Commentary

Every month sees new apps launched by established medical organizations. Although these apps don’t have data to confirm their usefulness, at least they come from known and trusted sources. Here’s a roundup of some of the latest. You decide whether or not they’re worth a try.

The Centers for Disease Control and Prevention (CDC) makes it easier for clinicians to find recommended immunization schedules for adults and children through its free CDC Vaccine Schedules app. Look up contraindications to vaccination or catch-up schedules for children and adolescents, or search recommendations for adults based on the presence of diabetes, HIV, pregnancy, or other conditions, among other features.

Courtesy CDC/Douglas Jordan, M.A.

The free Spot a Stroke FAST app from the American Heart Association and American Stroke Association can help patients and family members identify the signs and symptoms of stroke in order to get timely help. Named after the mnemonic FAST (Face, Arm, Speech, Time), the app includes the ability to phone 911, with a time stamp showing when the call was made, features that may help clinicians in management decisions.

The American College of Cardiology’s free Guideline Clinical App includes three recently updated practice guidelines in its first iteration, on the management of heart failure, assessment of cardiovascular risk, and the treatment of blood cholesterol.

Clinical pearls for emergency medicine developed by the University of Maryland are available in the university’s free app UMEM Pearls.

The U.S. Substance Abuse and Mental Health Services Administration’s free KnowBullying app guides parents and educators on how to start easy, meaningful conversations with children about preventing or responding to bullying. Parents and caregivers who spend at least 15 minutes a day talking with a child can help build a strong relationship that can help prevent bullying, the group says.

The CDC’s free Heads Up app can help parents and caregivers spot the signs and symptoms of a concussion and learn what to do if you think a child or adolescent may have a concussion or other serious brain injury. Bonus: It also offers information on picking the right helmet for specific activities.

While we’re on the topic of pediatrics – the American Academy of Pediatrics (AAP) offers a slew of apps for physicians and parents. One of the most recent is the free AAP Journals app, which received an overall positive but mixed review on iMedicalApps.com.

Residents in the states of Washington or Minnesota can use Planned Parenthood’s free Planned Parenthood Care app in a pilot program that lets them connect with clinicians via video to get birth control methods sent through the mail – contraceptive pills, patches, or rings. The video visit costs $45.

Women who are pregnant or nursing and want to eat fish may like the free Fish4Health app from Purdue University that provides information on the benefits and safety of various fish species and helps them track their intake of healthy fats and mercury.

The European Society of Human Reproduction and Embryology offers its members a free app and/or web-based guidelines on the “Management of Women with Endometriosis.” The app summarizes the 83 recommendations in the guidelines and offers a decision-aid on six key issues in endometriosis.

Among a bevy of apps from the American Red Cross, the recent free Blood Donor app streamlines the process of donating blood, offers rewards to donors from participating retailers, and includes social media features that help promote giving blood.

Is there a new app that you think we should highlight? Let us know.

[email protected]

On Twitter @sherryboschert

Every month sees new apps launched by established medical organizations. Although these apps don’t have data to confirm their usefulness, at least they come from known and trusted sources. Here’s a roundup of some of the latest. You decide whether or not they’re worth a try.

The Centers for Disease Control and Prevention (CDC) makes it easier for clinicians to find recommended immunization schedules for adults and children through its free CDC Vaccine Schedules app. Look up contraindications to vaccination or catch-up schedules for children and adolescents, or search recommendations for adults based on the presence of diabetes, HIV, pregnancy, or other conditions, among other features.

Courtesy CDC/Douglas Jordan, M.A.

The free Spot a Stroke FAST app from the American Heart Association and American Stroke Association can help patients and family members identify the signs and symptoms of stroke in order to get timely help. Named after the mnemonic FAST (Face, Arm, Speech, Time), the app includes the ability to phone 911, with a time stamp showing when the call was made, features that may help clinicians in management decisions.

The American College of Cardiology’s free Guideline Clinical App includes three recently updated practice guidelines in its first iteration, on the management of heart failure, assessment of cardiovascular risk, and the treatment of blood cholesterol.

Clinical pearls for emergency medicine developed by the University of Maryland are available in the university’s free app UMEM Pearls.

The U.S. Substance Abuse and Mental Health Services Administration’s free KnowBullying app guides parents and educators on how to start easy, meaningful conversations with children about preventing or responding to bullying. Parents and caregivers who spend at least 15 minutes a day talking with a child can help build a strong relationship that can help prevent bullying, the group says.

The CDC’s free Heads Up app can help parents and caregivers spot the signs and symptoms of a concussion and learn what to do if you think a child or adolescent may have a concussion or other serious brain injury. Bonus: It also offers information on picking the right helmet for specific activities.

While we’re on the topic of pediatrics – the American Academy of Pediatrics (AAP) offers a slew of apps for physicians and parents. One of the most recent is the free AAP Journals app, which received an overall positive but mixed review on iMedicalApps.com.

Residents in the states of Washington or Minnesota can use Planned Parenthood’s free Planned Parenthood Care app in a pilot program that lets them connect with clinicians via video to get birth control methods sent through the mail – contraceptive pills, patches, or rings. The video visit costs $45.

Women who are pregnant or nursing and want to eat fish may like the free Fish4Health app from Purdue University that provides information on the benefits and safety of various fish species and helps them track their intake of healthy fats and mercury.

The European Society of Human Reproduction and Embryology offers its members a free app and/or web-based guidelines on the “Management of Women with Endometriosis.” The app summarizes the 83 recommendations in the guidelines and offers a decision-aid on six key issues in endometriosis.

Among a bevy of apps from the American Red Cross, the recent free Blood Donor app streamlines the process of donating blood, offers rewards to donors from participating retailers, and includes social media features that help promote giving blood.

Is there a new app that you think we should highlight? Let us know.

[email protected]

On Twitter @sherryboschert

Every month sees new apps launched by established medical organizations. Although these apps don’t have data to confirm their usefulness, at least they come from known and trusted sources. Here’s a roundup of some of the latest. You decide whether or not they’re worth a try.

The Centers for Disease Control and Prevention (CDC) makes it easier for clinicians to find recommended immunization schedules for adults and children through its free CDC Vaccine Schedules app. Look up contraindications to vaccination or catch-up schedules for children and adolescents, or search recommendations for adults based on the presence of diabetes, HIV, pregnancy, or other conditions, among other features.

Courtesy CDC/Douglas Jordan, M.A.

The free Spot a Stroke FAST app from the American Heart Association and American Stroke Association can help patients and family members identify the signs and symptoms of stroke in order to get timely help. Named after the mnemonic FAST (Face, Arm, Speech, Time), the app includes the ability to phone 911, with a time stamp showing when the call was made, features that may help clinicians in management decisions.

The American College of Cardiology’s free Guideline Clinical App includes three recently updated practice guidelines in its first iteration, on the management of heart failure, assessment of cardiovascular risk, and the treatment of blood cholesterol.

Clinical pearls for emergency medicine developed by the University of Maryland are available in the university’s free app UMEM Pearls.

The U.S. Substance Abuse and Mental Health Services Administration’s free KnowBullying app guides parents and educators on how to start easy, meaningful conversations with children about preventing or responding to bullying. Parents and caregivers who spend at least 15 minutes a day talking with a child can help build a strong relationship that can help prevent bullying, the group says.

The CDC’s free Heads Up app can help parents and caregivers spot the signs and symptoms of a concussion and learn what to do if you think a child or adolescent may have a concussion or other serious brain injury. Bonus: It also offers information on picking the right helmet for specific activities.

While we’re on the topic of pediatrics – the American Academy of Pediatrics (AAP) offers a slew of apps for physicians and parents. One of the most recent is the free AAP Journals app, which received an overall positive but mixed review on iMedicalApps.com.

Residents in the states of Washington or Minnesota can use Planned Parenthood’s free Planned Parenthood Care app in a pilot program that lets them connect with clinicians via video to get birth control methods sent through the mail – contraceptive pills, patches, or rings. The video visit costs $45.

Women who are pregnant or nursing and want to eat fish may like the free Fish4Health app from Purdue University that provides information on the benefits and safety of various fish species and helps them track their intake of healthy fats and mercury.

The European Society of Human Reproduction and Embryology offers its members a free app and/or web-based guidelines on the “Management of Women with Endometriosis.” The app summarizes the 83 recommendations in the guidelines and offers a decision-aid on six key issues in endometriosis.

Among a bevy of apps from the American Red Cross, the recent free Blood Donor app streamlines the process of donating blood, offers rewards to donors from participating retailers, and includes social media features that help promote giving blood.

Is there a new app that you think we should highlight? Let us know.

[email protected]

On Twitter @sherryboschert

I would like to provide some perspective on the recent article on the Army STARRS study.

The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.

My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.

This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.

At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.

Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.

So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.

It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.

However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.

What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.

The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.

Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.

There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.

The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.

So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

I would like to provide some perspective on the recent article on the Army STARRS study.

The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.

My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.

This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.

At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.

Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.

So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.

It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.

However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.

What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.

The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.

Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.

There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.

The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.

So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

I would like to provide some perspective on the recent article on the Army STARRS study.

The article, “Predicting Suicides After Psychiatric Hospitalization in U.S. Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)” (JAMA Psychiatry 2014 Nov. 12 [doi: 10.1001/jamapsychiatry.2014.1754]), is one of a series from this multicenter, multiyear study.

My observations focus on four areas: 1) the history behind this research effort, 2) what we learn from the results, 3) how can we change the way we treat service members based on the results? and 4) the change in accession standards.

This research effort was launched after the rate of suicides continued to rise. Then vice chief of staff, Lt. Gen. Peter Chiarelli was frustrated. He developed a contract with the National Institute of Mental Health to fund an ambitious research agenda that included examining all known suicides to find a way to reduce them.

At that time, I was the chief psychiatrist for the Army and was frankly cynical about the STARRS research. We already knew the risk factors for suicide: previous psychiatric or criminal history, relationship difficulties, problems at work, substance abuse, and access to firearms. But, being a good Army Soldier, I saluted and worked to make it happen. After all, maybe the research would bring some clinically useful revelations.

Lt. Gen. Chiarelli also wanted quick results, within a year. Fat chance, I would have muttered under my breath, had I not been a good Soldier.

So, what does the research tell us, 5 years after the inception? Frankly not much that a military psychiatrist does not already know about the risk factors for suicide in military members. However, the article in JAMA Psychiatry does quantify those risk factors mentioned above.

It also stresses the high risk for those recently psychiatrically hospitalized. Civilian as well as military psychiatrists already know that high-risk patients are the ones who get hospitalized. A caveat: Only 12% of Army suicides were post hospitalization.

However, for a military servicemember, the hospitalization may add to their stress, as it often contributes to an exit from the military. Exit may mean a loss of job, housing, health care, and identity.

What is the actionable intelligence from the article? By actionable intelligence, a military term, I mean here what can clinicians do differently as a result of the research? Do you hospitalize less? Probably not.

The authors suggest more posthospitalization interventions but are guarded in their recommendations. More intensive follow-up could lead to more stigmatization and contribute to an accelerated exit from the military.

Nevertheless, that recommendation is where the value of this article lies. The military system is highly stressed with many competing priorities. Many posts, but not all, have posthospitalization easy access to care. As the article recommends, and I concur, there should be more intensive follow-up. This can be done in many ways, including group settings; military members often prefer groups, as then they can help one another.

There is another subtext to the whole suicide discussion: In the early years of the wars in Iraq and Afghanistan, when the Army was desperate for recruits, it relaxed its accession standards. More came in with prior psychiatric diagnoses. Later, the standards were tightened again; those soldiers were disqualified.

The changes in accession standards often happen in times of conflict. It is not surprising that increases in behavioral health difficulties happen when recruiters are strapped for new recruits and take in marginal performers. Now that the military is drawing down, and it is harder to get into the military with a bad background, suicides in the active duty may taper, irrespective of all the research and suicide prevention programs.

So the article cements what we already knew: People with previous psychiatric problems are more likely to suicide. The question is what can we do about it?

Dr. Ritchie is former chief of psychiatry for the U.S. Army and the current chief clinical officer in the department of behavioral health for the District of Columbia.

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.