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Connected care
I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.
In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me,
I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.
In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.
The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.
But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.
In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me,
I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.
In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.
The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.
But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.
In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me,
I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.
In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.
The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.
But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
Beyond symptom improvement: Practicing happiness
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Addressing the sexual and reproductive health needs of trans and gender nonconforming patients
Separating gender identity from sexual identity to allow for more comprehensive history-taking
Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.
By definition, gender identity refers to an internal experience of one’s gender, of one’s self.1 While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.
Overall, When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.2 The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.
With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.
A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.3 One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”
Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures
References
1. Sexual orientation and gender identity definitions. Human Rights Campaign.
2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.
3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.
Separating gender identity from sexual identity to allow for more comprehensive history-taking
Separating gender identity from sexual identity to allow for more comprehensive history-taking
Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.
By definition, gender identity refers to an internal experience of one’s gender, of one’s self.1 While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.
Overall, When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.2 The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.
With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.
A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.3 One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”
Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures
References
1. Sexual orientation and gender identity definitions. Human Rights Campaign.
2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.
3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.
Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.
By definition, gender identity refers to an internal experience of one’s gender, of one’s self.1 While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.
Overall, When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.2 The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.
With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.
A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.3 One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”
Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures
References
1. Sexual orientation and gender identity definitions. Human Rights Campaign.
2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.
3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.
Fear driven
I’m sometimes asked what was different about practicing pediatrics when I was at the apex of my clinical career. Colored by the recent memory of several painful adjustments to unworkable and time-gobbling electronic medical record systems, I usually answer, “It was more fun before the damn computer landed in my exam room.” However, an op-ed piece in the New York Times has prompted me to reconsider how the practice of medicine has changed over the last 50 years (“An Era Defined by Fear,” by David Brooks, April 29, 2019).
Mr. Brooks claims that the era in which we are living is defined by fear. He argues that beginning with the terrorist attacks of 9/11, fear has crept into every corner or our lives, influencing how we relate to one another and govern ourselves. Fueled by a media that feeds us “breaking news” at every hour of the day, we have become a country of people who see everything through the “dark filter” of fear.
I can recall monthly air raid drills during which my third-grade classmates and I scurried under our desks for what seemed hours. And I know my parents were concerned as polio swept through my hometown and the surrounding communities. But I don’t recall feeling the same omnipresent fear that I began to see over the last decade and a half of my practice.
Bombs never landed in Pleasantville, New York, and we knew our school was safe. Third graders today have been told that other third graders have been shot and killed in schools they thought were safe. I knew that there was a risk I might get my “bell rung” playing football. But neither my parents nor I worried that repeated concussions might hasten dementia. My parents and I knew that the weather was unpredictable, but we weren’t bombarded with warnings that the ocean might engulf our home or that the planet was dying.
I suspect my parents worried how I would find my way in the world, but not with the level of anxiety that I feel in parents today who are obsessed with their own fear of failure. And as David Brooks observes, “fear generates fear.” A fearful parent is likely to raise a fearful child. It’s not surprising that today’s pediatricians feel that their appointment lists are filled to the bursting point with patients who have mental health complaints, with anxiety and depression high on the list of diagnoses.
Foremost among our fears is the threat of malpractice litigation. We are coached in risk management strategies, and although we may not admit it, many of us are practicing defensive medicine, a scourge that appeared only infrequently in my first 2 decades of practice. While rumors always could tarnish a physician’s reputation in a small town, the damage done by Internet trolls wielding the power of social media can be several orders of magnitude more devastating.
Not surprisingly, physicians like to practice in comfortable surroundings, which of course draw other physicians, and in short order physicians can find themselves facing the fear of competition. Before insurance companies controlled the landscape, physicians didn’t have to worry about maintaining a stable panel of patients. Now a physician must worry that he or she may be delisted on the whim of a committee of number crunchers. Although I always was concerned on keeping current, my accreditation was grandfathered, and I didn’t have to worry about maintenance of certification (MOC) exams and deadlines. And of course I completed my education with what I considered at the time a whopping $3,200 of debt, but at an interest rate so low that we could make more money in CDs (certificates of deposit).
I wish I could end with something of more substance than Franklin Roosevelt’s advice that the only thing to fear is fear itself. But I’m afraid I can’t.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
I’m sometimes asked what was different about practicing pediatrics when I was at the apex of my clinical career. Colored by the recent memory of several painful adjustments to unworkable and time-gobbling electronic medical record systems, I usually answer, “It was more fun before the damn computer landed in my exam room.” However, an op-ed piece in the New York Times has prompted me to reconsider how the practice of medicine has changed over the last 50 years (“An Era Defined by Fear,” by David Brooks, April 29, 2019).
Mr. Brooks claims that the era in which we are living is defined by fear. He argues that beginning with the terrorist attacks of 9/11, fear has crept into every corner or our lives, influencing how we relate to one another and govern ourselves. Fueled by a media that feeds us “breaking news” at every hour of the day, we have become a country of people who see everything through the “dark filter” of fear.
I can recall monthly air raid drills during which my third-grade classmates and I scurried under our desks for what seemed hours. And I know my parents were concerned as polio swept through my hometown and the surrounding communities. But I don’t recall feeling the same omnipresent fear that I began to see over the last decade and a half of my practice.
Bombs never landed in Pleasantville, New York, and we knew our school was safe. Third graders today have been told that other third graders have been shot and killed in schools they thought were safe. I knew that there was a risk I might get my “bell rung” playing football. But neither my parents nor I worried that repeated concussions might hasten dementia. My parents and I knew that the weather was unpredictable, but we weren’t bombarded with warnings that the ocean might engulf our home or that the planet was dying.
I suspect my parents worried how I would find my way in the world, but not with the level of anxiety that I feel in parents today who are obsessed with their own fear of failure. And as David Brooks observes, “fear generates fear.” A fearful parent is likely to raise a fearful child. It’s not surprising that today’s pediatricians feel that their appointment lists are filled to the bursting point with patients who have mental health complaints, with anxiety and depression high on the list of diagnoses.
Foremost among our fears is the threat of malpractice litigation. We are coached in risk management strategies, and although we may not admit it, many of us are practicing defensive medicine, a scourge that appeared only infrequently in my first 2 decades of practice. While rumors always could tarnish a physician’s reputation in a small town, the damage done by Internet trolls wielding the power of social media can be several orders of magnitude more devastating.
Not surprisingly, physicians like to practice in comfortable surroundings, which of course draw other physicians, and in short order physicians can find themselves facing the fear of competition. Before insurance companies controlled the landscape, physicians didn’t have to worry about maintaining a stable panel of patients. Now a physician must worry that he or she may be delisted on the whim of a committee of number crunchers. Although I always was concerned on keeping current, my accreditation was grandfathered, and I didn’t have to worry about maintenance of certification (MOC) exams and deadlines. And of course I completed my education with what I considered at the time a whopping $3,200 of debt, but at an interest rate so low that we could make more money in CDs (certificates of deposit).
I wish I could end with something of more substance than Franklin Roosevelt’s advice that the only thing to fear is fear itself. But I’m afraid I can’t.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
I’m sometimes asked what was different about practicing pediatrics when I was at the apex of my clinical career. Colored by the recent memory of several painful adjustments to unworkable and time-gobbling electronic medical record systems, I usually answer, “It was more fun before the damn computer landed in my exam room.” However, an op-ed piece in the New York Times has prompted me to reconsider how the practice of medicine has changed over the last 50 years (“An Era Defined by Fear,” by David Brooks, April 29, 2019).
Mr. Brooks claims that the era in which we are living is defined by fear. He argues that beginning with the terrorist attacks of 9/11, fear has crept into every corner or our lives, influencing how we relate to one another and govern ourselves. Fueled by a media that feeds us “breaking news” at every hour of the day, we have become a country of people who see everything through the “dark filter” of fear.
I can recall monthly air raid drills during which my third-grade classmates and I scurried under our desks for what seemed hours. And I know my parents were concerned as polio swept through my hometown and the surrounding communities. But I don’t recall feeling the same omnipresent fear that I began to see over the last decade and a half of my practice.
Bombs never landed in Pleasantville, New York, and we knew our school was safe. Third graders today have been told that other third graders have been shot and killed in schools they thought were safe. I knew that there was a risk I might get my “bell rung” playing football. But neither my parents nor I worried that repeated concussions might hasten dementia. My parents and I knew that the weather was unpredictable, but we weren’t bombarded with warnings that the ocean might engulf our home or that the planet was dying.
I suspect my parents worried how I would find my way in the world, but not with the level of anxiety that I feel in parents today who are obsessed with their own fear of failure. And as David Brooks observes, “fear generates fear.” A fearful parent is likely to raise a fearful child. It’s not surprising that today’s pediatricians feel that their appointment lists are filled to the bursting point with patients who have mental health complaints, with anxiety and depression high on the list of diagnoses.
Foremost among our fears is the threat of malpractice litigation. We are coached in risk management strategies, and although we may not admit it, many of us are practicing defensive medicine, a scourge that appeared only infrequently in my first 2 decades of practice. While rumors always could tarnish a physician’s reputation in a small town, the damage done by Internet trolls wielding the power of social media can be several orders of magnitude more devastating.
Not surprisingly, physicians like to practice in comfortable surroundings, which of course draw other physicians, and in short order physicians can find themselves facing the fear of competition. Before insurance companies controlled the landscape, physicians didn’t have to worry about maintaining a stable panel of patients. Now a physician must worry that he or she may be delisted on the whim of a committee of number crunchers. Although I always was concerned on keeping current, my accreditation was grandfathered, and I didn’t have to worry about maintenance of certification (MOC) exams and deadlines. And of course I completed my education with what I considered at the time a whopping $3,200 of debt, but at an interest rate so low that we could make more money in CDs (certificates of deposit).
I wish I could end with something of more substance than Franklin Roosevelt’s advice that the only thing to fear is fear itself. But I’m afraid I can’t.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
The great sunscreen ingredient debate
In a commentary issued on May 6, the Food and Drug Administration stated that “with sunscreens now being used with greater frequency, in larger amounts, and by broader populations, it is more important than ever to ensure that sunscreens are safe and effective for daily, lifelong use.” The statement coincided with the publication of the randomized study, “Effect of sunscreen application under maximal use conditions on plasma concentrations of sunscreen active ingredients,” by Matta et al. of the FDA and others in JAMA (2019 May 6. doi: 10.1001/jama.2019.5586). A maximal usage trial examines the systemic absorption of a topical drug when used according to the guidelines given for the product’s maximum usage. In this study, adult participants were randomized to one of four commercially available sunscreen products: spray 1 (n = 6), spray 2 (n = 6), a lotion (n = 6), and a cream (n = 6). Two mg of sunscreen per 1 cm2 was applied to 75% of body surface area four times per day for 4 days, and blood samples were collected from each individual over 7 days.
The FDA’s guidance for industry and proposed rule on OTC sunscreens state that active ingredients with systemic absorption at 0.5 ng/mL or higher or with possible safety concerns need to undergo further nonclinical toxicology assessment to evaluate risk of systemic carcinogenicity, developmental/reproductive abnormalities, or other adverse effects.
Absorption of some sunscreen ingredients has been detected in other studies. Despite systemic absorption, two active ingredients – zinc oxide and titanium dioxide – have been found by the FDA to be generally recognized as safe and effective. But for 12 other active ingredients (cinoxate, dioxybenzone, ensulizole, homosalate, meradimate, octinoxate, octisalate, octocrylene, padimate O, sulisobenzone, oxybenzone, and avobenzone), there are insufficient data to make a “generally recognized as safe and effective” determination; thus, more data have been requested from the manufacturers. While physical blocking sunscreens have improved in their UV-blocking ability without compromising cosmesis over the past several years, some sunscreens containing chemical blockers are able to achieve higher SPFs with good cosmesis when applied to the skin.
Our skin acts as the ultimate barrier between ourselves and the environment, and it is not uncommon for substances to be blocked, absorbed, or excreted from the skin. Absorption of an ingredient through the skin and into the body does not indicate that the ingredient is unsafe. Rather, findings such as these call for further testing and research to determine the safety of that ingredient with repeated use. Per the FDA, such testing is part of the standard premarket safety evaluation of most chronically administered drugs with appreciable systemic absorption.
In February 2019, the FDA’s proposed rule was issued to “update regulatory requirements for most sunscreen products in the United States,” with the goal of bringing OTC sunscreens “up to date with the latest scientific standards,” according to the FDA May 6 commentary. “As part of this rule, the FDA is asking industry and other interested parties for additional safety data on the 12 active sunscreen ingredients currently available in marketed products” mentioned previously. These rules are being put into place to address the “key data gap” for these 12 ingredients, which is “understanding whether, and to what extent the ingredient is absorbed into the body after topical application.”
In other previously published studies, oxybenzone, along with some other sunscreen active ingredients including octocrylene, have been found in human breast milk. In addition, oxybenzone has been detected in amniotic fluid, urine, and blood. Whether these findings have any clinical implications needs to be further assessed. Some studies in the literature have raised questions about the potential for oxybenzone to affect endocrine activity.
Another issue that has been raised is the potential impact of sunscreen on the environment, specifically, coral reefs. In July 2018, Hawaii Governor David Ige (D) signed a bill (SB 2571) that bans the sale of sunscreens containing oxybenzone and octinoxate beginning in 2021, making Hawaii the first state to ban the sale of sunscreens containing these two chemicals. Shortly afterward, the Republic of Palau and city of Key West, Fla., also took action to ban sunscreens containing chemicals potentially harmful to marine life. In Hawaii, what’s know as “reef safe” sunscreen is sold.
More research in this area is needed, but studies have linked these ingredients to harming coral by bleaching, disease, and damage to DNA, and also to decreasing fertility in fish, impairing algae growth, inducing defects in mussel and sea urchin young, and accumulating in the tissues of dolphins. According to NASA, as much as 27% of monitored reef formation have already been lost and over the following 32 years, 32% more are at risk. Reefs cover a mere 0.2% of the ocean’s floor, but it is estimated that reefs are home to and protect nearly 1 million species of fish, invertebrates, and algae.
In early May, Rep. Tulsi Gabbard (D-Hawaii) and Sen. Tim Ryan (D-Ohio) introduced legislation known as the Oxybenzone and Octinoxate Impact Study Act of 2019 (H.R. 2588) to require the Environmental Protection Agency to study the impact of those two chemicals on human health and the environment and to provide findings to Congress and the public within 18 months.
The importance of sun protection and prevention of sunburns is paramount. We know that multiple sunburn events during childhood double a child’s risk of developing skin cancer later in life, and skin cancer is the most common cancer diagnosed in the United States, with 5 million cases treated every year. One in five Americans will develop skin cancer by age 70 years.
As a Mohs and a cosmetic dermatologic surgeon, I appreciate the unquestionable protective effects of sunscreen products with regards to skin cancer, dyspigmentation, solar elastosis, and rhytids associated with photoaging. We can applaud the FDA for improving testing and regulation of OTC ingredients, including those in sunscreen. These types of studies are important and monumental in ensuring that we are utilizing the right type of ingredients to protect our patients, our oceans, and our reefs.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
- Matta MK et al. JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586.
- Shedding new light on sunscreen absorption, by Janet Woodcock, MD, director, Center for Drug Evaluation and Research, and Theresa M. Michele, MD, director, CDER’s Division of Nonprescription Drug Products, Office of New Drugs
- Food and Drug Administration. Sunscreen drug products for over-the-counter human use: Proposed rule. Fed Regist. 2019;84(38):6204-75.
- Schlumpf M et al. Chemosphere. 2010 Nov;81(10):1171-83.
- Krause M et al. Int J Androl. 2012 Jun;35(3):424-36.
In a commentary issued on May 6, the Food and Drug Administration stated that “with sunscreens now being used with greater frequency, in larger amounts, and by broader populations, it is more important than ever to ensure that sunscreens are safe and effective for daily, lifelong use.” The statement coincided with the publication of the randomized study, “Effect of sunscreen application under maximal use conditions on plasma concentrations of sunscreen active ingredients,” by Matta et al. of the FDA and others in JAMA (2019 May 6. doi: 10.1001/jama.2019.5586). A maximal usage trial examines the systemic absorption of a topical drug when used according to the guidelines given for the product’s maximum usage. In this study, adult participants were randomized to one of four commercially available sunscreen products: spray 1 (n = 6), spray 2 (n = 6), a lotion (n = 6), and a cream (n = 6). Two mg of sunscreen per 1 cm2 was applied to 75% of body surface area four times per day for 4 days, and blood samples were collected from each individual over 7 days.
The FDA’s guidance for industry and proposed rule on OTC sunscreens state that active ingredients with systemic absorption at 0.5 ng/mL or higher or with possible safety concerns need to undergo further nonclinical toxicology assessment to evaluate risk of systemic carcinogenicity, developmental/reproductive abnormalities, or other adverse effects.
Absorption of some sunscreen ingredients has been detected in other studies. Despite systemic absorption, two active ingredients – zinc oxide and titanium dioxide – have been found by the FDA to be generally recognized as safe and effective. But for 12 other active ingredients (cinoxate, dioxybenzone, ensulizole, homosalate, meradimate, octinoxate, octisalate, octocrylene, padimate O, sulisobenzone, oxybenzone, and avobenzone), there are insufficient data to make a “generally recognized as safe and effective” determination; thus, more data have been requested from the manufacturers. While physical blocking sunscreens have improved in their UV-blocking ability without compromising cosmesis over the past several years, some sunscreens containing chemical blockers are able to achieve higher SPFs with good cosmesis when applied to the skin.
Our skin acts as the ultimate barrier between ourselves and the environment, and it is not uncommon for substances to be blocked, absorbed, or excreted from the skin. Absorption of an ingredient through the skin and into the body does not indicate that the ingredient is unsafe. Rather, findings such as these call for further testing and research to determine the safety of that ingredient with repeated use. Per the FDA, such testing is part of the standard premarket safety evaluation of most chronically administered drugs with appreciable systemic absorption.
In February 2019, the FDA’s proposed rule was issued to “update regulatory requirements for most sunscreen products in the United States,” with the goal of bringing OTC sunscreens “up to date with the latest scientific standards,” according to the FDA May 6 commentary. “As part of this rule, the FDA is asking industry and other interested parties for additional safety data on the 12 active sunscreen ingredients currently available in marketed products” mentioned previously. These rules are being put into place to address the “key data gap” for these 12 ingredients, which is “understanding whether, and to what extent the ingredient is absorbed into the body after topical application.”
In other previously published studies, oxybenzone, along with some other sunscreen active ingredients including octocrylene, have been found in human breast milk. In addition, oxybenzone has been detected in amniotic fluid, urine, and blood. Whether these findings have any clinical implications needs to be further assessed. Some studies in the literature have raised questions about the potential for oxybenzone to affect endocrine activity.
Another issue that has been raised is the potential impact of sunscreen on the environment, specifically, coral reefs. In July 2018, Hawaii Governor David Ige (D) signed a bill (SB 2571) that bans the sale of sunscreens containing oxybenzone and octinoxate beginning in 2021, making Hawaii the first state to ban the sale of sunscreens containing these two chemicals. Shortly afterward, the Republic of Palau and city of Key West, Fla., also took action to ban sunscreens containing chemicals potentially harmful to marine life. In Hawaii, what’s know as “reef safe” sunscreen is sold.
More research in this area is needed, but studies have linked these ingredients to harming coral by bleaching, disease, and damage to DNA, and also to decreasing fertility in fish, impairing algae growth, inducing defects in mussel and sea urchin young, and accumulating in the tissues of dolphins. According to NASA, as much as 27% of monitored reef formation have already been lost and over the following 32 years, 32% more are at risk. Reefs cover a mere 0.2% of the ocean’s floor, but it is estimated that reefs are home to and protect nearly 1 million species of fish, invertebrates, and algae.
In early May, Rep. Tulsi Gabbard (D-Hawaii) and Sen. Tim Ryan (D-Ohio) introduced legislation known as the Oxybenzone and Octinoxate Impact Study Act of 2019 (H.R. 2588) to require the Environmental Protection Agency to study the impact of those two chemicals on human health and the environment and to provide findings to Congress and the public within 18 months.
The importance of sun protection and prevention of sunburns is paramount. We know that multiple sunburn events during childhood double a child’s risk of developing skin cancer later in life, and skin cancer is the most common cancer diagnosed in the United States, with 5 million cases treated every year. One in five Americans will develop skin cancer by age 70 years.
As a Mohs and a cosmetic dermatologic surgeon, I appreciate the unquestionable protective effects of sunscreen products with regards to skin cancer, dyspigmentation, solar elastosis, and rhytids associated with photoaging. We can applaud the FDA for improving testing and regulation of OTC ingredients, including those in sunscreen. These types of studies are important and monumental in ensuring that we are utilizing the right type of ingredients to protect our patients, our oceans, and our reefs.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
- Matta MK et al. JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586.
- Shedding new light on sunscreen absorption, by Janet Woodcock, MD, director, Center for Drug Evaluation and Research, and Theresa M. Michele, MD, director, CDER’s Division of Nonprescription Drug Products, Office of New Drugs
- Food and Drug Administration. Sunscreen drug products for over-the-counter human use: Proposed rule. Fed Regist. 2019;84(38):6204-75.
- Schlumpf M et al. Chemosphere. 2010 Nov;81(10):1171-83.
- Krause M et al. Int J Androl. 2012 Jun;35(3):424-36.
In a commentary issued on May 6, the Food and Drug Administration stated that “with sunscreens now being used with greater frequency, in larger amounts, and by broader populations, it is more important than ever to ensure that sunscreens are safe and effective for daily, lifelong use.” The statement coincided with the publication of the randomized study, “Effect of sunscreen application under maximal use conditions on plasma concentrations of sunscreen active ingredients,” by Matta et al. of the FDA and others in JAMA (2019 May 6. doi: 10.1001/jama.2019.5586). A maximal usage trial examines the systemic absorption of a topical drug when used according to the guidelines given for the product’s maximum usage. In this study, adult participants were randomized to one of four commercially available sunscreen products: spray 1 (n = 6), spray 2 (n = 6), a lotion (n = 6), and a cream (n = 6). Two mg of sunscreen per 1 cm2 was applied to 75% of body surface area four times per day for 4 days, and blood samples were collected from each individual over 7 days.
The FDA’s guidance for industry and proposed rule on OTC sunscreens state that active ingredients with systemic absorption at 0.5 ng/mL or higher or with possible safety concerns need to undergo further nonclinical toxicology assessment to evaluate risk of systemic carcinogenicity, developmental/reproductive abnormalities, or other adverse effects.
Absorption of some sunscreen ingredients has been detected in other studies. Despite systemic absorption, two active ingredients – zinc oxide and titanium dioxide – have been found by the FDA to be generally recognized as safe and effective. But for 12 other active ingredients (cinoxate, dioxybenzone, ensulizole, homosalate, meradimate, octinoxate, octisalate, octocrylene, padimate O, sulisobenzone, oxybenzone, and avobenzone), there are insufficient data to make a “generally recognized as safe and effective” determination; thus, more data have been requested from the manufacturers. While physical blocking sunscreens have improved in their UV-blocking ability without compromising cosmesis over the past several years, some sunscreens containing chemical blockers are able to achieve higher SPFs with good cosmesis when applied to the skin.
Our skin acts as the ultimate barrier between ourselves and the environment, and it is not uncommon for substances to be blocked, absorbed, or excreted from the skin. Absorption of an ingredient through the skin and into the body does not indicate that the ingredient is unsafe. Rather, findings such as these call for further testing and research to determine the safety of that ingredient with repeated use. Per the FDA, such testing is part of the standard premarket safety evaluation of most chronically administered drugs with appreciable systemic absorption.
In February 2019, the FDA’s proposed rule was issued to “update regulatory requirements for most sunscreen products in the United States,” with the goal of bringing OTC sunscreens “up to date with the latest scientific standards,” according to the FDA May 6 commentary. “As part of this rule, the FDA is asking industry and other interested parties for additional safety data on the 12 active sunscreen ingredients currently available in marketed products” mentioned previously. These rules are being put into place to address the “key data gap” for these 12 ingredients, which is “understanding whether, and to what extent the ingredient is absorbed into the body after topical application.”
In other previously published studies, oxybenzone, along with some other sunscreen active ingredients including octocrylene, have been found in human breast milk. In addition, oxybenzone has been detected in amniotic fluid, urine, and blood. Whether these findings have any clinical implications needs to be further assessed. Some studies in the literature have raised questions about the potential for oxybenzone to affect endocrine activity.
Another issue that has been raised is the potential impact of sunscreen on the environment, specifically, coral reefs. In July 2018, Hawaii Governor David Ige (D) signed a bill (SB 2571) that bans the sale of sunscreens containing oxybenzone and octinoxate beginning in 2021, making Hawaii the first state to ban the sale of sunscreens containing these two chemicals. Shortly afterward, the Republic of Palau and city of Key West, Fla., also took action to ban sunscreens containing chemicals potentially harmful to marine life. In Hawaii, what’s know as “reef safe” sunscreen is sold.
More research in this area is needed, but studies have linked these ingredients to harming coral by bleaching, disease, and damage to DNA, and also to decreasing fertility in fish, impairing algae growth, inducing defects in mussel and sea urchin young, and accumulating in the tissues of dolphins. According to NASA, as much as 27% of monitored reef formation have already been lost and over the following 32 years, 32% more are at risk. Reefs cover a mere 0.2% of the ocean’s floor, but it is estimated that reefs are home to and protect nearly 1 million species of fish, invertebrates, and algae.
In early May, Rep. Tulsi Gabbard (D-Hawaii) and Sen. Tim Ryan (D-Ohio) introduced legislation known as the Oxybenzone and Octinoxate Impact Study Act of 2019 (H.R. 2588) to require the Environmental Protection Agency to study the impact of those two chemicals on human health and the environment and to provide findings to Congress and the public within 18 months.
The importance of sun protection and prevention of sunburns is paramount. We know that multiple sunburn events during childhood double a child’s risk of developing skin cancer later in life, and skin cancer is the most common cancer diagnosed in the United States, with 5 million cases treated every year. One in five Americans will develop skin cancer by age 70 years.
As a Mohs and a cosmetic dermatologic surgeon, I appreciate the unquestionable protective effects of sunscreen products with regards to skin cancer, dyspigmentation, solar elastosis, and rhytids associated with photoaging. We can applaud the FDA for improving testing and regulation of OTC ingredients, including those in sunscreen. These types of studies are important and monumental in ensuring that we are utilizing the right type of ingredients to protect our patients, our oceans, and our reefs.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
- Matta MK et al. JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586.
- Shedding new light on sunscreen absorption, by Janet Woodcock, MD, director, Center for Drug Evaluation and Research, and Theresa M. Michele, MD, director, CDER’s Division of Nonprescription Drug Products, Office of New Drugs
- Food and Drug Administration. Sunscreen drug products for over-the-counter human use: Proposed rule. Fed Regist. 2019;84(38):6204-75.
- Schlumpf M et al. Chemosphere. 2010 Nov;81(10):1171-83.
- Krause M et al. Int J Androl. 2012 Jun;35(3):424-36.
Acting up at APA
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.
We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.
Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.
Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.
The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.
On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.
“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”
A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.
It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.
The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.
Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.
Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. We discussed how improv might be useful in teaching trainees.
“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”
Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”
Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”
I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.
Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
Enzalutamide in castration-sensitive prostate cancer and ctDNA to monitor early colorectal cancer
In this edition of “How I will treat my next patient,” I take a look at two recent trials – a late-breaking abstract presented at the annual meeting of the American Urological Association on the value of enzalutamide in hormone-sensitive metastatic prostate cancer (mHSPC) patients and a recent publication in JAMA Oncology about the potential for circulating tumor DNA (ctDNA) testing to inform our management of early stage colorectal cancer (CRC).
ARCHES trial
The ARCHES trial was reported as a late-breaking abstract at AUA 2019. ARCHES was a double-blind, placebo-controlled trial in 1,150 men with mHSPC. Patients were required to have been free from radiographic disease progression or a rising prostate-specific antigen (PSA) level for at least 3 months on androgen deprivation therapy (ADT) or at least 6 months after prior docetaxel chemotherapy.
Patients were randomly assigned to receive either ADT plus enzalutamide (an androgen receptor signaling inhibitor) or ADT plus placebo. The coprimary endpoints of the trial were radiographic progression-free survival (rPFS) and death within 24 weeks.
ADT plus enzalutamide had dramatically better PSA-related endpoints (as expected) and produced significantly better rPFS (median PFS, not reached versus 19.5 months; 61% relative prolongation of rPFS) than placebo plus ADT.
Overall survival data were unreported and may be confounded by all patients being offered enzalutamide at progression. Despite the known adverse effects of enzalutamide from prior studies, enzalutamide-related adverse effects in ARCHES were no worse than placebo (about 85% in both study arms). Formal quality-of-life analyses are yet to be reported.
What this means in practice
It is no surprise that enzalutamide, a potent drug in castration-resistant prostate cancer, would beat placebo. It joins docetaxel and abiraterone in helping to delay the time until castration-resistant disease develops – a meaningful goal. The authors commented that baseline PSA level did not predict benefit from enzalutamide – again, no surprise given that other published trials have suggested that baseline PSA is more likely prognostic than predictive.
It is always prudent to wait for a formal manuscript, but this abstract suggests that men with mHSPC have yet another option for treatment with modest toxicity and broad applicability in practice.
ctDNA in early colorectal cancer
In JAMA Oncology, Yuxuan Wang, MD, PhD, and colleagues summarized their experience with 58 patients with stages I-III colorectal cancer (CRC) who had curative-intent surgical resection at four Swedish hospitals.
The patients had levels of ctDNA monitored every 3 months post operatively. Prediction of the development of metastatic disease using ctDNA was compared to conventional surveillance testing (carcinoembryonic antigen [CEA] blood tests and computed tomographic scanning) per guidelines from the National Comprehensive Cancer Network.
Among the 45 patients with no elevation of ctDNA, there were no recurrences at median follow-up of 49 months. In contrast, 10 of 13 patients (77%) with elevated ctDNA levels during follow-up developed metastatic disease. CEA levels were less sensitive, detecting just 63% of recurrences.
Among the three patients with false positive ctDNA levels, all three fell to undetectable levels with continued follow-up. One of the 18 patients who received adjuvant post-operative chemotherapy had the ctDNA levels fall to undetectable with chemotherapy and that patient remained relapse-free at 37 months.
What this means in practice
The results of this study are remarkably concordant with recently published work in the Journal of Clinical Oncology by Emil Christensen, PhD, and colleagues, that involved patients with localized bladder cancer and illustrate the predictive value of ctDNA over traditional risk factors and conventional surveillance monitoring.
Monitoring ctDNA remains a promising research tool that should not be used for clinical decision making at the present time. However, its potential to help us personalize treatment selection, surveillance intensity, and to select patients who may be spared costly, toxic, and anxiety-provoking treatment and monitoring could be practice changing in the near future.
Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.
In this edition of “How I will treat my next patient,” I take a look at two recent trials – a late-breaking abstract presented at the annual meeting of the American Urological Association on the value of enzalutamide in hormone-sensitive metastatic prostate cancer (mHSPC) patients and a recent publication in JAMA Oncology about the potential for circulating tumor DNA (ctDNA) testing to inform our management of early stage colorectal cancer (CRC).
ARCHES trial
The ARCHES trial was reported as a late-breaking abstract at AUA 2019. ARCHES was a double-blind, placebo-controlled trial in 1,150 men with mHSPC. Patients were required to have been free from radiographic disease progression or a rising prostate-specific antigen (PSA) level for at least 3 months on androgen deprivation therapy (ADT) or at least 6 months after prior docetaxel chemotherapy.
Patients were randomly assigned to receive either ADT plus enzalutamide (an androgen receptor signaling inhibitor) or ADT plus placebo. The coprimary endpoints of the trial were radiographic progression-free survival (rPFS) and death within 24 weeks.
ADT plus enzalutamide had dramatically better PSA-related endpoints (as expected) and produced significantly better rPFS (median PFS, not reached versus 19.5 months; 61% relative prolongation of rPFS) than placebo plus ADT.
Overall survival data were unreported and may be confounded by all patients being offered enzalutamide at progression. Despite the known adverse effects of enzalutamide from prior studies, enzalutamide-related adverse effects in ARCHES were no worse than placebo (about 85% in both study arms). Formal quality-of-life analyses are yet to be reported.
What this means in practice
It is no surprise that enzalutamide, a potent drug in castration-resistant prostate cancer, would beat placebo. It joins docetaxel and abiraterone in helping to delay the time until castration-resistant disease develops – a meaningful goal. The authors commented that baseline PSA level did not predict benefit from enzalutamide – again, no surprise given that other published trials have suggested that baseline PSA is more likely prognostic than predictive.
It is always prudent to wait for a formal manuscript, but this abstract suggests that men with mHSPC have yet another option for treatment with modest toxicity and broad applicability in practice.
ctDNA in early colorectal cancer
In JAMA Oncology, Yuxuan Wang, MD, PhD, and colleagues summarized their experience with 58 patients with stages I-III colorectal cancer (CRC) who had curative-intent surgical resection at four Swedish hospitals.
The patients had levels of ctDNA monitored every 3 months post operatively. Prediction of the development of metastatic disease using ctDNA was compared to conventional surveillance testing (carcinoembryonic antigen [CEA] blood tests and computed tomographic scanning) per guidelines from the National Comprehensive Cancer Network.
Among the 45 patients with no elevation of ctDNA, there were no recurrences at median follow-up of 49 months. In contrast, 10 of 13 patients (77%) with elevated ctDNA levels during follow-up developed metastatic disease. CEA levels were less sensitive, detecting just 63% of recurrences.
Among the three patients with false positive ctDNA levels, all three fell to undetectable levels with continued follow-up. One of the 18 patients who received adjuvant post-operative chemotherapy had the ctDNA levels fall to undetectable with chemotherapy and that patient remained relapse-free at 37 months.
What this means in practice
The results of this study are remarkably concordant with recently published work in the Journal of Clinical Oncology by Emil Christensen, PhD, and colleagues, that involved patients with localized bladder cancer and illustrate the predictive value of ctDNA over traditional risk factors and conventional surveillance monitoring.
Monitoring ctDNA remains a promising research tool that should not be used for clinical decision making at the present time. However, its potential to help us personalize treatment selection, surveillance intensity, and to select patients who may be spared costly, toxic, and anxiety-provoking treatment and monitoring could be practice changing in the near future.
Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.
In this edition of “How I will treat my next patient,” I take a look at two recent trials – a late-breaking abstract presented at the annual meeting of the American Urological Association on the value of enzalutamide in hormone-sensitive metastatic prostate cancer (mHSPC) patients and a recent publication in JAMA Oncology about the potential for circulating tumor DNA (ctDNA) testing to inform our management of early stage colorectal cancer (CRC).
ARCHES trial
The ARCHES trial was reported as a late-breaking abstract at AUA 2019. ARCHES was a double-blind, placebo-controlled trial in 1,150 men with mHSPC. Patients were required to have been free from radiographic disease progression or a rising prostate-specific antigen (PSA) level for at least 3 months on androgen deprivation therapy (ADT) or at least 6 months after prior docetaxel chemotherapy.
Patients were randomly assigned to receive either ADT plus enzalutamide (an androgen receptor signaling inhibitor) or ADT plus placebo. The coprimary endpoints of the trial were radiographic progression-free survival (rPFS) and death within 24 weeks.
ADT plus enzalutamide had dramatically better PSA-related endpoints (as expected) and produced significantly better rPFS (median PFS, not reached versus 19.5 months; 61% relative prolongation of rPFS) than placebo plus ADT.
Overall survival data were unreported and may be confounded by all patients being offered enzalutamide at progression. Despite the known adverse effects of enzalutamide from prior studies, enzalutamide-related adverse effects in ARCHES were no worse than placebo (about 85% in both study arms). Formal quality-of-life analyses are yet to be reported.
What this means in practice
It is no surprise that enzalutamide, a potent drug in castration-resistant prostate cancer, would beat placebo. It joins docetaxel and abiraterone in helping to delay the time until castration-resistant disease develops – a meaningful goal. The authors commented that baseline PSA level did not predict benefit from enzalutamide – again, no surprise given that other published trials have suggested that baseline PSA is more likely prognostic than predictive.
It is always prudent to wait for a formal manuscript, but this abstract suggests that men with mHSPC have yet another option for treatment with modest toxicity and broad applicability in practice.
ctDNA in early colorectal cancer
In JAMA Oncology, Yuxuan Wang, MD, PhD, and colleagues summarized their experience with 58 patients with stages I-III colorectal cancer (CRC) who had curative-intent surgical resection at four Swedish hospitals.
The patients had levels of ctDNA monitored every 3 months post operatively. Prediction of the development of metastatic disease using ctDNA was compared to conventional surveillance testing (carcinoembryonic antigen [CEA] blood tests and computed tomographic scanning) per guidelines from the National Comprehensive Cancer Network.
Among the 45 patients with no elevation of ctDNA, there were no recurrences at median follow-up of 49 months. In contrast, 10 of 13 patients (77%) with elevated ctDNA levels during follow-up developed metastatic disease. CEA levels were less sensitive, detecting just 63% of recurrences.
Among the three patients with false positive ctDNA levels, all three fell to undetectable levels with continued follow-up. One of the 18 patients who received adjuvant post-operative chemotherapy had the ctDNA levels fall to undetectable with chemotherapy and that patient remained relapse-free at 37 months.
What this means in practice
The results of this study are remarkably concordant with recently published work in the Journal of Clinical Oncology by Emil Christensen, PhD, and colleagues, that involved patients with localized bladder cancer and illustrate the predictive value of ctDNA over traditional risk factors and conventional surveillance monitoring.
Monitoring ctDNA remains a promising research tool that should not be used for clinical decision making at the present time. However, its potential to help us personalize treatment selection, surveillance intensity, and to select patients who may be spared costly, toxic, and anxiety-provoking treatment and monitoring could be practice changing in the near future.
Dr. Lyss has been a community-based medical oncologist and clinical researcher for more than 35 years, practicing in St. Louis. His clinical and research interests are in the prevention, diagnosis, and treatment of breast and lung cancers and in expanding access to clinical trials to medically underserved populations.
How an office theft can change your habits
Last week, my secretary was checking a patient out when I went into the little galley area across from her desk to get coffee. Unfortunately, I knocked the pot over and it broke, sending glass and hot coffee everywhere.
My secretary asked the patient to wait a minute, grabbed a roll of paper towels that was behind her, and ran over to help me clean up. She was with me for 1-2 minutes, then returned to finish signing the patient out while I picked up glass shards.
A while later, we realized that somewhere in that 2 minutes an envelope containing roughly $200 in copays had disappeared from her desk drawer. It had been there 30 minutes before when another patient had paid a copay in cash, and now it was gone.
My secretary? No. She’s been with me for more than 15 years. She’s never stolen from the practice before, so why would she start now? I trust her.
The only people who had access to the drawer in that time were the patient, her, and me. While the money was out of sight, it was within reach of anyone who leaned over the counter, opened the drawer to look through it, and grabbed it.
I admit I probably should have gone to the bank sooner. Normally, we only have $20-$40 in small bills on hand, which we use for change. Most people prefer credit cards. But in the 2-3 weeks before this, we had had an unusual number of people using cash for copays. Combined with a crazier schedule than usual, I just hadn’t had a chance to deposit the bills.
Obviously, I’m not going to do that again.
Generally, no one has a chance to reach over and grab the drawer, either. When a patient is checking out, my secretary is always there making the transaction. But this one time, we had an unexpected distraction and she left the desk to help me.
She’s not going to do that again with someone standing there, either.
$200 isn’t, even in a small practice, a make-or-break amount. It stings, but I’ll still be able to make payroll and pay the rent. At the end of the year, it will have to come out of my own salary, because that’s the nature of owning a business. I can’t (and wouldn’t) charge the next 200 patients a $1 “administrative fee” to cover it.
Of course, it’s possible I’m accusing the wrong person. But there wasn’t anyone in the office besides me, my secretary, and the patient in that time frame. I don’t have any actual proof, like a video, though, so I certainly can’t press charges. She didn’t schedule a follow-up visit, either, so doubt she’ll be coming back.
Why would a patient steal from a doctor who’s trying to help her? Money is the simple answer. She had an opportunity to look and take it, and she did. Her moral compass must be skewed toward dishonesty, and she took advantage of the situation. I doubt it was anything personal against me, or doctors, or the situation in general. She’s a thief, and in her mind, it was a business decision.
Of course, I could be wrong on that point. Maybe she did rationalize it by the incorrect, but widespread, belief that doctors are “rich.” In her mind, she may have thought I’d never notice it, therefore there’s nothing wrong with stealing from me.
Do I hold it against future patients? No. In 20 years this is the first time one has stolen anything of significant financial value from my office (we’ve lost pens, magazines, a stapler, and a snowman-shaped candy dish in the past). The vast majority of my patients are decent people who wouldn’t do something like this.
But it does cast a pall over new patients we don’t know. Next time I need help while someone’s being checked out, my secretary won’t be able to give it. Any amount over a few small bills for change will be promptly taken to the bank.
It’s a bitter pill that leaves a bad taste in my mouth. Not harmful in the grand scheme of things, but certainly unpleasant. My job is based on the idea that people trust me to do my best for them, and in return, I trust them to be honest with me in return.
But one morning last week, it was just a one-way street.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Last week, my secretary was checking a patient out when I went into the little galley area across from her desk to get coffee. Unfortunately, I knocked the pot over and it broke, sending glass and hot coffee everywhere.
My secretary asked the patient to wait a minute, grabbed a roll of paper towels that was behind her, and ran over to help me clean up. She was with me for 1-2 minutes, then returned to finish signing the patient out while I picked up glass shards.
A while later, we realized that somewhere in that 2 minutes an envelope containing roughly $200 in copays had disappeared from her desk drawer. It had been there 30 minutes before when another patient had paid a copay in cash, and now it was gone.
My secretary? No. She’s been with me for more than 15 years. She’s never stolen from the practice before, so why would she start now? I trust her.
The only people who had access to the drawer in that time were the patient, her, and me. While the money was out of sight, it was within reach of anyone who leaned over the counter, opened the drawer to look through it, and grabbed it.
I admit I probably should have gone to the bank sooner. Normally, we only have $20-$40 in small bills on hand, which we use for change. Most people prefer credit cards. But in the 2-3 weeks before this, we had had an unusual number of people using cash for copays. Combined with a crazier schedule than usual, I just hadn’t had a chance to deposit the bills.
Obviously, I’m not going to do that again.
Generally, no one has a chance to reach over and grab the drawer, either. When a patient is checking out, my secretary is always there making the transaction. But this one time, we had an unexpected distraction and she left the desk to help me.
She’s not going to do that again with someone standing there, either.
$200 isn’t, even in a small practice, a make-or-break amount. It stings, but I’ll still be able to make payroll and pay the rent. At the end of the year, it will have to come out of my own salary, because that’s the nature of owning a business. I can’t (and wouldn’t) charge the next 200 patients a $1 “administrative fee” to cover it.
Of course, it’s possible I’m accusing the wrong person. But there wasn’t anyone in the office besides me, my secretary, and the patient in that time frame. I don’t have any actual proof, like a video, though, so I certainly can’t press charges. She didn’t schedule a follow-up visit, either, so doubt she’ll be coming back.
Why would a patient steal from a doctor who’s trying to help her? Money is the simple answer. She had an opportunity to look and take it, and she did. Her moral compass must be skewed toward dishonesty, and she took advantage of the situation. I doubt it was anything personal against me, or doctors, or the situation in general. She’s a thief, and in her mind, it was a business decision.
Of course, I could be wrong on that point. Maybe she did rationalize it by the incorrect, but widespread, belief that doctors are “rich.” In her mind, she may have thought I’d never notice it, therefore there’s nothing wrong with stealing from me.
Do I hold it against future patients? No. In 20 years this is the first time one has stolen anything of significant financial value from my office (we’ve lost pens, magazines, a stapler, and a snowman-shaped candy dish in the past). The vast majority of my patients are decent people who wouldn’t do something like this.
But it does cast a pall over new patients we don’t know. Next time I need help while someone’s being checked out, my secretary won’t be able to give it. Any amount over a few small bills for change will be promptly taken to the bank.
It’s a bitter pill that leaves a bad taste in my mouth. Not harmful in the grand scheme of things, but certainly unpleasant. My job is based on the idea that people trust me to do my best for them, and in return, I trust them to be honest with me in return.
But one morning last week, it was just a one-way street.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Last week, my secretary was checking a patient out when I went into the little galley area across from her desk to get coffee. Unfortunately, I knocked the pot over and it broke, sending glass and hot coffee everywhere.
My secretary asked the patient to wait a minute, grabbed a roll of paper towels that was behind her, and ran over to help me clean up. She was with me for 1-2 minutes, then returned to finish signing the patient out while I picked up glass shards.
A while later, we realized that somewhere in that 2 minutes an envelope containing roughly $200 in copays had disappeared from her desk drawer. It had been there 30 minutes before when another patient had paid a copay in cash, and now it was gone.
My secretary? No. She’s been with me for more than 15 years. She’s never stolen from the practice before, so why would she start now? I trust her.
The only people who had access to the drawer in that time were the patient, her, and me. While the money was out of sight, it was within reach of anyone who leaned over the counter, opened the drawer to look through it, and grabbed it.
I admit I probably should have gone to the bank sooner. Normally, we only have $20-$40 in small bills on hand, which we use for change. Most people prefer credit cards. But in the 2-3 weeks before this, we had had an unusual number of people using cash for copays. Combined with a crazier schedule than usual, I just hadn’t had a chance to deposit the bills.
Obviously, I’m not going to do that again.
Generally, no one has a chance to reach over and grab the drawer, either. When a patient is checking out, my secretary is always there making the transaction. But this one time, we had an unexpected distraction and she left the desk to help me.
She’s not going to do that again with someone standing there, either.
$200 isn’t, even in a small practice, a make-or-break amount. It stings, but I’ll still be able to make payroll and pay the rent. At the end of the year, it will have to come out of my own salary, because that’s the nature of owning a business. I can’t (and wouldn’t) charge the next 200 patients a $1 “administrative fee” to cover it.
Of course, it’s possible I’m accusing the wrong person. But there wasn’t anyone in the office besides me, my secretary, and the patient in that time frame. I don’t have any actual proof, like a video, though, so I certainly can’t press charges. She didn’t schedule a follow-up visit, either, so doubt she’ll be coming back.
Why would a patient steal from a doctor who’s trying to help her? Money is the simple answer. She had an opportunity to look and take it, and she did. Her moral compass must be skewed toward dishonesty, and she took advantage of the situation. I doubt it was anything personal against me, or doctors, or the situation in general. She’s a thief, and in her mind, it was a business decision.
Of course, I could be wrong on that point. Maybe she did rationalize it by the incorrect, but widespread, belief that doctors are “rich.” In her mind, she may have thought I’d never notice it, therefore there’s nothing wrong with stealing from me.
Do I hold it against future patients? No. In 20 years this is the first time one has stolen anything of significant financial value from my office (we’ve lost pens, magazines, a stapler, and a snowman-shaped candy dish in the past). The vast majority of my patients are decent people who wouldn’t do something like this.
But it does cast a pall over new patients we don’t know. Next time I need help while someone’s being checked out, my secretary won’t be able to give it. Any amount over a few small bills for change will be promptly taken to the bank.
It’s a bitter pill that leaves a bad taste in my mouth. Not harmful in the grand scheme of things, but certainly unpleasant. My job is based on the idea that people trust me to do my best for them, and in return, I trust them to be honest with me in return.
But one morning last week, it was just a one-way street.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Eminently qualified physician
Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?
For all the talk about In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.
There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).
Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”
What about your effectiveness under stress?
Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”
How about your leadership performance?
Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”
We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.
The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.
Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.
This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?
For all the talk about In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.
There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).
Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”
What about your effectiveness under stress?
Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”
How about your leadership performance?
Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”
We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.
The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.
Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.
This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Just how good are you? Are you a pretty good doc? A better-than-average leader? Or, are you truly an eminently qualified physician?
For all the talk about In medicine, we’re careful to show respect to each other and tend to be slow to be critical. This might seem a kind approach to feedback, but I wonder if it is.
There are other professions where evaluations and feedback are more direct. In the military, performance standards are often quite explicit. The Marines, for instance, take performance evaluations seriously. This is evident if you’ve ever completed, or been a recipient of, a U.S. Marine Corps fitness report. Reading it, I realized many of the criteria could apply to us in medicine. Here are a few examples from that form (lightly modified for physicians).
Think about your clinical and technical expertise. Would you grade yourself as “competent. Possesses requisite range of skills and knowledge commensurate with training and experience?” Or maybe the next grade “demonstrates mastery of all required skills. Expertise, education and experience consistently enhance department. Innovative troubleshooter and problem solver. Effectively imparts skills to trainees.” Or perhaps you’re a “true expert in the field. Knowledge and skills impact far beyond those of peers. Translates broad-based education into forward-thinking, innovative actions. Makes immeasurable impact on department. Peerless teacher, selflessly imparts expertise to peers, residents, students.”
What about your effectiveness under stress?
Do you act “commensurate with your training and role?” Or do you have an “uncanny ability to anticipate requirements and quickly formulate original solutions?” Do you always “take decisive, effective action?”
How about your leadership performance?
Are you simply “engaged, providing instruction and direction?” Or do you “achieve a highly effective balance between direction and delegation, effectively tasking subordinates and clearly delineating standards expected?” A few of us even “engender willing loyalty and trust that allow subordinates to overcome their perceived limitations.” And exhibit “leadership that fosters the highest levels of motivation and morale, ensuring accomplishment in the most difficult circumstances.”
We might even mitigate physician burnout better if we had better performance standards. For example, do you simply “deal confidently with issues pertinent to subordinate welfare and recognize suitable courses of action?” Maybe you’re at the next level, “actively fostering the development of and uses of support systems for subordinates which improve their ability to perform.” I’m fortunate to know a few physician leaders who “noticeably enhance subordinate well-being, resulting in measurable increase in department effectiveness and proactively energize team members to ‘take care of their own.’ Widely recognized for techniques and policies that produce results and build morale.” By codifying what the standard should be, we can better hold ourselves accountable for our performance. In doing so, we might be better at recognizing and reducing burnout in our direct reports and peers.
The final question on the Marine fitness report is a comparative assessment. The evaluating officer checks one of the following boxes: 1. Unsatisfactory; 2. A qualified Marine; 3. One of many highly qualified Marines; 4. One of the few exceptionally qualified Marines; or, 5. The eminently qualified Marine.
Which are you? Can you describe yourself as “the eminently qualified physician?” You’ll have to define that standard in order to reach it.
This post was inspired by the “Set Standards. Aspire to Achieve Them” episode of Jocko Podcast.
Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
More empathy for women
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.
About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.
After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.
Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.
All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.
Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.