^2,3 Her model describes the five levels of expertise as
• Novice: A beginner with little to no experience. Novices face the inability to use discretionary judgment and require significant supervision.
• Advanced beginner: Able to demonstrate marginally acceptable performance based on some real-life experience.
• Competent: Has usually been on the job for two to three years. At this level, the clinician has a sense of mastery and the ability to cope with and manage many aspects of patient care.
• Proficient: Able to grasp clinical solutions quicker and able to hone in on accurate regions of the problem faster.
• Expert: No longer relies on analytics to connect to understanding of the problem but has an intuitive grasp and is able to zero in on all aspects of the problem at hand without any wasteful or unfruitful possibilities.³

Benner maintains that knowledge accrues over time in clinical practice and is developed through dialogue in relationship and situational contexts.⁴ Of note, clinical experience is not the mere passage of time or longevity within a clinical experience but rather the actual level of clinical interaction. The clinician, therefore, may move forward or backward, depending on the situation.

In 2011, Chuck defined six levels of competency, postulating that for each we find ways to scale the learning curve. It is where we are on the curve that determines our competence in a skill set. His six levels include
• Naïve/Newcomer: Exhibits little observable knowledge, skill, or sincere interest
• Intermediate: Has received minimal but not sufficient training to exhibit a core set of knowledge, skills, or ­interest
• Proficient: Has completed sufficient training (usually through a set of required classes) to reliably reproduce a core set of knowledge and skills, but requires further training when confronted with situations in which it needs to be applied
• Confident: Has above-average knowledge and skills and demonstrates appropriate confidence in adapting to new situations that challenge those skills
• Master: Demonstrates consistent excellence in knowledge and skills and can appropriately seek affirmation and criticism to independently develop additional skills
• Expert: Has received external validation of superior quality knowledge and skills and is considered an innovator, leader, or authority in a specific area.⁵

In the Chuck model, levels 1 and 2 would be prematriculants and students. You can see variations of this learning curve in different situations, whether it is a new clinician in the emergency department (ED) or an experienced clinician moving to a new practice.

So when is a clinician (specifically, a PA or NP) fully competent to see patients? This question is undoubtedly being asked more than we realize, and both professions should develop a serious answer to it. Are we doing enough research to make an objective argument in response? No matter how we answer, I think it is important to note that our respective professions have excellent patient care outcomes, even when taking into account the particular clinician level (novice through expert).

This is a challenging topic because what we do requires factual knowledge and the consistent, appropriate application of that knowledge. We know how to measure factual knowledge, more or less, but assuredly we don’t know how to measure the latter (possibly the more important part). In my opinion, we need a pragmatic approach to determine whether a clinician is competent and continues to be so.

One method is to do what is known as a 360 survey. Here’s how it might work: All coworkers of a particular clinician would be surveyed on the perceived elements of clinical competence, including knowledge, application of knowledge, efficiency, ability to make decisions, and attitude toward patients. Every person in the department—say, the ED—could anonymously complete the survey. (This would include nurses, techs, other PAs/NPs, housekeeping, on-call members of the medical staff—literally everybody, although not all of them will be capable of making some of these determinations.) Then the ED director would let the clinician review and discuss the feedback. Everyone in the department would know he or she would be similarly evaluated.⁶

This is the most brutal, yet fair and efficient, way to assess competency in its broadest sense. Will all opinions be factually substantiated? No! But what better technique do we have, at least for now?

But wait! Perhaps competence is not the end game. Perhaps competence is really a minimum standard. Competence (albeit novice) is measured by completion of the PA or NP curricula (meeting the course objectives) and passage of board/licensure exams, just as, essentially, physician competence is.

Most, if not all, would agree that mastery is achieved by the acquisition of knowledge coupled with sound practice and experience. Mastery or expertise, some say, is what we should focus on, the achievement of which is quite individual. All clinicians can move toward mastery, but not all will actually achieve it. Therefore, how can we mandate a minimum standard, beyond competence, for PAs and NPs but not for other providers?

So, after all the rhetorical ranting about when a PA or NP becomes fully competent, the answer is … It depends! There are too many moving parts. I would suggest that competency is the starting point and mastery (expertise) is a journey.

What do you think? Share your thoughts with me via [email protected].

REFERENCES
1. Norman GR. Defining competence: a methodological review. In: Neufeld VR, Norman GR, eds. Assessing Clinical Competence. New York, NY: Springer; 1985:15-35.

2. Gentile DL. Applying the novice-to-expert model to infusion nursing. J Infus Nurs. 2012;35(2):101-107.

3. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407.

4. Brykczynski KA. Patricia Benner: caring, clinical wisdom, and ethics in nursing practice. In: Alligood MR, ed. Nursing Theorists and Their Work. 8th ed. St Louis, MO: Elsevier. 2014; 120-146.

5. Chuck E. The competency manifesto: part 3. The Student Doctor Network. www.student doctor.net/2011/04/the-competency-mani festo-part-3. Accessed November 11, 2014.

6. Lepsinger R, Luca AD. The Art and Science of 360-Degree Feedback. 2nd ed. San Francisco, CA: Jossey-Bass; 2009. 

Rarely do I post online as a knee-jerk reaction! But recently, a topic hit me right in the middle of the forehead. I received an email from a colleague who asked:

“Is there any study looking at how long a PA or NP needs after completing his/her training to be fully competent? I’m at a hospital board meeting and one member is suggesting ‘midlevels’ need three more years of training, at the expense of the institution hiring them.”

I must admit that I was at a loss as to how to respond! (Not least because I dislike the term midlevel.) Lately, competency has been a hot topic as hospitals and large health care organizations hire more new graduates and want to know how long it will take for them to get up to speed within the institution. Competence is thus defined as how long it takes these PAs/NPs to become fully functional in a particular setting. It’s a narrow, specific question rather than a broad, philosophical one—but it begs the competency question, does it not?

Let’s start with the definition of competency. I had to laugh when I consulted Merriam-Webster, which says competency is “the quality or state of being functionally adequate.” Now, that is what I strive to be … “adequate”!  

I prefer Norman’s definition of professional competence: “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”¹

He goes on to say that competence has multiple functions: cognitive (using acquired knowledge to solve real-life problems); integrative (using biomedical and psychosocial data in clinical reasoning); relational (communicating effectively with patients and colleagues); and affective/moral (the willingness, patience, and emotional awareness to use these skills judiciously and humanely). I was particularly struck by a final comment that competence is “developmental, impermanent, and context-dependent.”¹ Competence is certainly developmental in the context of lifelong learning. If it is indeed impermanent (temporary, transient, transitory, passing, fleeting), then it must be evaluated frequently. There is no argument that it is context-dependent, whether by level of care, specialty knowledge required, or institution.

Clearly, competence is complex. While the PA and NP professions have developed and published clinical competencies in the past decade (which mirror and parallel those of our physician colleagues), how do we actually demonstrate them?

Continue for competency definitions >>

Patricia Benner developed one of the best-known competency definitions in 1982 with her Novice to Expert model, which applied the Dreyfus Model of Skill Acquisition to nursing. It has been widely used as a tool to determine “expertise.”^2,3 Her model describes the five levels of expertise as
• Novice: A beginner with little to no experience. Novices face the inability to use discretionary judgment and require significant supervision.
• Advanced beginner: Able to demonstrate marginally acceptable performance based on some real-life experience.
• Competent: Has usually been on the job for two to three years. At this level, the clinician has a sense of mastery and the ability to cope with and manage many aspects of patient care.
• Proficient: Able to grasp clinical solutions quicker and able to hone in on accurate regions of the problem faster.
• Expert: No longer relies on analytics to connect to understanding of the problem but has an intuitive grasp and is able to zero in on all aspects of the problem at hand without any wasteful or unfruitful possibilities.³

Benner maintains that knowledge accrues over time in clinical practice and is developed through dialogue in relationship and situational contexts.⁴ Of note, clinical experience is not the mere passage of time or longevity within a clinical experience but rather the actual level of clinical interaction. The clinician, therefore, may move forward or backward, depending on the situation.

In 2011, Chuck defined six levels of competency, postulating that for each we find ways to scale the learning curve. It is where we are on the curve that determines our competence in a skill set. His six levels include
• Naïve/Newcomer: Exhibits little observable knowledge, skill, or sincere interest
• Intermediate: Has received minimal but not sufficient training to exhibit a core set of knowledge, skills, or ­interest
• Proficient: Has completed sufficient training (usually through a set of required classes) to reliably reproduce a core set of knowledge and skills, but requires further training when confronted with situations in which it needs to be applied
• Confident: Has above-average knowledge and skills and demonstrates appropriate confidence in adapting to new situations that challenge those skills
• Master: Demonstrates consistent excellence in knowledge and skills and can appropriately seek affirmation and criticism to independently develop additional skills
• Expert: Has received external validation of superior quality knowledge and skills and is considered an innovator, leader, or authority in a specific area.⁵

In the Chuck model, levels 1 and 2 would be prematriculants and students. You can see variations of this learning curve in different situations, whether it is a new clinician in the emergency department (ED) or an experienced clinician moving to a new practice.

So when is a clinician (specifically, a PA or NP) fully competent to see patients? This question is undoubtedly being asked more than we realize, and both professions should develop a serious answer to it. Are we doing enough research to make an objective argument in response? No matter how we answer, I think it is important to note that our respective professions have excellent patient care outcomes, even when taking into account the particular clinician level (novice through expert).

This is a challenging topic because what we do requires factual knowledge and the consistent, appropriate application of that knowledge. We know how to measure factual knowledge, more or less, but assuredly we don’t know how to measure the latter (possibly the more important part). In my opinion, we need a pragmatic approach to determine whether a clinician is competent and continues to be so.

One method is to do what is known as a 360 survey. Here’s how it might work: All coworkers of a particular clinician would be surveyed on the perceived elements of clinical competence, including knowledge, application of knowledge, efficiency, ability to make decisions, and attitude toward patients. Every person in the department—say, the ED—could anonymously complete the survey. (This would include nurses, techs, other PAs/NPs, housekeeping, on-call members of the medical staff—literally everybody, although not all of them will be capable of making some of these determinations.) Then the ED director would let the clinician review and discuss the feedback. Everyone in the department would know he or she would be similarly evaluated.⁶

This is the most brutal, yet fair and efficient, way to assess competency in its broadest sense. Will all opinions be factually substantiated? No! But what better technique do we have, at least for now?

But wait! Perhaps competence is not the end game. Perhaps competence is really a minimum standard. Competence (albeit novice) is measured by completion of the PA or NP curricula (meeting the course objectives) and passage of board/licensure exams, just as, essentially, physician competence is.

Most, if not all, would agree that mastery is achieved by the acquisition of knowledge coupled with sound practice and experience. Mastery or expertise, some say, is what we should focus on, the achievement of which is quite individual. All clinicians can move toward mastery, but not all will actually achieve it. Therefore, how can we mandate a minimum standard, beyond competence, for PAs and NPs but not for other providers?

So, after all the rhetorical ranting about when a PA or NP becomes fully competent, the answer is … It depends! There are too many moving parts. I would suggest that competency is the starting point and mastery (expertise) is a journey.

What do you think? Share your thoughts with me via [email protected].

REFERENCES
1. Norman GR. Defining competence: a methodological review. In: Neufeld VR, Norman GR, eds. Assessing Clinical Competence. New York, NY: Springer; 1985:15-35.

2. Gentile DL. Applying the novice-to-expert model to infusion nursing. J Infus Nurs. 2012;35(2):101-107.

3. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407.

4. Brykczynski KA. Patricia Benner: caring, clinical wisdom, and ethics in nursing practice. In: Alligood MR, ed. Nursing Theorists and Their Work. 8th ed. St Louis, MO: Elsevier. 2014; 120-146.

5. Chuck E. The competency manifesto: part 3. The Student Doctor Network. www.student doctor.net/2011/04/the-competency-mani festo-part-3. Accessed November 11, 2014.

6. Lepsinger R, Luca AD. The Art and Science of 360-Degree Feedback. 2nd ed. San Francisco, CA: Jossey-Bass; 2009. 

At first it seems to be a fairly straightforward proposition. The older gentleman you are seeing in the clinic reports that he has been running rather low on energy in recent weeks, and he also mentions that there’s not much lead in his pencil these days. As a conscientious clinician, you immediately entertain the possibility that hypogonadism might explain some of his symptoms. You dutifully order up a total testosterone level, and then a free testosterone level when the total comes back low, recognizing that binding protein abnormalities might produce a low total even when the clinically relevant free level is still normal. Both levels do come back well below the age-adjusted lower limits of normal, which gives you some transient level of satisfaction that you have identified a very significant factor contributing to your patient’s difficulties.

You have confirmed a deficiency of a major hormone, and it seems logical that you would want to restore the hormone level to normal in this particular patient. But before you reach for your prescription pad (or your mouse), a fundamental question hangs uneasily in the air. Are you going to be doing more harm than good by prescribing testosterone replacement therapy (TRT) to this rather trusting older fellow? In light of recent studies, might you actually increase this patent’s chances of a heart attack or a stroke? That would not be a nice thing to do to this pleasant older gentleman. (As a newly minted senior citizen, I pray mightily that my own caregivers adhere rigorously to Hippocrates’ hoary admonition to, above all, do no harm.)

I’m not going to be able to resolve this clinical conundrum definitively in this editorial. (Please don’t stop reading just yet!) But maybe a review of the pros and cons for testosterone replacement therapy can help you faithful readers gain just a little bit better sense of the operative risk/benefit considerations at play here.

Let’s look first at the case for prescribing TRT when the laboratory test values show definitive evidence of low testosterone levels. I don’t want to delve into the distracting issue of which form of testosterone replacement to consider, which pits injections vs gels vs patches vs pills (don’t use the potentially hepatotoxic methyltestosterone pills passed out like candy by some urologists). Apart from the possibly relevant issue of peaks and troughs seen with injection therapy, the same risk/benefit considerations pretty much apply to all forms of TRT.

The benefits of TRT clearly include an increase in lean muscle mass, an increase in red blood cell concentration due to the hematopoetic effects of the male hormone, and a reduction in both the total amount and the percentage of body fat. A number of studies have shown that testosterone enhances insulin sensitivity—surely a good thing given the massive number of older patients with either prediabetes or full-blown type 2 diabetes. Some men also report a significant increase in their hard-to-define-but-still important sense of manliness, and sometimes a major improvement in their ability to perform in the sack. The latter effects, though, are often very modest and of considerably less potency (sorry, pun intended) than seen with sildenafil or one of the other PDE-5 inhibitors. In spite of all these seemingly positive effects, the clear majority of men report that they really don’t feel much different after starting on TRT, and many discontinue it on their own after relatively short periods, especially those enduring intramuscular injections every 2 weeks.

So the benefits derived from TRT are not really very impressive in many patients. What about the downside of giving testosterone? Surely there can’t be any problems associated with simply replacing an important hormone that has fallen to low levels? After all, we don’t hesitate to give thyroid hormone to hypothyroid patients, to give growth hormone to children with low levels of this critical hormone, or to give insulin to diabetic patients whose pancreases are not producing enough of that life-saving hormone.

For a very long time the risk/benefit arguments over whether or not to give TRT were almost entirely theoretical. Those in favor cited the several aforementioned benefits, and those in opposition decried replacement therapy as a perverse form of tinkering with nature by trying to alter the natural decline in the levels of certain hormones that were part and parcel of the natural aging process.

Then along came 3 rather worrisome studies in fairly rapid-fire succession, which seamed collectively to deliver a true body blow to TRT. However, a closer examination of these studies reveals that each is so severely flawed that no meaningful conclusions can be derived from any of them.

The Testosterone in Older Men with Sarcopenia (TOM) trial was a randomized trial of TRT vs placebo in older men (mean age 74 years) with mobility limitations (sarcopenia, after all, means decreased muscle bulk) and a high prevalence of chronic disease.¹ The trial was stopped early because of a much higher occurrence of self-reported cardiovascular-related adverse events. However, these adverse events were extremely disparate and were all self-reported; none had been prespecified outcomes. Any objective observer would have to conclude that the study was poorly designed and that no meaningful conclusions can be drawn from its premature termination.

The second trial that seemed to cast doubt on the safety of TRT suffered from an even worse design. It was a retrospective cohort study of 8,709 veterans aged 60 to 64 years with low testosterone levels who were undergoing coronary artery angiography. The authors reported in the Journal of the American Medical Association that those receiving testosterone therapy had a higher risk of experiencing a composite outcome of all-cause mortality, myocardial infarction (MI), or cerebrovascular accident than did those who had not received testosterone therapy (hazard ratio [HR] = 1.29; 95% confidence interval [CI]: 1.04-1.58).² Right off the bat, you should be very wary of any HR emanating from a retrospective study that shows a small increase in risk of 29%; it’s only when a HR is 2.0 or more that it’s likely you’re looking at a real phenomenon. But to add insult to injury, the percentage of actual adverse outcomes was actually SMALLER in those taking testosterone than in those who did not get any! The authors had used such an incredibly tortured series of risk adjustments for a variety of comorbidities that they actually managed to stand the raw numbers on their head.

The third study, which had seamed at first blush to demonstrate cardiovascular toxicity of TRT, was a much larger retrospective cohort study of 55,793 men who had received replacement testosterone.³ The authors reported an increase in the relative risk of MI in the first 3 months after starting testosterone compared with the risk of MI in the same men in the prior year (relative risk [RR] = 1.36). However, the much more important absolute risk increase was very, very low, with only an additional 1.25 cases of MI seen over 1,000 patient-years. Apart from the fact that a RR of 1.36 is most unimpressive in a retrospective study, the simple fact that the men were older by a few months after TRT is probably more than adequate to explain this tiny increase in apparent risk.

The FDA has monitored these studies closely and has chosen not to make a determination that there is an increased risk of cardiovascular events associated with TRT. That is not at all the same as saying that it has been proven to be completely free of cardiovascular risk; rather it is a common-sense acknowledgment that there is not any convincing evidence to date of such a risk.

Thus, the conscientious clinician is left to conclude that TRT is a reasonable option in symptomatic patients who have been shown to have low levels of free testosterone. It has not been conclusively demonstrated that TRT will have significant beneficial effects, but neither has it been proven to have any true cardiovascular toxicity. It is a therapy worth trying in those symptomatic patients who understand that they will be receiving therapy of uncertain benefit, if any, and with the possibility of uncertain risk, if any.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

At first it seems to be a fairly straightforward proposition. The older gentleman you are seeing in the clinic reports that he has been running rather low on energy in recent weeks, and he also mentions that there’s not much lead in his pencil these days. As a conscientious clinician, you immediately entertain the possibility that hypogonadism might explain some of his symptoms. You dutifully order up a total testosterone level, and then a free testosterone level when the total comes back low, recognizing that binding protein abnormalities might produce a low total even when the clinically relevant free level is still normal. Both levels do come back well below the age-adjusted lower limits of normal, which gives you some transient level of satisfaction that you have identified a very significant factor contributing to your patient’s difficulties.

You have confirmed a deficiency of a major hormone, and it seems logical that you would want to restore the hormone level to normal in this particular patient. But before you reach for your prescription pad (or your mouse), a fundamental question hangs uneasily in the air. Are you going to be doing more harm than good by prescribing testosterone replacement therapy (TRT) to this rather trusting older fellow? In light of recent studies, might you actually increase this patent’s chances of a heart attack or a stroke? That would not be a nice thing to do to this pleasant older gentleman. (As a newly minted senior citizen, I pray mightily that my own caregivers adhere rigorously to Hippocrates’ hoary admonition to, above all, do no harm.)

I’m not going to be able to resolve this clinical conundrum definitively in this editorial. (Please don’t stop reading just yet!) But maybe a review of the pros and cons for testosterone replacement therapy can help you faithful readers gain just a little bit better sense of the operative risk/benefit considerations at play here.

Let’s look first at the case for prescribing TRT when the laboratory test values show definitive evidence of low testosterone levels. I don’t want to delve into the distracting issue of which form of testosterone replacement to consider, which pits injections vs gels vs patches vs pills (don’t use the potentially hepatotoxic methyltestosterone pills passed out like candy by some urologists). Apart from the possibly relevant issue of peaks and troughs seen with injection therapy, the same risk/benefit considerations pretty much apply to all forms of TRT.

The benefits of TRT clearly include an increase in lean muscle mass, an increase in red blood cell concentration due to the hematopoetic effects of the male hormone, and a reduction in both the total amount and the percentage of body fat. A number of studies have shown that testosterone enhances insulin sensitivity—surely a good thing given the massive number of older patients with either prediabetes or full-blown type 2 diabetes. Some men also report a significant increase in their hard-to-define-but-still important sense of manliness, and sometimes a major improvement in their ability to perform in the sack. The latter effects, though, are often very modest and of considerably less potency (sorry, pun intended) than seen with sildenafil or one of the other PDE-5 inhibitors. In spite of all these seemingly positive effects, the clear majority of men report that they really don’t feel much different after starting on TRT, and many discontinue it on their own after relatively short periods, especially those enduring intramuscular injections every 2 weeks.

So the benefits derived from TRT are not really very impressive in many patients. What about the downside of giving testosterone? Surely there can’t be any problems associated with simply replacing an important hormone that has fallen to low levels? After all, we don’t hesitate to give thyroid hormone to hypothyroid patients, to give growth hormone to children with low levels of this critical hormone, or to give insulin to diabetic patients whose pancreases are not producing enough of that life-saving hormone.

For a very long time the risk/benefit arguments over whether or not to give TRT were almost entirely theoretical. Those in favor cited the several aforementioned benefits, and those in opposition decried replacement therapy as a perverse form of tinkering with nature by trying to alter the natural decline in the levels of certain hormones that were part and parcel of the natural aging process.

Then along came 3 rather worrisome studies in fairly rapid-fire succession, which seamed collectively to deliver a true body blow to TRT. However, a closer examination of these studies reveals that each is so severely flawed that no meaningful conclusions can be derived from any of them.

The Testosterone in Older Men with Sarcopenia (TOM) trial was a randomized trial of TRT vs placebo in older men (mean age 74 years) with mobility limitations (sarcopenia, after all, means decreased muscle bulk) and a high prevalence of chronic disease.¹ The trial was stopped early because of a much higher occurrence of self-reported cardiovascular-related adverse events. However, these adverse events were extremely disparate and were all self-reported; none had been prespecified outcomes. Any objective observer would have to conclude that the study was poorly designed and that no meaningful conclusions can be drawn from its premature termination.

The second trial that seemed to cast doubt on the safety of TRT suffered from an even worse design. It was a retrospective cohort study of 8,709 veterans aged 60 to 64 years with low testosterone levels who were undergoing coronary artery angiography. The authors reported in the Journal of the American Medical Association that those receiving testosterone therapy had a higher risk of experiencing a composite outcome of all-cause mortality, myocardial infarction (MI), or cerebrovascular accident than did those who had not received testosterone therapy (hazard ratio [HR] = 1.29; 95% confidence interval [CI]: 1.04-1.58).² Right off the bat, you should be very wary of any HR emanating from a retrospective study that shows a small increase in risk of 29%; it’s only when a HR is 2.0 or more that it’s likely you’re looking at a real phenomenon. But to add insult to injury, the percentage of actual adverse outcomes was actually SMALLER in those taking testosterone than in those who did not get any! The authors had used such an incredibly tortured series of risk adjustments for a variety of comorbidities that they actually managed to stand the raw numbers on their head.

The third study, which had seamed at first blush to demonstrate cardiovascular toxicity of TRT, was a much larger retrospective cohort study of 55,793 men who had received replacement testosterone.³ The authors reported an increase in the relative risk of MI in the first 3 months after starting testosterone compared with the risk of MI in the same men in the prior year (relative risk [RR] = 1.36). However, the much more important absolute risk increase was very, very low, with only an additional 1.25 cases of MI seen over 1,000 patient-years. Apart from the fact that a RR of 1.36 is most unimpressive in a retrospective study, the simple fact that the men were older by a few months after TRT is probably more than adequate to explain this tiny increase in apparent risk.

The FDA has monitored these studies closely and has chosen not to make a determination that there is an increased risk of cardiovascular events associated with TRT. That is not at all the same as saying that it has been proven to be completely free of cardiovascular risk; rather it is a common-sense acknowledgment that there is not any convincing evidence to date of such a risk.

Thus, the conscientious clinician is left to conclude that TRT is a reasonable option in symptomatic patients who have been shown to have low levels of free testosterone. It has not been conclusively demonstrated that TRT will have significant beneficial effects, but neither has it been proven to have any true cardiovascular toxicity. It is a therapy worth trying in those symptomatic patients who understand that they will be receiving therapy of uncertain benefit, if any, and with the possibility of uncertain risk, if any.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

At first it seems to be a fairly straightforward proposition. The older gentleman you are seeing in the clinic reports that he has been running rather low on energy in recent weeks, and he also mentions that there’s not much lead in his pencil these days. As a conscientious clinician, you immediately entertain the possibility that hypogonadism might explain some of his symptoms. You dutifully order up a total testosterone level, and then a free testosterone level when the total comes back low, recognizing that binding protein abnormalities might produce a low total even when the clinically relevant free level is still normal. Both levels do come back well below the age-adjusted lower limits of normal, which gives you some transient level of satisfaction that you have identified a very significant factor contributing to your patient’s difficulties.

You have confirmed a deficiency of a major hormone, and it seems logical that you would want to restore the hormone level to normal in this particular patient. But before you reach for your prescription pad (or your mouse), a fundamental question hangs uneasily in the air. Are you going to be doing more harm than good by prescribing testosterone replacement therapy (TRT) to this rather trusting older fellow? In light of recent studies, might you actually increase this patent’s chances of a heart attack or a stroke? That would not be a nice thing to do to this pleasant older gentleman. (As a newly minted senior citizen, I pray mightily that my own caregivers adhere rigorously to Hippocrates’ hoary admonition to, above all, do no harm.)

I’m not going to be able to resolve this clinical conundrum definitively in this editorial. (Please don’t stop reading just yet!) But maybe a review of the pros and cons for testosterone replacement therapy can help you faithful readers gain just a little bit better sense of the operative risk/benefit considerations at play here.

Let’s look first at the case for prescribing TRT when the laboratory test values show definitive evidence of low testosterone levels. I don’t want to delve into the distracting issue of which form of testosterone replacement to consider, which pits injections vs gels vs patches vs pills (don’t use the potentially hepatotoxic methyltestosterone pills passed out like candy by some urologists). Apart from the possibly relevant issue of peaks and troughs seen with injection therapy, the same risk/benefit considerations pretty much apply to all forms of TRT.

The benefits of TRT clearly include an increase in lean muscle mass, an increase in red blood cell concentration due to the hematopoetic effects of the male hormone, and a reduction in both the total amount and the percentage of body fat. A number of studies have shown that testosterone enhances insulin sensitivity—surely a good thing given the massive number of older patients with either prediabetes or full-blown type 2 diabetes. Some men also report a significant increase in their hard-to-define-but-still important sense of manliness, and sometimes a major improvement in their ability to perform in the sack. The latter effects, though, are often very modest and of considerably less potency (sorry, pun intended) than seen with sildenafil or one of the other PDE-5 inhibitors. In spite of all these seemingly positive effects, the clear majority of men report that they really don’t feel much different after starting on TRT, and many discontinue it on their own after relatively short periods, especially those enduring intramuscular injections every 2 weeks.

So the benefits derived from TRT are not really very impressive in many patients. What about the downside of giving testosterone? Surely there can’t be any problems associated with simply replacing an important hormone that has fallen to low levels? After all, we don’t hesitate to give thyroid hormone to hypothyroid patients, to give growth hormone to children with low levels of this critical hormone, or to give insulin to diabetic patients whose pancreases are not producing enough of that life-saving hormone.

For a very long time the risk/benefit arguments over whether or not to give TRT were almost entirely theoretical. Those in favor cited the several aforementioned benefits, and those in opposition decried replacement therapy as a perverse form of tinkering with nature by trying to alter the natural decline in the levels of certain hormones that were part and parcel of the natural aging process.

Then along came 3 rather worrisome studies in fairly rapid-fire succession, which seamed collectively to deliver a true body blow to TRT. However, a closer examination of these studies reveals that each is so severely flawed that no meaningful conclusions can be derived from any of them.

The Testosterone in Older Men with Sarcopenia (TOM) trial was a randomized trial of TRT vs placebo in older men (mean age 74 years) with mobility limitations (sarcopenia, after all, means decreased muscle bulk) and a high prevalence of chronic disease.¹ The trial was stopped early because of a much higher occurrence of self-reported cardiovascular-related adverse events. However, these adverse events were extremely disparate and were all self-reported; none had been prespecified outcomes. Any objective observer would have to conclude that the study was poorly designed and that no meaningful conclusions can be drawn from its premature termination.

The second trial that seemed to cast doubt on the safety of TRT suffered from an even worse design. It was a retrospective cohort study of 8,709 veterans aged 60 to 64 years with low testosterone levels who were undergoing coronary artery angiography. The authors reported in the Journal of the American Medical Association that those receiving testosterone therapy had a higher risk of experiencing a composite outcome of all-cause mortality, myocardial infarction (MI), or cerebrovascular accident than did those who had not received testosterone therapy (hazard ratio [HR] = 1.29; 95% confidence interval [CI]: 1.04-1.58).² Right off the bat, you should be very wary of any HR emanating from a retrospective study that shows a small increase in risk of 29%; it’s only when a HR is 2.0 or more that it’s likely you’re looking at a real phenomenon. But to add insult to injury, the percentage of actual adverse outcomes was actually SMALLER in those taking testosterone than in those who did not get any! The authors had used such an incredibly tortured series of risk adjustments for a variety of comorbidities that they actually managed to stand the raw numbers on their head.

The third study, which had seamed at first blush to demonstrate cardiovascular toxicity of TRT, was a much larger retrospective cohort study of 55,793 men who had received replacement testosterone.³ The authors reported an increase in the relative risk of MI in the first 3 months after starting testosterone compared with the risk of MI in the same men in the prior year (relative risk [RR] = 1.36). However, the much more important absolute risk increase was very, very low, with only an additional 1.25 cases of MI seen over 1,000 patient-years. Apart from the fact that a RR of 1.36 is most unimpressive in a retrospective study, the simple fact that the men were older by a few months after TRT is probably more than adequate to explain this tiny increase in apparent risk.

The FDA has monitored these studies closely and has chosen not to make a determination that there is an increased risk of cardiovascular events associated with TRT. That is not at all the same as saying that it has been proven to be completely free of cardiovascular risk; rather it is a common-sense acknowledgment that there is not any convincing evidence to date of such a risk.

Thus, the conscientious clinician is left to conclude that TRT is a reasonable option in symptomatic patients who have been shown to have low levels of free testosterone. It has not been conclusively demonstrated that TRT will have significant beneficial effects, but neither has it been proven to have any true cardiovascular toxicity. It is a therapy worth trying in those symptomatic patients who understand that they will be receiving therapy of uncertain benefit, if any, and with the possibility of uncertain risk, if any.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Of all the things you learn in training, one of the most nebulous, but useful, is “Spidey Sense.”

In comics, Spider-Man had a power called Spidey Sense, which caused a skull-base tingling when danger was present. It was a prescient, clairvoyant ability that allowed him to take action to protect himself.

Somewhere along the line, most doctors I know get a similar ability, but it warns us when something is seriously wrong with a patient. Often, it fires before you even have a rational reason to be worried, and it’s almost never wrong.

As a senior in medical school, I heard a conversation between a resident and an attending. The resident was talking about how she’d seen a patient in the emergency department who she sent to the ICU without a concrete reason. An hour after arriving, the patient suffered a cardiac arrest and was successfully resuscitated. The attending told her that this was one of the most critical skills to develop: knowing when patients are really sick, even before you have any obvious reason to think they are.

I have no idea when I learned it. At some point it was just there. I assume it’s a result of years of medical training making you subconsciously recognize a bad situation. It doesn’t fire very often, but when it does it can’t be ignored. Sometimes even a few words typed on my schedule will set it off.

My staff knows when it’s hit me because I’ll bring an MRI order up to the front desk before I’ve completed the appointment and tell them to start working on it.

Not every sick patient sets it off. In fact, obviously sick people never do. In those cases, it’s not needed. But when the tingling starts when you first start talking to someone … don’t ignore it.

There are a lot of intangibles in medicine, and this is one of them. I can’t explain it, but it’s one of the most important skills I’ve learned, although I have no idea when I did. I’m just glad it’s there.

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

Of all the things you learn in training, one of the most nebulous, but useful, is “Spidey Sense.”

In comics, Spider-Man had a power called Spidey Sense, which caused a skull-base tingling when danger was present. It was a prescient, clairvoyant ability that allowed him to take action to protect himself.

Somewhere along the line, most doctors I know get a similar ability, but it warns us when something is seriously wrong with a patient. Often, it fires before you even have a rational reason to be worried, and it’s almost never wrong.

As a senior in medical school, I heard a conversation between a resident and an attending. The resident was talking about how she’d seen a patient in the emergency department who she sent to the ICU without a concrete reason. An hour after arriving, the patient suffered a cardiac arrest and was successfully resuscitated. The attending told her that this was one of the most critical skills to develop: knowing when patients are really sick, even before you have any obvious reason to think they are.

I have no idea when I learned it. At some point it was just there. I assume it’s a result of years of medical training making you subconsciously recognize a bad situation. It doesn’t fire very often, but when it does it can’t be ignored. Sometimes even a few words typed on my schedule will set it off.

My staff knows when it’s hit me because I’ll bring an MRI order up to the front desk before I’ve completed the appointment and tell them to start working on it.

Not every sick patient sets it off. In fact, obviously sick people never do. In those cases, it’s not needed. But when the tingling starts when you first start talking to someone … don’t ignore it.

There are a lot of intangibles in medicine, and this is one of them. I can’t explain it, but it’s one of the most important skills I’ve learned, although I have no idea when I did. I’m just glad it’s there.

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

Of all the things you learn in training, one of the most nebulous, but useful, is “Spidey Sense.”

In comics, Spider-Man had a power called Spidey Sense, which caused a skull-base tingling when danger was present. It was a prescient, clairvoyant ability that allowed him to take action to protect himself.

Somewhere along the line, most doctors I know get a similar ability, but it warns us when something is seriously wrong with a patient. Often, it fires before you even have a rational reason to be worried, and it’s almost never wrong.

As a senior in medical school, I heard a conversation between a resident and an attending. The resident was talking about how she’d seen a patient in the emergency department who she sent to the ICU without a concrete reason. An hour after arriving, the patient suffered a cardiac arrest and was successfully resuscitated. The attending told her that this was one of the most critical skills to develop: knowing when patients are really sick, even before you have any obvious reason to think they are.

I have no idea when I learned it. At some point it was just there. I assume it’s a result of years of medical training making you subconsciously recognize a bad situation. It doesn’t fire very often, but when it does it can’t be ignored. Sometimes even a few words typed on my schedule will set it off.

My staff knows when it’s hit me because I’ll bring an MRI order up to the front desk before I’ve completed the appointment and tell them to start working on it.

Not every sick patient sets it off. In fact, obviously sick people never do. In those cases, it’s not needed. But when the tingling starts when you first start talking to someone … don’t ignore it.

There are a lot of intangibles in medicine, and this is one of them. I can’t explain it, but it’s one of the most important skills I’ve learned, although I have no idea when I did. I’m just glad it’s there.

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