For Residents

As part of my psychiatry residency training, I had the privilege to work with and learn from an aerospace psychiatrist. Aerospace medicine is a branch of preventive and occupational medicine in which aviators (pilots, aircrew, or astronauts) are subject to evaluation/treatment. The goal is to assess physical and mental health factors to mitigate risks, protect public safety, and ensure the aviators’ well-being.^1,2 Aerospace psychiatry is a highly specialized area in which practitioners are trained to perform specific evaluations. In this article, I review those evaluations for those looking to gain insight into the field.

Aviation medical examination

Under Title 14 of the Code of Federal Regulations, the Federal Aviation Administration (FAA) requires aviators to be evaluated for medical certification by undergoing an aviation medical exam.² In order to be deemed “fit for duty,” aviators must meet strict physical and mental health standards set by the FAA. The extent of these standards varies by the class of licensure (Table 1³). Aviation medical exams are performed by any physician who has been designated by the FAA and completed the appropriate FAA aviation medical examiner (AME) training. Aviators who meet the medical standards for their licensure class are recommended for medical certification. If the AME brings up further questions due to the limits of the examination and/or a lack of medical records, the certification will likely be deferred pending further evaluation by an FAA-approved medical specialist and/or the receipt of additional medical records. Questions about a possible psychiatric diagnosis/history or substance use disorder will lead to referral to a psychiatrist familiar with aviation standards for further evaluation.

_

Special issuances and Conditions AMEs Can Issue

There are 15 disqualifying conditions for medical certification (Table 1³). However, a special issuance of a medical certification may be granted if the aviator shows to the satisfaction of the aviation medical examiner that the duties of the licensure class can be performed without endangering the public safety and that the condition is deemed stable. This may be shown through additional medical evaluations/tests and/or records.

There are certain medical conditions for which an AME can issue a medical certificate without further review from other specialists; thus, an AME can review and follow the Conditions AMEs Can Issue (CACI) worksheet to recommend medical certification (Table 2⁴). The CACI guidelines and worksheets are updated by the FAA regularly to ensure aviators’ health and minimize public risk.

Psychiatric & Psychological Evaluation

Aviators may be referred for Psychiatric and Psychological Evaluation (P&P) if an AME discovers additional concerns about psychiatric and neurocognitive disorders. These cases are not clear-cut. An example would be an aviator who was receiving a psychotropic medication in the past and reported past heavy alcohol use. The P&P includes a thorough psychiatric evaluation by an aerospace psychiatrist and extensive psychological testing by an aerospace psychologist. These clinicians also review collateral information and past medical/AME records. Aviators may be recommended for medical certification with special issuance or may be denied medical certification as a result of these examinations.

Human Intervention Motivation Study program

The Human Intervention Motivation Study (HIMS) program was established to provide an avenue whereby commercial pilots with active substance use disorders can be identified, treated, and successfully returned to active flight status.⁵ The goal of the HIMS program is to save lives and careers while enhancing flight safety. Physicians trained in HIMS evaluations follow the multifactorial addiction disease model. This evaluation is used to identify active substance use and initiate treatment, and to maintain sobriety and monitor aftercare adherence.

As part of my psychiatry residency training, I had the privilege to work with and learn from an aerospace psychiatrist. Aerospace medicine is a branch of preventive and occupational medicine in which aviators (pilots, aircrew, or astronauts) are subject to evaluation/treatment. The goal is to assess physical and mental health factors to mitigate risks, protect public safety, and ensure the aviators’ well-being.^1,2 Aerospace psychiatry is a highly specialized area in which practitioners are trained to perform specific evaluations. In this article, I review those evaluations for those looking to gain insight into the field.

Aviation medical examination

Under Title 14 of the Code of Federal Regulations, the Federal Aviation Administration (FAA) requires aviators to be evaluated for medical certification by undergoing an aviation medical exam.² In order to be deemed “fit for duty,” aviators must meet strict physical and mental health standards set by the FAA. The extent of these standards varies by the class of licensure (Table 1³). Aviation medical exams are performed by any physician who has been designated by the FAA and completed the appropriate FAA aviation medical examiner (AME) training. Aviators who meet the medical standards for their licensure class are recommended for medical certification. If the AME brings up further questions due to the limits of the examination and/or a lack of medical records, the certification will likely be deferred pending further evaluation by an FAA-approved medical specialist and/or the receipt of additional medical records. Questions about a possible psychiatric diagnosis/history or substance use disorder will lead to referral to a psychiatrist familiar with aviation standards for further evaluation.

_

Special issuances and Conditions AMEs Can Issue

There are 15 disqualifying conditions for medical certification (Table 1³). However, a special issuance of a medical certification may be granted if the aviator shows to the satisfaction of the aviation medical examiner that the duties of the licensure class can be performed without endangering the public safety and that the condition is deemed stable. This may be shown through additional medical evaluations/tests and/or records.

There are certain medical conditions for which an AME can issue a medical certificate without further review from other specialists; thus, an AME can review and follow the Conditions AMEs Can Issue (CACI) worksheet to recommend medical certification (Table 2⁴). The CACI guidelines and worksheets are updated by the FAA regularly to ensure aviators’ health and minimize public risk.

Psychiatric & Psychological Evaluation

Aviators may be referred for Psychiatric and Psychological Evaluation (P&P) if an AME discovers additional concerns about psychiatric and neurocognitive disorders. These cases are not clear-cut. An example would be an aviator who was receiving a psychotropic medication in the past and reported past heavy alcohol use. The P&P includes a thorough psychiatric evaluation by an aerospace psychiatrist and extensive psychological testing by an aerospace psychologist. These clinicians also review collateral information and past medical/AME records. Aviators may be recommended for medical certification with special issuance or may be denied medical certification as a result of these examinations.

Human Intervention Motivation Study program

The Human Intervention Motivation Study (HIMS) program was established to provide an avenue whereby commercial pilots with active substance use disorders can be identified, treated, and successfully returned to active flight status.⁵ The goal of the HIMS program is to save lives and careers while enhancing flight safety. Physicians trained in HIMS evaluations follow the multifactorial addiction disease model. This evaluation is used to identify active substance use and initiate treatment, and to maintain sobriety and monitor aftercare adherence.

As part of my psychiatry residency training, I had the privilege to work with and learn from an aerospace psychiatrist. Aerospace medicine is a branch of preventive and occupational medicine in which aviators (pilots, aircrew, or astronauts) are subject to evaluation/treatment. The goal is to assess physical and mental health factors to mitigate risks, protect public safety, and ensure the aviators’ well-being.^1,2 Aerospace psychiatry is a highly specialized area in which practitioners are trained to perform specific evaluations. In this article, I review those evaluations for those looking to gain insight into the field.

Aviation medical examination

Under Title 14 of the Code of Federal Regulations, the Federal Aviation Administration (FAA) requires aviators to be evaluated for medical certification by undergoing an aviation medical exam.² In order to be deemed “fit for duty,” aviators must meet strict physical and mental health standards set by the FAA. The extent of these standards varies by the class of licensure (Table 1³). Aviation medical exams are performed by any physician who has been designated by the FAA and completed the appropriate FAA aviation medical examiner (AME) training. Aviators who meet the medical standards for their licensure class are recommended for medical certification. If the AME brings up further questions due to the limits of the examination and/or a lack of medical records, the certification will likely be deferred pending further evaluation by an FAA-approved medical specialist and/or the receipt of additional medical records. Questions about a possible psychiatric diagnosis/history or substance use disorder will lead to referral to a psychiatrist familiar with aviation standards for further evaluation.

_

Special issuances and Conditions AMEs Can Issue

There are 15 disqualifying conditions for medical certification (Table 1³). However, a special issuance of a medical certification may be granted if the aviator shows to the satisfaction of the aviation medical examiner that the duties of the licensure class can be performed without endangering the public safety and that the condition is deemed stable. This may be shown through additional medical evaluations/tests and/or records.

There are certain medical conditions for which an AME can issue a medical certificate without further review from other specialists; thus, an AME can review and follow the Conditions AMEs Can Issue (CACI) worksheet to recommend medical certification (Table 2⁴). The CACI guidelines and worksheets are updated by the FAA regularly to ensure aviators’ health and minimize public risk.

Psychiatric & Psychological Evaluation

Aviators may be referred for Psychiatric and Psychological Evaluation (P&P) if an AME discovers additional concerns about psychiatric and neurocognitive disorders. These cases are not clear-cut. An example would be an aviator who was receiving a psychotropic medication in the past and reported past heavy alcohol use. The P&P includes a thorough psychiatric evaluation by an aerospace psychiatrist and extensive psychological testing by an aerospace psychologist. These clinicians also review collateral information and past medical/AME records. Aviators may be recommended for medical certification with special issuance or may be denied medical certification as a result of these examinations.

Human Intervention Motivation Study program

The Human Intervention Motivation Study (HIMS) program was established to provide an avenue whereby commercial pilots with active substance use disorders can be identified, treated, and successfully returned to active flight status.⁵ The goal of the HIMS program is to save lives and careers while enhancing flight safety. Physicians trained in HIMS evaluations follow the multifactorial addiction disease model. This evaluation is used to identify active substance use and initiate treatment, and to maintain sobriety and monitor aftercare adherence.

In this episode, Daniel G. Haller, MD, of the University of Pennsylvania joins David H. Henry, MD, to talk about the best ways to read and review scientific literature.
And Ilana Yurkiewicz, MD, talks about chaos and opportunity. Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University and is also a columnist for Hematology News. More from Dr. Yurkiewicz here.

Subscribe to Blood & Cancer here:

Apple Podcasts
Google Podcasts

Show notes
By Hitomi Hosoya, MD, PhD,
Resident in the department of internal medicine, University of Pennsylvania Health System

- If you are a peer reviewer of a manuscript submitted to a journal, you should be unbiased, consistent, constructive, and focused on the research. COPE guideline is a good resource.

- If you are a reader of a published article, it is important to ensure that the abstract has the same conclusion as the body of the article. 

- If you are a clinical practitioner and wondering how to apply findings of published data, the editorial section is a good source.

- If you are a trainee and wondering how to stay up-to-date, Oxford Textbook of Oncology or ASCO University are recommended.

Reference:

https://publicationethics.org/resources/guidelines-new/cope-ethical-guidelines-peer-reviewers

In this episode, Daniel G. Haller, MD, of the University of Pennsylvania joins David H. Henry, MD, to talk about the best ways to read and review scientific literature.
And Ilana Yurkiewicz, MD, talks about chaos and opportunity. Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University and is also a columnist for Hematology News. More from Dr. Yurkiewicz here.

Subscribe to Blood & Cancer here:

Apple Podcasts
Google Podcasts

Show notes
By Hitomi Hosoya, MD, PhD,
Resident in the department of internal medicine, University of Pennsylvania Health System

- If you are a peer reviewer of a manuscript submitted to a journal, you should be unbiased, consistent, constructive, and focused on the research. COPE guideline is a good resource.

- If you are a reader of a published article, it is important to ensure that the abstract has the same conclusion as the body of the article. 

- If you are a clinical practitioner and wondering how to apply findings of published data, the editorial section is a good source.

- If you are a trainee and wondering how to stay up-to-date, Oxford Textbook of Oncology or ASCO University are recommended.

Reference:

https://publicationethics.org/resources/guidelines-new/cope-ethical-guidelines-peer-reviewers

In this episode, Daniel G. Haller, MD, of the University of Pennsylvania joins David H. Henry, MD, to talk about the best ways to read and review scientific literature.
And Ilana Yurkiewicz, MD, talks about chaos and opportunity. Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University and is also a columnist for Hematology News. More from Dr. Yurkiewicz here.

Subscribe to Blood & Cancer here:

Apple Podcasts
Google Podcasts

Show notes
By Hitomi Hosoya, MD, PhD,
Resident in the department of internal medicine, University of Pennsylvania Health System

- If you are a peer reviewer of a manuscript submitted to a journal, you should be unbiased, consistent, constructive, and focused on the research. COPE guideline is a good resource.

- If you are a reader of a published article, it is important to ensure that the abstract has the same conclusion as the body of the article. 

- If you are a clinical practitioner and wondering how to apply findings of published data, the editorial section is a good source.

- If you are a trainee and wondering how to stay up-to-date, Oxford Textbook of Oncology or ASCO University are recommended.

Reference:

https://publicationethics.org/resources/guidelines-new/cope-ethical-guidelines-peer-reviewers

I was a third-year medical student, dutifully reviewing discharge instructions with a patient and her family. The patient’s adult daughter asked, “What about that diet you put her on?” As they looked at me quizzically, I looked back equally confused, until it clicked: We needed to talk about the word diet. In everyday conversation, diet generally is understood to mean restriction of food to lose weight, which is what the family hoped would be prescribed for their obese family member. I needed to tell them that I was sorry for the misunderstanding. If they overheard us “ordering a diet,” we simply meant providing trays of hospital food.

We become so familiar with the language of our profession that we do not remember it may be foreign to our patients. In dermatology, we are aware that our specialty is full of esoteric jargon and complex concepts that need to be carefully explained to our patients in simpler terms. But since that incident in medical school, I have been interested in the more insidious potential misunderstandings that can arise from words as seemingly simple as diet. There are many examples in dermatology, particularly in the way we prescribe topical therapy and use trade names.

Topical Therapy

Instructions for systemic medications may be as simple as “take 1 pill twice daily.” Prescriptions for topical medications can be written with an equally simple patient signature such as “apply twice daily to affected area,” but the simplicity is deceptive. The direction to “apply” may seem intuitive to the prescriber, but we do not always specify the amount. Sunscreen, for example, is notoriously underapplied when the actual amount of product needed for protection is not demonstrated.¹ One study of new dermatology patients given a prescription for a new topical medication found that the majority of patients underdosed.²

Determination of an “affected area,” regardless of whether the site is indicated, can be even less straightforward. In acne treatment, the affected area is the whole region prone to acne breakouts, whereas in psoriasis it may be discrete psoriatic plaques. We may believe our explanations are perfectly clear, but we have all seen patients spot treating their acne or psoriasis patients covering entire territories of normal skin with topical steroids, despite our education. One study of eczema action plans found that there was considerable variability in the way different providers described disease flares that require treatment. For example, redness was only used as a descriptor of an eczema flare in 68.2% of eczema action plans studied.³ Ensuring our patients understand our criteria for skin requiring topical treatment may mean the difference between treatment success and failure and also may help to avoid unnecessary side effects.

Adherence to topical medication regimens is poor, and inadequate patient education is only one factor.^4,5 One study found that more than one-third of new prescriptions for topical medications were never even filled.⁶ However, improving our communication about application of topical drugs is one way we must address the complicated issue of adherence.

Trade Names

In dermatology, we often use trade names to refer to our medications, even if we do not intend to reference the brand name of the drug specifically. We may tell a patient to use Lidex (Medicis Pharmaceutical Corporation) for her hands but then send an escript to her pharmacy for fluocinonide. Trade names are designed to roll off the tongue, in contrast to the unwieldy, clumsily long generic names assigned to many of our medications.

Substituting trade names may facilitate more natural conversation to promote patient understanding in some cases; however, there are pitfalls associated with this habit. First, we may be doing our patients a disservice if we do not clarify when it would be acceptable to substitute with the generic when the medication is available over-the-counter. If we decide to treat with Rogaine (Johnson & Johnson Consumer Inc) but do not suggest the option of purchasing the generic minoxidil, the patient could be unnecessarily overpaying for a brand name by following our instructions.

Conversely, there are scenarios in which the use of a brand name is actually not specific enough. A patient once told me she was using Differin (Galderma Laboratories, LP) as discussed at her prior visit, but she revealed she was washing it off after application. I initially assumed she misunderstood that adapalene was a gel to be applied and left on. After additional questioning, however, it became clear that she purchased the Differin gentle cleanser, a nonmedicated facial wash, rather than the retinoid we had intended for her. I had not considered that Differin would market an entire line of skin care products but now realize we must be cautious using Differin and adapalene interchangeably. Other examples include popular over-the-counter antihistamine brands such as Allegra (Chattem, a Sanofi company) or Benadryl (Johnson & Johnson Consumer Inc) that market multiple products with different active ingredients.

Final Thoughts

The smooth transfer of information between physician and patient is key to a healthy therapeutic relationship. In residency and throughout our careers, we will continue to develop and refine our communication skills to best serve our patients. We should pay particular attention to the unexpected and surprising ways in which we fail to adequately communicate, make note of these patterns, and share with our colleagues so that we can all learn from our collective experiences.

I was a third-year medical student, dutifully reviewing discharge instructions with a patient and her family. The patient’s adult daughter asked, “What about that diet you put her on?” As they looked at me quizzically, I looked back equally confused, until it clicked: We needed to talk about the word diet. In everyday conversation, diet generally is understood to mean restriction of food to lose weight, which is what the family hoped would be prescribed for their obese family member. I needed to tell them that I was sorry for the misunderstanding. If they overheard us “ordering a diet,” we simply meant providing trays of hospital food.

We become so familiar with the language of our profession that we do not remember it may be foreign to our patients. In dermatology, we are aware that our specialty is full of esoteric jargon and complex concepts that need to be carefully explained to our patients in simpler terms. But since that incident in medical school, I have been interested in the more insidious potential misunderstandings that can arise from words as seemingly simple as diet. There are many examples in dermatology, particularly in the way we prescribe topical therapy and use trade names.

Topical Therapy

Instructions for systemic medications may be as simple as “take 1 pill twice daily.” Prescriptions for topical medications can be written with an equally simple patient signature such as “apply twice daily to affected area,” but the simplicity is deceptive. The direction to “apply” may seem intuitive to the prescriber, but we do not always specify the amount. Sunscreen, for example, is notoriously underapplied when the actual amount of product needed for protection is not demonstrated.¹ One study of new dermatology patients given a prescription for a new topical medication found that the majority of patients underdosed.²

Determination of an “affected area,” regardless of whether the site is indicated, can be even less straightforward. In acne treatment, the affected area is the whole region prone to acne breakouts, whereas in psoriasis it may be discrete psoriatic plaques. We may believe our explanations are perfectly clear, but we have all seen patients spot treating their acne or psoriasis patients covering entire territories of normal skin with topical steroids, despite our education. One study of eczema action plans found that there was considerable variability in the way different providers described disease flares that require treatment. For example, redness was only used as a descriptor of an eczema flare in 68.2% of eczema action plans studied.³ Ensuring our patients understand our criteria for skin requiring topical treatment may mean the difference between treatment success and failure and also may help to avoid unnecessary side effects.

Adherence to topical medication regimens is poor, and inadequate patient education is only one factor.^4,5 One study found that more than one-third of new prescriptions for topical medications were never even filled.⁶ However, improving our communication about application of topical drugs is one way we must address the complicated issue of adherence.

Trade Names

In dermatology, we often use trade names to refer to our medications, even if we do not intend to reference the brand name of the drug specifically. We may tell a patient to use Lidex (Medicis Pharmaceutical Corporation) for her hands but then send an escript to her pharmacy for fluocinonide. Trade names are designed to roll off the tongue, in contrast to the unwieldy, clumsily long generic names assigned to many of our medications.

Substituting trade names may facilitate more natural conversation to promote patient understanding in some cases; however, there are pitfalls associated with this habit. First, we may be doing our patients a disservice if we do not clarify when it would be acceptable to substitute with the generic when the medication is available over-the-counter. If we decide to treat with Rogaine (Johnson & Johnson Consumer Inc) but do not suggest the option of purchasing the generic minoxidil, the patient could be unnecessarily overpaying for a brand name by following our instructions.

Conversely, there are scenarios in which the use of a brand name is actually not specific enough. A patient once told me she was using Differin (Galderma Laboratories, LP) as discussed at her prior visit, but she revealed she was washing it off after application. I initially assumed she misunderstood that adapalene was a gel to be applied and left on. After additional questioning, however, it became clear that she purchased the Differin gentle cleanser, a nonmedicated facial wash, rather than the retinoid we had intended for her. I had not considered that Differin would market an entire line of skin care products but now realize we must be cautious using Differin and adapalene interchangeably. Other examples include popular over-the-counter antihistamine brands such as Allegra (Chattem, a Sanofi company) or Benadryl (Johnson & Johnson Consumer Inc) that market multiple products with different active ingredients.

Final Thoughts

The smooth transfer of information between physician and patient is key to a healthy therapeutic relationship. In residency and throughout our careers, we will continue to develop and refine our communication skills to best serve our patients. We should pay particular attention to the unexpected and surprising ways in which we fail to adequately communicate, make note of these patterns, and share with our colleagues so that we can all learn from our collective experiences.

I was a third-year medical student, dutifully reviewing discharge instructions with a patient and her family. The patient’s adult daughter asked, “What about that diet you put her on?” As they looked at me quizzically, I looked back equally confused, until it clicked: We needed to talk about the word diet. In everyday conversation, diet generally is understood to mean restriction of food to lose weight, which is what the family hoped would be prescribed for their obese family member. I needed to tell them that I was sorry for the misunderstanding. If they overheard us “ordering a diet,” we simply meant providing trays of hospital food.

We become so familiar with the language of our profession that we do not remember it may be foreign to our patients. In dermatology, we are aware that our specialty is full of esoteric jargon and complex concepts that need to be carefully explained to our patients in simpler terms. But since that incident in medical school, I have been interested in the more insidious potential misunderstandings that can arise from words as seemingly simple as diet. There are many examples in dermatology, particularly in the way we prescribe topical therapy and use trade names.

Topical Therapy

Instructions for systemic medications may be as simple as “take 1 pill twice daily.” Prescriptions for topical medications can be written with an equally simple patient signature such as “apply twice daily to affected area,” but the simplicity is deceptive. The direction to “apply” may seem intuitive to the prescriber, but we do not always specify the amount. Sunscreen, for example, is notoriously underapplied when the actual amount of product needed for protection is not demonstrated.¹ One study of new dermatology patients given a prescription for a new topical medication found that the majority of patients underdosed.²

Determination of an “affected area,” regardless of whether the site is indicated, can be even less straightforward. In acne treatment, the affected area is the whole region prone to acne breakouts, whereas in psoriasis it may be discrete psoriatic plaques. We may believe our explanations are perfectly clear, but we have all seen patients spot treating their acne or psoriasis patients covering entire territories of normal skin with topical steroids, despite our education. One study of eczema action plans found that there was considerable variability in the way different providers described disease flares that require treatment. For example, redness was only used as a descriptor of an eczema flare in 68.2% of eczema action plans studied.³ Ensuring our patients understand our criteria for skin requiring topical treatment may mean the difference between treatment success and failure and also may help to avoid unnecessary side effects.

Adherence to topical medication regimens is poor, and inadequate patient education is only one factor.^4,5 One study found that more than one-third of new prescriptions for topical medications were never even filled.⁶ However, improving our communication about application of topical drugs is one way we must address the complicated issue of adherence.

Trade Names

In dermatology, we often use trade names to refer to our medications, even if we do not intend to reference the brand name of the drug specifically. We may tell a patient to use Lidex (Medicis Pharmaceutical Corporation) for her hands but then send an escript to her pharmacy for fluocinonide. Trade names are designed to roll off the tongue, in contrast to the unwieldy, clumsily long generic names assigned to many of our medications.

Substituting trade names may facilitate more natural conversation to promote patient understanding in some cases; however, there are pitfalls associated with this habit. First, we may be doing our patients a disservice if we do not clarify when it would be acceptable to substitute with the generic when the medication is available over-the-counter. If we decide to treat with Rogaine (Johnson & Johnson Consumer Inc) but do not suggest the option of purchasing the generic minoxidil, the patient could be unnecessarily overpaying for a brand name by following our instructions.

Conversely, there are scenarios in which the use of a brand name is actually not specific enough. A patient once told me she was using Differin (Galderma Laboratories, LP) as discussed at her prior visit, but she revealed she was washing it off after application. I initially assumed she misunderstood that adapalene was a gel to be applied and left on. After additional questioning, however, it became clear that she purchased the Differin gentle cleanser, a nonmedicated facial wash, rather than the retinoid we had intended for her. I had not considered that Differin would market an entire line of skin care products but now realize we must be cautious using Differin and adapalene interchangeably. Other examples include popular over-the-counter antihistamine brands such as Allegra (Chattem, a Sanofi company) or Benadryl (Johnson & Johnson Consumer Inc) that market multiple products with different active ingredients.

Final Thoughts

The smooth transfer of information between physician and patient is key to a healthy therapeutic relationship. In residency and throughout our careers, we will continue to develop and refine our communication skills to best serve our patients. We should pay particular attention to the unexpected and surprising ways in which we fail to adequately communicate, make note of these patterns, and share with our colleagues so that we can all learn from our collective experiences.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Numb and empty, I continued to drive home in a daze. My mind focused only on the light ahead changing from yellow to red. “Remember to step on the brake,” commanded the internal boss to my stunned mind. No tears, I continued to drive as green blinked its eye.

Earlier that afternoon as I stepped out of my second outpatient appointment of the day, the office administrator’s assistant gingerly informed me, “The guy who answered the phone for your no-show said she passed.”

“Passed? Like … died?” I asked in shock.

She nodded. “I looked her up in the system. She passed away 2 Saturdays ago.”

That was only 2 days after the last time I met with her when we celebrated her progress.

“Too soon, too soon in your career,” my attending bemoaned as I shared the news.

Gathering my scattered wit, I smoothed my furrowed brow and forced a smile back into my eyes. I had other patients to see.

Continue to: Soothed by the hum of my car...

Soothed by the hum of my car, my mind replayed our last meeting where hope and active plans had replaced broken hopelessness. For the past 2 weeks, I had erroneously dismissed her no-shows as her volatile borderline personality’s decision to fire me. I was wrong.

Holding things together until a silly domestic dispute unleashed the brewing tornado inside, I stormed upstairs to contain the pain. Behind locked doors, my body shuddered from uncontrollable tears that blinded my eyes. She was the first patient I helped through psychotherapy and the first I lost through suicide.

The news of her death triggered anguish from past suicides of dear friends. Chopper, who blew off his face during our sophomore year of high school. Chopper had already transferred to another school, but those closer to him received a surprise visit with gifts of his personal possessions when he drove up to our school that morning. Later that afternoon, law enforcement found him in a nearby park. In a graduating class of around 100 students, we all grieved.

A few years later, another classmate, Aaron, sank into depression. He, too, shot himself. Just months before I’d received the call requesting my presence at his funeral, he had asked me if I would be his Valentine. Jokingly, I agreed, knowing our paths would never cross after our graduation. At his funeral, his parents insisted that I sat as a member of his immediate family.

Oh … the blinding lies of depression. Those who have fallen prey to suicide never knew the truth: Their lives and their deaths matter.

Even strangers weep.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

Collateral information is a key component obtained during the psychiatric admission process whereby clinicians gather information provided about the patient from the patient’s known contacts. Despite its usefulness in formulating an assessment and plan, collateral information may be misleading and create false biases that lead clinicians to uphold or prolong an involuntary commitment. This raises concern for the need to screen for misleading collateral information, as involuntary admission to an inpatient psychiatric setting can have lasting negative effects on individuals for whom inpatient psychiatric care is not indicated.¹

Here I describe a case in which collateral information obtained about a patient was a primary factor in that patient’s involuntary commitment. However, the patient’s subsequent behavior observed on an inpatient psychiatric unit was entirely inconsistent with those behaviors described by the collateral informant to be “continuous and dangerous.”

CASE

Mr. M, age 18, presented to an emergency psychiatric center for evaluation of dangerous and aggressive behavior. He had a history of autism spectrum disorder (ASD), which was well managed with oral risperidone. He was petitioned for an involuntary psychiatric admission by his foster mother, who reported that Mr. M was aggressive and dangerous, often punching holes in the walls of their home, and that he threatened to assault his foster siblings on several occasions. She detailed a progressively declining history for Mr. M and said that he was “constantly talking to voices in his head that absolutely consume him,” to the extent that Mr. M could not pay attention to his daily tasks. The admitting psychiatrist upheld the petition for involuntary admission, citing that based on the foster’s mother collateral information, Mr. M was deemed to be a danger to others and therefore fulfilled criteria for involuntary psychiatric admission.

Once admitted to the inpatient psychiatric unit, Mr. M was observed to be pleasant, cooperative, and fully engaged in the milieu. At no point during his 7-day admission was he observed to be internally preoccupied or remotely disorganized. Mr. M was switched from oral risperidone to oral haloperidol because he developed acute gynecomastia, and was discharged home.

Does collateral information lead to unfair bias?

The importance of collateral information on the psychiatric admission process must not be understated. It is an opportunity to hear a first-hand account of behaviors consistent with an acute psychiatric disturbance, and guides us in formulating a clinically appropriate assessment and plan. But what happens when our patients’ close contacts or informants provide misleading or unintentionally suboptimal collateral information? How must we reconcile the ethical and legal obligation we have to balance patient autonomy with beneficence?

Studies examining patients’ attitudes toward involuntary admissions have routinely found that patients are less likely than clinical staff to view the involuntary admission as clinically justified.² Consistent with these findings, Mr. M did not view his admission as necessary. At first, he seemed to lack insight regarding the events precipitating his involuntary admission, describing himself not as responding to internal stimuli, but rather, “imaginative because I have autism.” As time went on, though, it was clear that his account of his behavior was in fact correct.

Mr. M’s diagnosis of ASD further complicated the over-reliance on misleading collateral information provided by his foster mother, because the admitting psychiatrist invariably perceived Mr. M as a poor historian. A study examining how subjective histories described by patients with neurologic or psychiatric disorders are perceived by clinicians found physicians had a tendency for negative stereotyping and placed less credence on those patients’ subjective histories.³ Other literature has similarly concluded that there is an urgent need to carefully weigh information supplied to us by collateral informants because the first-hand accounts of perceivably dangerous behavior often are incomplete or misleading.^4-5

Continue to: Ideas for improvement...

Ideas for improvement: respecting patient autonomy

These issues underscore the need for a more thorough review of collateral information to ensure that patient autonomy is not unjustly violated. How do we implement these necessary ideas without creating further undue burden during the admission process? Certainly, I am not suggesting that we evaluate the collateral informant to the degree that we evaluate the patient. However, I have outlined some suggestions for ensuring we act in our patients’ best interest when processing collateral information during an admission:

• Until proven otherwise, the patient’s story is true. If our patient maintains descriptions of his behavior that exist in stark opposition to the collateral information we obtain, we should only not believe the patient if his presentation suggests he may be acutely impaired or a poor historian (such as profound disorganization, overt psychosis, or failing to have capacity).
• Treat symptoms, not diagnoses. In this case, Mr. M was described by his foster mother to be psychotic in addition to having ASD, and an inexperienced psychiatrist may have initiated a titration to a higher antipsychotic dose. However, in the absence of any observable signs of aggression or psychosis, there was simply no indication for further titration of his antipsychotic.
• Document, document, document. When collateral information is supplied to us, it is crucial that we maintain a detailed account of this information. If we have a reason to believe that a patient poses an immediate danger to himself or others, we should carefully document our reasoning so that changes in behavior (if any) can be observed on a day-to-day basis.

On the afternoon of November 19, 2018, Dr. Tamara O’Neal was shot and killed by her ex-fiancé outside Mercy Hospital and Medical Center in Chicago, Illinois. After killing Dr. O’Neal, the gunman ran into the hospital where he exchanged gunfire with police, killing a pharmacy resident and a police officer, before he was killed by police.¹

This horrific encounter between a woman and her former partner begs for a conversation about intimate partner violence (IPV). A data brief of The National Intimate Partner and Sexual Violence Survey was published in November 2018. According to this report, 30.6% of women experienced physical violence by an intimate partner in 2015, with 21.4% of women experiencing severe physical violence. In addition, 31.0% of men experienced physical violence by an intimate partner in 2015; 14.9% of men experienced severe physical violence.²

Intimate partner violence is “our lane”

The shooting at Mercy Hospital occurred amongst a backdrop of controversy between the National Rifle Association (NRA) and the medical community. On November 7, 2018, the NRA tweeted that doctors should “stay in their lane” with regard to gun control after a position paper from the American College of Physicians on reducing firearm deaths and injuries was published in the Annals of Internal Medicine.³ Doctors from every field and from all over the country responded through social media by stating that treating bullet wounds and caring for those affected by gun violence was “their lane.”⁴

It is time for us as a community to recognize that gun violence affects us all. The majority of mass shooters have a history of IPV and often target their current or prior partner during the shooting.⁵ At this intersection of IPV and gun control, the physician has a unique role. We not only treat those affected by gun violence and advocate for better gun control but we also have a duty to screen our patients for IPV. Part of the sacred patient-physician relationship is being present for our patients when they need us most. The American College of Obstetricians and Gynecologists (ACOG) recommends that ObGyns screen patients for IPV at regular intervals and recognizes that it may take several conversations before a patient discloses her history of IPV.⁶ Additionally, given the increased risk of gun injuries and death, it behooves us to also screen for gun safety in the home.

Ask patients about IPV, and ask again

The shooting at Mercy Hospital was a stark reminder that IPV can affect any of us. With nearly one-third of women and more than one-quarter of men experiencing IPV in their lifetime, action must be taken. The first step is to routinely screen patients for IPV, offering support and community resources. (see “Screening for intimate partner violence). The second step is to work to decrease the access perpetrators of IPV have to weapons with which to enact violence—through legislation, community engagement, and using our physician voices.

States that have passed legislation that prohibits persons with active restraining orders or a history of IPV or domestic violence from possessing firearms has seen a decrease in IPV firearm homicide rates.⁷ These policies can make a profound impact on the safety of our patients. Women who are in violent relationships are 5 times more likely to die if their partner has access to a firearm.⁵

Continue to: #BreakTheCycle...

#BreakTheCycle

The 116th Congress convened in January. We have an opportunity to make real gun legislation reform and work to keep our communities and our patients at risk for IPV safer. Tweet your representatives with #BreakTheCycle, and be on the lookout for important legislation to enact real change.

To sign the open letter from American Healthcare Professionals to the NRA regarding their recent comments and our medical experiences with gun violence, click here. Currently, there are more than 41,000 signatures.

If you, or someone you know, needs help, please call The National Domestic Violence Hotline at 1-800-799-7233.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On the afternoon of November 19, 2018, Dr. Tamara O’Neal was shot and killed by her ex-fiancé outside Mercy Hospital and Medical Center in Chicago, Illinois. After killing Dr. O’Neal, the gunman ran into the hospital where he exchanged gunfire with police, killing a pharmacy resident and a police officer, before he was killed by police.¹

This horrific encounter between a woman and her former partner begs for a conversation about intimate partner violence (IPV). A data brief of The National Intimate Partner and Sexual Violence Survey was published in November 2018. According to this report, 30.6% of women experienced physical violence by an intimate partner in 2015, with 21.4% of women experiencing severe physical violence. In addition, 31.0% of men experienced physical violence by an intimate partner in 2015; 14.9% of men experienced severe physical violence.²

Intimate partner violence is “our lane”

The shooting at Mercy Hospital occurred amongst a backdrop of controversy between the National Rifle Association (NRA) and the medical community. On November 7, 2018, the NRA tweeted that doctors should “stay in their lane” with regard to gun control after a position paper from the American College of Physicians on reducing firearm deaths and injuries was published in the Annals of Internal Medicine.³ Doctors from every field and from all over the country responded through social media by stating that treating bullet wounds and caring for those affected by gun violence was “their lane.”⁴

It is time for us as a community to recognize that gun violence affects us all. The majority of mass shooters have a history of IPV and often target their current or prior partner during the shooting.⁵ At this intersection of IPV and gun control, the physician has a unique role. We not only treat those affected by gun violence and advocate for better gun control but we also have a duty to screen our patients for IPV. Part of the sacred patient-physician relationship is being present for our patients when they need us most. The American College of Obstetricians and Gynecologists (ACOG) recommends that ObGyns screen patients for IPV at regular intervals and recognizes that it may take several conversations before a patient discloses her history of IPV.⁶ Additionally, given the increased risk of gun injuries and death, it behooves us to also screen for gun safety in the home.

Ask patients about IPV, and ask again

The shooting at Mercy Hospital was a stark reminder that IPV can affect any of us. With nearly one-third of women and more than one-quarter of men experiencing IPV in their lifetime, action must be taken. The first step is to routinely screen patients for IPV, offering support and community resources. (see “Screening for intimate partner violence). The second step is to work to decrease the access perpetrators of IPV have to weapons with which to enact violence—through legislation, community engagement, and using our physician voices.

States that have passed legislation that prohibits persons with active restraining orders or a history of IPV or domestic violence from possessing firearms has seen a decrease in IPV firearm homicide rates.⁷ These policies can make a profound impact on the safety of our patients. Women who are in violent relationships are 5 times more likely to die if their partner has access to a firearm.⁵

Continue to: #BreakTheCycle...

#BreakTheCycle

The 116th Congress convened in January. We have an opportunity to make real gun legislation reform and work to keep our communities and our patients at risk for IPV safer. Tweet your representatives with #BreakTheCycle, and be on the lookout for important legislation to enact real change.

To sign the open letter from American Healthcare Professionals to the NRA regarding their recent comments and our medical experiences with gun violence, click here. Currently, there are more than 41,000 signatures.

If you, or someone you know, needs help, please call The National Domestic Violence Hotline at 1-800-799-7233.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

On the afternoon of November 19, 2018, Dr. Tamara O’Neal was shot and killed by her ex-fiancé outside Mercy Hospital and Medical Center in Chicago, Illinois. After killing Dr. O’Neal, the gunman ran into the hospital where he exchanged gunfire with police, killing a pharmacy resident and a police officer, before he was killed by police.¹

This horrific encounter between a woman and her former partner begs for a conversation about intimate partner violence (IPV). A data brief of The National Intimate Partner and Sexual Violence Survey was published in November 2018. According to this report, 30.6% of women experienced physical violence by an intimate partner in 2015, with 21.4% of women experiencing severe physical violence. In addition, 31.0% of men experienced physical violence by an intimate partner in 2015; 14.9% of men experienced severe physical violence.²

Intimate partner violence is “our lane”

The shooting at Mercy Hospital occurred amongst a backdrop of controversy between the National Rifle Association (NRA) and the medical community. On November 7, 2018, the NRA tweeted that doctors should “stay in their lane” with regard to gun control after a position paper from the American College of Physicians on reducing firearm deaths and injuries was published in the Annals of Internal Medicine.³ Doctors from every field and from all over the country responded through social media by stating that treating bullet wounds and caring for those affected by gun violence was “their lane.”⁴

It is time for us as a community to recognize that gun violence affects us all. The majority of mass shooters have a history of IPV and often target their current or prior partner during the shooting.⁵ At this intersection of IPV and gun control, the physician has a unique role. We not only treat those affected by gun violence and advocate for better gun control but we also have a duty to screen our patients for IPV. Part of the sacred patient-physician relationship is being present for our patients when they need us most. The American College of Obstetricians and Gynecologists (ACOG) recommends that ObGyns screen patients for IPV at regular intervals and recognizes that it may take several conversations before a patient discloses her history of IPV.⁶ Additionally, given the increased risk of gun injuries and death, it behooves us to also screen for gun safety in the home.

Ask patients about IPV, and ask again

The shooting at Mercy Hospital was a stark reminder that IPV can affect any of us. With nearly one-third of women and more than one-quarter of men experiencing IPV in their lifetime, action must be taken. The first step is to routinely screen patients for IPV, offering support and community resources. (see “Screening for intimate partner violence). The second step is to work to decrease the access perpetrators of IPV have to weapons with which to enact violence—through legislation, community engagement, and using our physician voices.

States that have passed legislation that prohibits persons with active restraining orders or a history of IPV or domestic violence from possessing firearms has seen a decrease in IPV firearm homicide rates.⁷ These policies can make a profound impact on the safety of our patients. Women who are in violent relationships are 5 times more likely to die if their partner has access to a firearm.⁵

Continue to: #BreakTheCycle...

#BreakTheCycle

The 116th Congress convened in January. We have an opportunity to make real gun legislation reform and work to keep our communities and our patients at risk for IPV safer. Tweet your representatives with #BreakTheCycle, and be on the lookout for important legislation to enact real change.

To sign the open letter from American Healthcare Professionals to the NRA regarding their recent comments and our medical experiences with gun violence, click here. Currently, there are more than 41,000 signatures.

If you, or someone you know, needs help, please call The National Domestic Violence Hotline at 1-800-799-7233.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

A lack of diversity in the field of dermatology is a top reason that students of color reject a dermatology career, a new analysis finds.

Yssra S. Soliman of the division of dermatology, in the department of medicine, Albert Einstein College of Medicine, New York, and colleagues surveyed 155 students from 28 different medical schools between January and April 2018 about barriers to applying for a dermatology residency. Of total participants, 43% expressed an interest in applying for a dermatology residency. Of the 155 survey respondents, 58% were nonwhite.

Students of ethnic minorities and students with lower incomes cited lack of diversity in dermatology as a top barrier to applying for a dermatology residency, according to a research letter published in JAMA Dermatology.Other primary barriers reported by students of color were negative perceptions of minority students by residencies, such as lower performance expectations; socioeconomic factors, such as lack of loan forgiveness; and a lack of mentors. (Minorities in the study were defined as nonwhite students and lower-income students were defined as those with annual household incomes below $40,000.)

Study authors wrote that the results highlight the need to recruit and mentor students of all backgrounds. Furthermore, efforts should be made to increase minority students’ exposure to dermatology through curriculum, providing research opportunities, and reducing the cost of visiting electives by providing stipends, they concluded.

The survey results are not surprising, said Susan C. Taylor, MD, cofounder of the Skin of Color Center at St. Luke’s-Roosevelt Hospital in New York and a Philadelphia-based dermatologist. “I think that [the survey] is accurate and reflects the most common barriers for minority students,” Dr. Taylor said in an interview.

While recent progress has been made in discussing the subject of diversity in dermatology and identifying ways to improve, there has been little change in the actual numbers of diverse dermatologists, she noted.

“More research in a larger population of students is needed to learn more about the barriers to matching in dermatology, particularly for students from an under-represented minority background,” Dr. Pandya, professor of dermatology at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

He added that AAD is making marked efforts to improve diversity in dermatology through its diversity committee. AAD diversity initiatives include an intersociety Work Group on Diversity in Dermatology, a diversity mentorship program for medical students, sponsorship of Nth Dimension bioskill workshops, and the Diversity Champion program, which promotes mentorship, volunteerism, and educational activities for students underrepresented in medicine.

It’s too early to tell if the efforts are working, Dr. Pandya said. It will take a few years to see if the efforts result in more minority applicants being interviewed or accepted to a dermatology residency program.

The AAD will hold a Diversity Champion conference in September in Chicago, which is open to “diversity champions” from dermatology residency programs across the United States. The conference is sponsored by the AAD, Association of Professors of Dermatology, Women’s Dermatologic Society, Skin of Color Society, and Society of Investigative Dermatology.

“It will be an annual conference with the goal of improving diversity in our field,” said Dr. Pandya, conference cochair.

SOURCE: Soliman YS et al. JAMA Dermatol. 2019 Jan 9. doi: 10.1001/jamadermatol.2018.4813.

A lack of diversity in the field of dermatology is a top reason that students of color reject a dermatology career, a new analysis finds.

Yssra S. Soliman of the division of dermatology, in the department of medicine, Albert Einstein College of Medicine, New York, and colleagues surveyed 155 students from 28 different medical schools between January and April 2018 about barriers to applying for a dermatology residency. Of total participants, 43% expressed an interest in applying for a dermatology residency. Of the 155 survey respondents, 58% were nonwhite.

Students of ethnic minorities and students with lower incomes cited lack of diversity in dermatology as a top barrier to applying for a dermatology residency, according to a research letter published in JAMA Dermatology.Other primary barriers reported by students of color were negative perceptions of minority students by residencies, such as lower performance expectations; socioeconomic factors, such as lack of loan forgiveness; and a lack of mentors. (Minorities in the study were defined as nonwhite students and lower-income students were defined as those with annual household incomes below $40,000.)

Study authors wrote that the results highlight the need to recruit and mentor students of all backgrounds. Furthermore, efforts should be made to increase minority students’ exposure to dermatology through curriculum, providing research opportunities, and reducing the cost of visiting electives by providing stipends, they concluded.

The survey results are not surprising, said Susan C. Taylor, MD, cofounder of the Skin of Color Center at St. Luke’s-Roosevelt Hospital in New York and a Philadelphia-based dermatologist. “I think that [the survey] is accurate and reflects the most common barriers for minority students,” Dr. Taylor said in an interview.

While recent progress has been made in discussing the subject of diversity in dermatology and identifying ways to improve, there has been little change in the actual numbers of diverse dermatologists, she noted.

“More research in a larger population of students is needed to learn more about the barriers to matching in dermatology, particularly for students from an under-represented minority background,” Dr. Pandya, professor of dermatology at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

He added that AAD is making marked efforts to improve diversity in dermatology through its diversity committee. AAD diversity initiatives include an intersociety Work Group on Diversity in Dermatology, a diversity mentorship program for medical students, sponsorship of Nth Dimension bioskill workshops, and the Diversity Champion program, which promotes mentorship, volunteerism, and educational activities for students underrepresented in medicine.

It’s too early to tell if the efforts are working, Dr. Pandya said. It will take a few years to see if the efforts result in more minority applicants being interviewed or accepted to a dermatology residency program.

The AAD will hold a Diversity Champion conference in September in Chicago, which is open to “diversity champions” from dermatology residency programs across the United States. The conference is sponsored by the AAD, Association of Professors of Dermatology, Women’s Dermatologic Society, Skin of Color Society, and Society of Investigative Dermatology.

“It will be an annual conference with the goal of improving diversity in our field,” said Dr. Pandya, conference cochair.

SOURCE: Soliman YS et al. JAMA Dermatol. 2019 Jan 9. doi: 10.1001/jamadermatol.2018.4813.

A lack of diversity in the field of dermatology is a top reason that students of color reject a dermatology career, a new analysis finds.

Yssra S. Soliman of the division of dermatology, in the department of medicine, Albert Einstein College of Medicine, New York, and colleagues surveyed 155 students from 28 different medical schools between January and April 2018 about barriers to applying for a dermatology residency. Of total participants, 43% expressed an interest in applying for a dermatology residency. Of the 155 survey respondents, 58% were nonwhite.

Students of ethnic minorities and students with lower incomes cited lack of diversity in dermatology as a top barrier to applying for a dermatology residency, according to a research letter published in JAMA Dermatology.Other primary barriers reported by students of color were negative perceptions of minority students by residencies, such as lower performance expectations; socioeconomic factors, such as lack of loan forgiveness; and a lack of mentors. (Minorities in the study were defined as nonwhite students and lower-income students were defined as those with annual household incomes below $40,000.)

Study authors wrote that the results highlight the need to recruit and mentor students of all backgrounds. Furthermore, efforts should be made to increase minority students’ exposure to dermatology through curriculum, providing research opportunities, and reducing the cost of visiting electives by providing stipends, they concluded.

The survey results are not surprising, said Susan C. Taylor, MD, cofounder of the Skin of Color Center at St. Luke’s-Roosevelt Hospital in New York and a Philadelphia-based dermatologist. “I think that [the survey] is accurate and reflects the most common barriers for minority students,” Dr. Taylor said in an interview.

While recent progress has been made in discussing the subject of diversity in dermatology and identifying ways to improve, there has been little change in the actual numbers of diverse dermatologists, she noted.

“More research in a larger population of students is needed to learn more about the barriers to matching in dermatology, particularly for students from an under-represented minority background,” Dr. Pandya, professor of dermatology at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

He added that AAD is making marked efforts to improve diversity in dermatology through its diversity committee. AAD diversity initiatives include an intersociety Work Group on Diversity in Dermatology, a diversity mentorship program for medical students, sponsorship of Nth Dimension bioskill workshops, and the Diversity Champion program, which promotes mentorship, volunteerism, and educational activities for students underrepresented in medicine.

It’s too early to tell if the efforts are working, Dr. Pandya said. It will take a few years to see if the efforts result in more minority applicants being interviewed or accepted to a dermatology residency program.

The AAD will hold a Diversity Champion conference in September in Chicago, which is open to “diversity champions” from dermatology residency programs across the United States. The conference is sponsored by the AAD, Association of Professors of Dermatology, Women’s Dermatologic Society, Skin of Color Society, and Society of Investigative Dermatology.

“It will be an annual conference with the goal of improving diversity in our field,” said Dr. Pandya, conference cochair.

SOURCE: Soliman YS et al. JAMA Dermatol. 2019 Jan 9. doi: 10.1001/jamadermatol.2018.4813.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.

As the residents on the podium ran through case presentations at the Texas Dermatological Society meeting this past fall (September 21-22, 2018; Galveston, Texas), I discretely surveyed the room. To no surprise, perhaps half of the attendees at some point during the hour-long presentation glanced down at their smartphones, and 2018 statistics suggest that approximately 74% of these Internet glances were made by engagers of social media sites.¹ My FOMO (fear of missing out) kicked in. What was everyone looking at? I opened Instagram on my smartphone and plastered at the top of my home page were Texas Dermatological Society–related “stories” posted by other dermatology residents from across the state, one story featuring the very presentation I was attending. I peeked 2 rows ahead to find the social media “influencer” I have been following on Instagram for months in real life for the first time.

It is not just the younger population glued to their social media accounts. In fact, Facebook boasted a more than 80% increase in users 55 years and older between 2011 and 2014 and a 41% increase in users aged 35 to 54 years.² In total, there were 3.2 billion social media users globally in 2018.³ With such a large portion of the population engaged in social media, it is no wonder that it has become a rapidly emerging presence within the field of dermatology.

#Ad

Social media has become a powerful marketing tool for the practicing dermatologist. In a recent survey, 41% of social media users reported that social media influenced their choice of a particular physician, facility, or medical practice.⁴ Corresponding to this behavior, dermatology practices also have used social media to educate patients on services offered, acquire new patients, engage existing patients, create brand loyalty, become a trusted source of medical information in a sea of digital misinformation, and facilitate positive word-of-mouth opportunities.⁵ In fact, 53% of physician practices in the United States operate a Facebook page.⁶ For these physicians, marketing through social media carries the advantages of low cost and rapid transmission of information to a wide audience.⁷ Furthermore, the development of business insights and statistics by some social media platforms, such as those available to users on business profiles on Instagram, enables practices and marketers to target their audiences and optimize reach.

#DermLife

The role of social media in dermatology extends far beyond marketing. Lifestyle blogs centered on daily life as a medical provider, even within the field of dermatology, are gaining popularity. Dermatology-centered lifestyle blogs often incorporate the root derm in their handle, enabling other users to identify the account holder and interact in meaningful ways. According to a post from one popular Instagram influencer Dr. Audrey Sue Cruz (@dr.audreyxsue), such profiles may serve to prevent burnout, provide a creative outlet, share life as a resident, develop a supportive community, provide mentorship, and spread inspiration.

#Hashtag

Another interesting utility of social media is the use of standardized hashtags to facilitate scientific and clinical dialogue among medical professionals. Standardization of hashtag ontology on Twitter and Instagram has been adopted by the urology and gastroenterology fields to filter out “noise” by individuals not intending to join academic discussion.⁸ In dermatology, standardized hashtags have not been adopted, to my knowledge; however, a search for esoteric dermatologic terms such as #dermatopathology or #mohssurgery directs users to specialty-specific discussions.

#DontFryDay

Another role of social media in dermatology is dissemination of information. One notable example is the reach on Twitter of the “Don’t Fry Day” campaign, an annual campaign by the National Council on Skin Cancer Prevention to promote sun safety awareness and sun protection behaviors. In a recent study by Nguyen et al,⁹ the hashtag #DontFryDay was tracked on Twitter to assess the reach of the campaign. They found that this campaign had an impressive reach of approximately 1200 contributors, resulting in more than 16.5 million impressions; 18 celebrities and verified individuals accounted for 8,735,549 impressions.⁹

Despite the large potential for dissemination of information on social media, in 2014 none of the top 10 dermatologic journals or professional dermatologic organizations maintained an Instagram account. Only one of the top 10 patient advocate groups related to dermatology conditions—the Melanoma Research Foundation—was found on Instagram as of 2014.¹⁰ Furthermore, none of the top 10 most popular dermatology journals, professional dermatology organizations, or dermatology-related patient advocate groups could be found on Tumblr as of 2014.¹¹ Although some of the aforementioned organizations have since adopted social media accounts, such as Cutis and Dermatology News (@mdedgederm) on Instagram in 2018, these social media platforms remain largely untapped outlets for dissemination of information to the public by reputable sources.

#VerifyHealthcare

Although social media has offered many advantages to the field of dermatology, it also has brought about unique challenges such as blind authorship, lack of source citation, and presentation of opinion as fact.⁷ To compound the challenge, 90% of millennials aged 18 to 24 years reportedly trust health care information shared by others on social media.¹² Do we, as dermatologists, have a duty to take to social media to provide reputable health information? In an effort to address this emerging problem, popular Instagram influencer Dr. Austin Chiang (@austinchiangmd) initiated the #VerifyHealthcare movement, which called for physicians active on social media to practice transparency by providing users with their credentials.¹³ The goal of the movement is to help users differentiate medical information disseminated by trained medical professionals from misinformation by disreputable sources.

Final Thoughts

Despite its shortcomings, the emerging roles of social media in dermatology have proven to be a prominent force here to stay, providing new and innovative opportunities to dermatologists for social networking, dissemination of health information, motivation and inspiration, and marketing.

SAN DIEGO – Looking to get your study published in a top medical journal? Bob Löwenberg, MD, PhD, editor-in-chief of Blood, says to start thinking about what appeals to readers.

Courtesy Erasmus University

“What do readers want? They want important information with impact in a clinical or biological sense,” Dr. Löwenberg of Erasmus University Rotterdam (the Netherlands) said at the annual meeting of the American Society of Hematology. “Usually they want to get novel information – new and cutting-edge insights, if possible. And readers want to receive access to information that is right. This is about quality.”

Dr. Löwenberg offered several tips for getting published:
 

• Make sure your paper has a “clear message” that comes across in both its title and a concisely written abstract. “When your colleagues are going to scan the journal, they should say ‘Hey, this is an interesting title’ or ‘This is an interesting abstract,’ ” Dr. Löwenberg said.
• Avoid jargon and slang. And don’t fill your paper with abbreviations because that will make it unreadable.
• Don’t just cut and paste the abstract from your meeting submission. Update the information and rewrite it before submitting it. “The abstract is so important because it is the part of your manuscript that’s copied by reference systems,” Dr. Löwenberg said. “It’s more broadly published than your manuscript. Write it in such a way that it tells your entire story in a minimal number of words, without changing the overall message of your paper, and in clear language.”
• Focus on providing important background in the introduction, which usually summarizes existing research.
• “Distill the essentials” in the discussion section. “Don’t repeat the results. Discuss the importance of your findings in relation to the state-of-the-art information that you have presented in the introduction,” he said.
• Beware of plagiarism, which includes “self-plagiarism” – duplicating your own previous research without acknowledgment.
• Understand new rules regarding data-sharing requirements developed by the International Committee of Medical Journal Editors. In order to be considered for publication by the committee’s member journals, clinical trials that begin enrolling participants as of Jan. 1, 2019, must include a data-sharing plan in the trial’s registration.
• Don’t be surprised if your paper is turned down. “We all have experience with rejected papers,” he said. “This is part of the game.”

If you are rejected, you may wish to send a rebuttal – a form of appeal – to the journal. Consider this option if the journal “clearly misunderstood or misrepresented the paper,” he said. “Be polite, try to be unemotional and clear, and never [write] it the same day as when you are still angry about this decision.” Once you send a rebuttal, wait for at least a week for a response. If one doesn’t come, he said, feel free to submit the paper elsewhere.

Dr. Löwenberg reported having no relevant financial disclosures.

SAN DIEGO – Looking to get your study published in a top medical journal? Bob Löwenberg, MD, PhD, editor-in-chief of Blood, says to start thinking about what appeals to readers.

Courtesy Erasmus University

“What do readers want? They want important information with impact in a clinical or biological sense,” Dr. Löwenberg of Erasmus University Rotterdam (the Netherlands) said at the annual meeting of the American Society of Hematology. “Usually they want to get novel information – new and cutting-edge insights, if possible. And readers want to receive access to information that is right. This is about quality.”

Dr. Löwenberg offered several tips for getting published:
 

• Make sure your paper has a “clear message” that comes across in both its title and a concisely written abstract. “When your colleagues are going to scan the journal, they should say ‘Hey, this is an interesting title’ or ‘This is an interesting abstract,’ ” Dr. Löwenberg said.
• Avoid jargon and slang. And don’t fill your paper with abbreviations because that will make it unreadable.
• Don’t just cut and paste the abstract from your meeting submission. Update the information and rewrite it before submitting it. “The abstract is so important because it is the part of your manuscript that’s copied by reference systems,” Dr. Löwenberg said. “It’s more broadly published than your manuscript. Write it in such a way that it tells your entire story in a minimal number of words, without changing the overall message of your paper, and in clear language.”
• Focus on providing important background in the introduction, which usually summarizes existing research.
• “Distill the essentials” in the discussion section. “Don’t repeat the results. Discuss the importance of your findings in relation to the state-of-the-art information that you have presented in the introduction,” he said.
• Beware of plagiarism, which includes “self-plagiarism” – duplicating your own previous research without acknowledgment.
• Understand new rules regarding data-sharing requirements developed by the International Committee of Medical Journal Editors. In order to be considered for publication by the committee’s member journals, clinical trials that begin enrolling participants as of Jan. 1, 2019, must include a data-sharing plan in the trial’s registration.
• Don’t be surprised if your paper is turned down. “We all have experience with rejected papers,” he said. “This is part of the game.”

If you are rejected, you may wish to send a rebuttal – a form of appeal – to the journal. Consider this option if the journal “clearly misunderstood or misrepresented the paper,” he said. “Be polite, try to be unemotional and clear, and never [write] it the same day as when you are still angry about this decision.” Once you send a rebuttal, wait for at least a week for a response. If one doesn’t come, he said, feel free to submit the paper elsewhere.

Dr. Löwenberg reported having no relevant financial disclosures.

SAN DIEGO – Looking to get your study published in a top medical journal? Bob Löwenberg, MD, PhD, editor-in-chief of Blood, says to start thinking about what appeals to readers.

Courtesy Erasmus University

“What do readers want? They want important information with impact in a clinical or biological sense,” Dr. Löwenberg of Erasmus University Rotterdam (the Netherlands) said at the annual meeting of the American Society of Hematology. “Usually they want to get novel information – new and cutting-edge insights, if possible. And readers want to receive access to information that is right. This is about quality.”

Dr. Löwenberg offered several tips for getting published:
 

• Make sure your paper has a “clear message” that comes across in both its title and a concisely written abstract. “When your colleagues are going to scan the journal, they should say ‘Hey, this is an interesting title’ or ‘This is an interesting abstract,’ ” Dr. Löwenberg said.
• Avoid jargon and slang. And don’t fill your paper with abbreviations because that will make it unreadable.
• Don’t just cut and paste the abstract from your meeting submission. Update the information and rewrite it before submitting it. “The abstract is so important because it is the part of your manuscript that’s copied by reference systems,” Dr. Löwenberg said. “It’s more broadly published than your manuscript. Write it in such a way that it tells your entire story in a minimal number of words, without changing the overall message of your paper, and in clear language.”
• Focus on providing important background in the introduction, which usually summarizes existing research.
• “Distill the essentials” in the discussion section. “Don’t repeat the results. Discuss the importance of your findings in relation to the state-of-the-art information that you have presented in the introduction,” he said.
• Beware of plagiarism, which includes “self-plagiarism” – duplicating your own previous research without acknowledgment.
• Understand new rules regarding data-sharing requirements developed by the International Committee of Medical Journal Editors. In order to be considered for publication by the committee’s member journals, clinical trials that begin enrolling participants as of Jan. 1, 2019, must include a data-sharing plan in the trial’s registration.
• Don’t be surprised if your paper is turned down. “We all have experience with rejected papers,” he said. “This is part of the game.”

If you are rejected, you may wish to send a rebuttal – a form of appeal – to the journal. Consider this option if the journal “clearly misunderstood or misrepresented the paper,” he said. “Be polite, try to be unemotional and clear, and never [write] it the same day as when you are still angry about this decision.” Once you send a rebuttal, wait for at least a week for a response. If one doesn’t come, he said, feel free to submit the paper elsewhere.

Dr. Löwenberg reported having no relevant financial disclosures.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

Outside the clinic room, I paced the hallway and pressed the phone to my ear, waiting for the resident to pick up.

“I have patient SB in clinic for her appointment now. I’m hoping to get preliminary results of her bone marrow biopsy.”

I had known SB well from her month-long inpatient stay on our leukemia service. She had come in with a white blood cell count through the roof – a relapse of her leukemia, 4 years out from her bone marrow transplant. It was devastating. After a few cycles of chemotherapy and a bone marrow biopsy yesterday to see if it had worked, she was here now to get her results and decide next steps.

“Hello!” I said and we hugged. Her mother and father accompanied her, sitting still with their hands folded nervously. SB had multiple complications during her hospitalization, and we went through how each was doing. Did she get her new heart medication? Did she do okay on the antibiotics? Was the rash improving? With each question, she and her parents seemed more nervous.

There was an elephant in that exam room. Asking a cancer patient in limbo if she refilled her heart medications becomes as trivial as asking her about the weather. SB and her parents were here for one thing, from which everything else was a distraction. The only question that mattered was the one splitting their world in two: Is their daughter in remission or not?

“She’s here with her parents now,” I said outside the door. “What do you think?” The resident told me he had looked at the case this morning, and it looked like 3% blasts. I smiled – anything under 5% is good, considered a remission. But the pathology resident still hadn’t reviewed the sample with his attending.

Inside the room, after exhausting all other conversation, I hesitated. Should I tell SB the preliminary results? Or should I wait for the final diagnosis?

I’d been burned before. Once, I told a patient with a new diagnosis of esophageal cancer that it was early stage. It was not. Upon additional radiology review, the surrounding lymph nodes were enlarged, and they were ultimately found to be metastases. That initial conversation – and the subsequent one, in which I had to walk back my reassurance that the cancer was contained – was seared into my mind.

I learned from it. Giving preliminary results can be dangerous. What if we say all clear and then learn days later it isn’t so? Or what if we reveal the cancer is progressing, causing despair and re-evaluation of life’s priorities, only to find out it was a false alarm? False alarms are terrifying, and false reassurance is cruel, yet all the while, excessive waiting can feel excruciating for the person whose very existence is suspended.

As hematologists and oncologists, we scroll through CT scans, and we look at slides ourselves. But we also value and depend on the expertise of our colleagues in other departments like pathology and radiology who have their own workflow. It’s a process; it’s for quality assurance that we don’t get immediate results, and that’s a good thing.

It depends on the patient, but often I find the most straightforward solution is to say exactly what is true. For some, the combination of incredibly high stakes coupled with extended wait times becomes agonizing. They might incorrectly read into unrelated, benign actions – if my pager goes off or I look at the computer screen a moment too long – as clues into something I know and am not sharing. They might be so distracted we cannot address anything else.

So I’ve walked back from my initial “do not share anything” reaction to “it’s sometimes okay” – as long as the patient understands the nuances of what preliminary results do and do not mean. The problem with my esophageal cancer patient was not that I had shared preliminary results; it was that I hadn’t framed them as such. I had simply stated the findings, portraying them as certain.

Now, I tend to break the fourth wall. I explain that it’s the resident’s read, that it isn’t final, and that it can be amended. Do you still want to know?

Most people say yes.

SB and her parents were in that boat. They had driven 3 hours to make this appointment. They didn’t want to drive home empty handed.

“It’s preliminary,” I carefully qualified.

“Okay.”

“The final results may be different.”

“Okay, yes. We understand.”

The three of them held hands. They were holding their breath.

“It looks like remission.”

SB cried. Her mother threw her arms around my neck. “You know, she broke down when you stepped out,” her father whispered to me. “She was sure it meant bad news.”

I tried to be happy for them and with them, but now I was the one holding my breath. I hoped I wouldn’t have to take it all away.

For the next 24 hours, I compulsively checked SB’s chart, hoping final results would populate that would be consistent with what I had shared.

The next day, the pathologist called me, and I called SB.

“I have the final results,” I said, followed by my favorite phrase in hematology and oncology. “I have good news.”

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.