Commentary

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

The COVID-19 pandemic has overwhelmed health care facilities and health care providers (HCPs) due to the limited resources available to treat a rapidly expanding patient population. Health care providers have been required to work long hours and put themselves at increased risk of infection by coming into frequent contact with infected patients. In addition to the risk of becoming infected with severe acute respiratory syndrome coronavirus 2, HCPs might be required to wear personal protective equipment (PPE) for the entirety of the workday, which can cause a variety of adverse effects.

During the COVID-19 pandemic, there has been an increase in reported cases of facial acne, pressure injury, urticaria, allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), and exacerbation of underlying cutaneous conditions among health care workers.^1-4 This increase in dermatologic disorders among HCPs has been associated with the increased utilization of and duration of exposure to PPE—particularly N95 respirator masks and surgical masks.^5-7 Most studies of these reactions have attributed them to local pressure, friction, hyperhydration, elevated pH, and occlusion caused by prolonged wearing of the masks, resulting ultimately in acne and other rashes^8-10; however, a few studies have suggested that formaldehyde is a potential culprit underlying the increase in skin reactions to face masks.^11-14

Formaldehyde is a known skin irritant and has been found to cause ACD and ICD from exposure to textiles and cosmetics treated with this chemical.^15-18 Both N95 and surgical masks previously have been found to contain sufficient levels of formaldehyde or formaldehyde-releasing resins (FRRs) to induce ACD or ICD in susceptible people.^12-14 In this article, we focus on the role of formaldehyde in N95 masks as a potential cause of ACD and ICD in HCPs who have been wearing PPE during the COVID-19 pandemic.

Formaldehyde: Benefits With Significant Problems

Formaldehyde is nearly ubiquitous in the textile industry because it confers advantageous properties, including resistance to flames, water, and wrinkling.¹⁵ Despite these advantages, it has long been established that consumers can become sensitized to formaldehyde and FRRs in textiles after chronic exposure.^15-18

A study of Australian HCPs found that 5.2% of those tested had ACD in response to formaldehyde, which was attributed to their PPE.¹¹ In a case report of ACD caused by FRRs, Donovan and Skotnicki-Grant¹² suggested that individuals who are sensitive to formaldehyde are vulnerable to reactions that are exacerbated by friction, warmth, moisture, and tight-fitting materials—all of which can occur when wearing an N95 mask. In that report, a formaldehyde-sensitive patient had a strong positive reaction on patch testing to melamine formaldehyde and to a piece of her N95 mask while taking prednisone 8 mg/d, suggesting that some sensitized patients have a strong reaction to their mask even when they are immunosuppressed.¹²

This finding, along with the known formaldehyde content of some N95 masks, suggests that these masks might be a cause of contact dermatitis in some HCPs. Somewhat complicating the situation is that false-negative patch testing can occur in and might contribute to the underdiagnosis of formaldehyde-induced N95 mask facial dermatitis.^12,13 Some HCPs have reported mild respiratory symptoms and eye irritation associated with the use of an N95 mask—symptoms that are consistent with formaldehyde exposure. In some cases, those symptoms have caused discomfort sufficient to prompt HCPs to take leave from work.^13,14

Development of contact dermatitis in response to an N95 mask is not novel; this problem also was observed during the severe acute respiratory syndrome pandemic of the early 2000s.^9,17 Some HCPs noticed onset of skin reactions after they were required to wear an N95 mask in the workplace, which some studies attributed to material in the mask increasing the likelihood of developing an adverse reaction.^2,6,8 The components of N95 masks and the materials from which they are manufactured are listed in the Table.¹⁹

Face Masks, Adverse Reactions, and Formaldehyde

Allergic contact dermatitis and ICD typically are rare responses to wearing facial masks, but the recent COVID-19 pandemic has forced HCPs to wear masks for longer than 6 hours at a time and to reuse a single mask, which has been shown to increase the likelihood of adverse reactions.^1,4,6 Additionally, humid environments, tight-fitting materials, and skin abrasions—all of which can be induced by wearing an N95 mask—have been found to increase the likelihood of formaldehyde-related contact dermatitis by increasing the release of free formaldehyde or by enhancing its penetration into the skin.^6,20,21

Formaldehyde is an ubiquitous chemical agent that is part of indoor and outdoor working and residential environments. Health care professionals have many opportunities to be exposed to formaldehyde, which is a well-known mucous membrane irritant and a primary skin-sensitizing agent associated with both contact dermatitis (type IV hypersensitivity reaction), and an immediate anaphylactic reaction (type I hypersensitivity reaction).^22-25 Exposure to formaldehyde by inhalation has been identified as a potential cause of asthma.^26,27 More studies on the prevalence of formaldehyde-induced hypersensitivity reactions would be beneficial to HCPs for early diagnosis of hypersensitivity, adequate prophylaxis, and occupational risk assessment.

N95 mask dermatitis also heightens the potential for breaches of PPE protocols. The discomfort that HCPs experience in response to adverse skin reactions to masks can cause an increased rate of inappropriate mask-wearing, face-touching during mask adjustment, and removal of the mask in the health care setting.²⁸ These acts of face-touching and PPE adjustment have been shown to increase microbial transmission and to reduce the efficacy of PPE in blocking pathogens.^29,30

Considering the mounting evidence that widespread use of masks effectively prevents viral transmission, it is crucial that all HCPs wear appropriate PPE when treating patients during the COVID-19 pandemic.^31,32 The recent surge in ACD and ICD among HCPs in response to wearing N95 masks creates a need to determine the underlying cause of these dermatoses and find methods of mitigating sensitization of HCPs to the offending agents. The current epidemiology of COVID-19 in the United States suggests that PPE will be necessary for much longer than originally anticipated and will continue to be worn for long hours by HCPs.

Formaldehyde-Free Alternatives?

Some researchers have proposed that using materials that are free of allergens like formaldehyde might be a long-term solution to the development of contact dermatitis.^15,33 Formaldehyde is used in the finishing process of N95 masks for wrinkle and crease resistance and to prevent mildew. It is possible that formaldehyde could be completely removed from the manufacturing process, although no studies on the effects of such alternatives on mask efficacy have been performed.

Formaldehyde-free alternatives that would confer similar properties on textiles have been explored; the most promising alternative to formaldehyde in cross-linking cellulose fibers is polycarboxylic acid in combination with sodium hypophosphite, which can help avoid the adverse health outcomes and environmental impact of formaldehyde.^34-36 Studies of such alternatives in the manufacturing of N95 masks would be needed to establish the efficacy and durability of formaldehyde-free PPE.

Final Thoughts

Additional studies are needed to confirm the presence of formaldehyde in N95 masks and to confirm that the mask material yields a positive patch test in sensitized individuals. The paucity of available studies that quantify formaldehyde or FRR content of N95 and surgical masks makes it difficult to establish an association between the chemical content of masks and the prevalence of mask dermatitis among HCPs; however, available reports of skin reactions, including contact dermatitis, from PPE suggest that formaldehyde sensitivity might be at least part of the problem. As such, we propose that manufacturers of N95 and surgical masks be required to reveal the chemical components of their products so that consumers can make educated purchasing decisions.

The COVID-19 pandemic has overwhelmed health care facilities and health care providers (HCPs) due to the limited resources available to treat a rapidly expanding patient population. Health care providers have been required to work long hours and put themselves at increased risk of infection by coming into frequent contact with infected patients. In addition to the risk of becoming infected with severe acute respiratory syndrome coronavirus 2, HCPs might be required to wear personal protective equipment (PPE) for the entirety of the workday, which can cause a variety of adverse effects.

During the COVID-19 pandemic, there has been an increase in reported cases of facial acne, pressure injury, urticaria, allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), and exacerbation of underlying cutaneous conditions among health care workers.^1-4 This increase in dermatologic disorders among HCPs has been associated with the increased utilization of and duration of exposure to PPE—particularly N95 respirator masks and surgical masks.^5-7 Most studies of these reactions have attributed them to local pressure, friction, hyperhydration, elevated pH, and occlusion caused by prolonged wearing of the masks, resulting ultimately in acne and other rashes^8-10; however, a few studies have suggested that formaldehyde is a potential culprit underlying the increase in skin reactions to face masks.^11-14

Formaldehyde is a known skin irritant and has been found to cause ACD and ICD from exposure to textiles and cosmetics treated with this chemical.^15-18 Both N95 and surgical masks previously have been found to contain sufficient levels of formaldehyde or formaldehyde-releasing resins (FRRs) to induce ACD or ICD in susceptible people.^12-14 In this article, we focus on the role of formaldehyde in N95 masks as a potential cause of ACD and ICD in HCPs who have been wearing PPE during the COVID-19 pandemic.

Formaldehyde: Benefits With Significant Problems

Formaldehyde is nearly ubiquitous in the textile industry because it confers advantageous properties, including resistance to flames, water, and wrinkling.¹⁵ Despite these advantages, it has long been established that consumers can become sensitized to formaldehyde and FRRs in textiles after chronic exposure.^15-18

A study of Australian HCPs found that 5.2% of those tested had ACD in response to formaldehyde, which was attributed to their PPE.¹¹ In a case report of ACD caused by FRRs, Donovan and Skotnicki-Grant¹² suggested that individuals who are sensitive to formaldehyde are vulnerable to reactions that are exacerbated by friction, warmth, moisture, and tight-fitting materials—all of which can occur when wearing an N95 mask. In that report, a formaldehyde-sensitive patient had a strong positive reaction on patch testing to melamine formaldehyde and to a piece of her N95 mask while taking prednisone 8 mg/d, suggesting that some sensitized patients have a strong reaction to their mask even when they are immunosuppressed.¹²

This finding, along with the known formaldehyde content of some N95 masks, suggests that these masks might be a cause of contact dermatitis in some HCPs. Somewhat complicating the situation is that false-negative patch testing can occur in and might contribute to the underdiagnosis of formaldehyde-induced N95 mask facial dermatitis.^12,13 Some HCPs have reported mild respiratory symptoms and eye irritation associated with the use of an N95 mask—symptoms that are consistent with formaldehyde exposure. In some cases, those symptoms have caused discomfort sufficient to prompt HCPs to take leave from work.^13,14

Development of contact dermatitis in response to an N95 mask is not novel; this problem also was observed during the severe acute respiratory syndrome pandemic of the early 2000s.^9,17 Some HCPs noticed onset of skin reactions after they were required to wear an N95 mask in the workplace, which some studies attributed to material in the mask increasing the likelihood of developing an adverse reaction.^2,6,8 The components of N95 masks and the materials from which they are manufactured are listed in the Table.¹⁹

Face Masks, Adverse Reactions, and Formaldehyde

Allergic contact dermatitis and ICD typically are rare responses to wearing facial masks, but the recent COVID-19 pandemic has forced HCPs to wear masks for longer than 6 hours at a time and to reuse a single mask, which has been shown to increase the likelihood of adverse reactions.^1,4,6 Additionally, humid environments, tight-fitting materials, and skin abrasions—all of which can be induced by wearing an N95 mask—have been found to increase the likelihood of formaldehyde-related contact dermatitis by increasing the release of free formaldehyde or by enhancing its penetration into the skin.^6,20,21

Formaldehyde is an ubiquitous chemical agent that is part of indoor and outdoor working and residential environments. Health care professionals have many opportunities to be exposed to formaldehyde, which is a well-known mucous membrane irritant and a primary skin-sensitizing agent associated with both contact dermatitis (type IV hypersensitivity reaction), and an immediate anaphylactic reaction (type I hypersensitivity reaction).^22-25 Exposure to formaldehyde by inhalation has been identified as a potential cause of asthma.^26,27 More studies on the prevalence of formaldehyde-induced hypersensitivity reactions would be beneficial to HCPs for early diagnosis of hypersensitivity, adequate prophylaxis, and occupational risk assessment.

N95 mask dermatitis also heightens the potential for breaches of PPE protocols. The discomfort that HCPs experience in response to adverse skin reactions to masks can cause an increased rate of inappropriate mask-wearing, face-touching during mask adjustment, and removal of the mask in the health care setting.²⁸ These acts of face-touching and PPE adjustment have been shown to increase microbial transmission and to reduce the efficacy of PPE in blocking pathogens.^29,30

Considering the mounting evidence that widespread use of masks effectively prevents viral transmission, it is crucial that all HCPs wear appropriate PPE when treating patients during the COVID-19 pandemic.^31,32 The recent surge in ACD and ICD among HCPs in response to wearing N95 masks creates a need to determine the underlying cause of these dermatoses and find methods of mitigating sensitization of HCPs to the offending agents. The current epidemiology of COVID-19 in the United States suggests that PPE will be necessary for much longer than originally anticipated and will continue to be worn for long hours by HCPs.

Formaldehyde-Free Alternatives?

Some researchers have proposed that using materials that are free of allergens like formaldehyde might be a long-term solution to the development of contact dermatitis.^15,33 Formaldehyde is used in the finishing process of N95 masks for wrinkle and crease resistance and to prevent mildew. It is possible that formaldehyde could be completely removed from the manufacturing process, although no studies on the effects of such alternatives on mask efficacy have been performed.

Formaldehyde-free alternatives that would confer similar properties on textiles have been explored; the most promising alternative to formaldehyde in cross-linking cellulose fibers is polycarboxylic acid in combination with sodium hypophosphite, which can help avoid the adverse health outcomes and environmental impact of formaldehyde.^34-36 Studies of such alternatives in the manufacturing of N95 masks would be needed to establish the efficacy and durability of formaldehyde-free PPE.

Final Thoughts

Additional studies are needed to confirm the presence of formaldehyde in N95 masks and to confirm that the mask material yields a positive patch test in sensitized individuals. The paucity of available studies that quantify formaldehyde or FRR content of N95 and surgical masks makes it difficult to establish an association between the chemical content of masks and the prevalence of mask dermatitis among HCPs; however, available reports of skin reactions, including contact dermatitis, from PPE suggest that formaldehyde sensitivity might be at least part of the problem. As such, we propose that manufacturers of N95 and surgical masks be required to reveal the chemical components of their products so that consumers can make educated purchasing decisions.

The COVID-19 pandemic has overwhelmed health care facilities and health care providers (HCPs) due to the limited resources available to treat a rapidly expanding patient population. Health care providers have been required to work long hours and put themselves at increased risk of infection by coming into frequent contact with infected patients. In addition to the risk of becoming infected with severe acute respiratory syndrome coronavirus 2, HCPs might be required to wear personal protective equipment (PPE) for the entirety of the workday, which can cause a variety of adverse effects.

During the COVID-19 pandemic, there has been an increase in reported cases of facial acne, pressure injury, urticaria, allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), and exacerbation of underlying cutaneous conditions among health care workers.^1-4 This increase in dermatologic disorders among HCPs has been associated with the increased utilization of and duration of exposure to PPE—particularly N95 respirator masks and surgical masks.^5-7 Most studies of these reactions have attributed them to local pressure, friction, hyperhydration, elevated pH, and occlusion caused by prolonged wearing of the masks, resulting ultimately in acne and other rashes^8-10; however, a few studies have suggested that formaldehyde is a potential culprit underlying the increase in skin reactions to face masks.^11-14

Formaldehyde is a known skin irritant and has been found to cause ACD and ICD from exposure to textiles and cosmetics treated with this chemical.^15-18 Both N95 and surgical masks previously have been found to contain sufficient levels of formaldehyde or formaldehyde-releasing resins (FRRs) to induce ACD or ICD in susceptible people.^12-14 In this article, we focus on the role of formaldehyde in N95 masks as a potential cause of ACD and ICD in HCPs who have been wearing PPE during the COVID-19 pandemic.

Formaldehyde: Benefits With Significant Problems

Formaldehyde is nearly ubiquitous in the textile industry because it confers advantageous properties, including resistance to flames, water, and wrinkling.¹⁵ Despite these advantages, it has long been established that consumers can become sensitized to formaldehyde and FRRs in textiles after chronic exposure.^15-18

A study of Australian HCPs found that 5.2% of those tested had ACD in response to formaldehyde, which was attributed to their PPE.¹¹ In a case report of ACD caused by FRRs, Donovan and Skotnicki-Grant¹² suggested that individuals who are sensitive to formaldehyde are vulnerable to reactions that are exacerbated by friction, warmth, moisture, and tight-fitting materials—all of which can occur when wearing an N95 mask. In that report, a formaldehyde-sensitive patient had a strong positive reaction on patch testing to melamine formaldehyde and to a piece of her N95 mask while taking prednisone 8 mg/d, suggesting that some sensitized patients have a strong reaction to their mask even when they are immunosuppressed.¹²

This finding, along with the known formaldehyde content of some N95 masks, suggests that these masks might be a cause of contact dermatitis in some HCPs. Somewhat complicating the situation is that false-negative patch testing can occur in and might contribute to the underdiagnosis of formaldehyde-induced N95 mask facial dermatitis.^12,13 Some HCPs have reported mild respiratory symptoms and eye irritation associated with the use of an N95 mask—symptoms that are consistent with formaldehyde exposure. In some cases, those symptoms have caused discomfort sufficient to prompt HCPs to take leave from work.^13,14

Development of contact dermatitis in response to an N95 mask is not novel; this problem also was observed during the severe acute respiratory syndrome pandemic of the early 2000s.^9,17 Some HCPs noticed onset of skin reactions after they were required to wear an N95 mask in the workplace, which some studies attributed to material in the mask increasing the likelihood of developing an adverse reaction.^2,6,8 The components of N95 masks and the materials from which they are manufactured are listed in the Table.¹⁹

Face Masks, Adverse Reactions, and Formaldehyde

Allergic contact dermatitis and ICD typically are rare responses to wearing facial masks, but the recent COVID-19 pandemic has forced HCPs to wear masks for longer than 6 hours at a time and to reuse a single mask, which has been shown to increase the likelihood of adverse reactions.^1,4,6 Additionally, humid environments, tight-fitting materials, and skin abrasions—all of which can be induced by wearing an N95 mask—have been found to increase the likelihood of formaldehyde-related contact dermatitis by increasing the release of free formaldehyde or by enhancing its penetration into the skin.^6,20,21

Formaldehyde is an ubiquitous chemical agent that is part of indoor and outdoor working and residential environments. Health care professionals have many opportunities to be exposed to formaldehyde, which is a well-known mucous membrane irritant and a primary skin-sensitizing agent associated with both contact dermatitis (type IV hypersensitivity reaction), and an immediate anaphylactic reaction (type I hypersensitivity reaction).^22-25 Exposure to formaldehyde by inhalation has been identified as a potential cause of asthma.^26,27 More studies on the prevalence of formaldehyde-induced hypersensitivity reactions would be beneficial to HCPs for early diagnosis of hypersensitivity, adequate prophylaxis, and occupational risk assessment.

N95 mask dermatitis also heightens the potential for breaches of PPE protocols. The discomfort that HCPs experience in response to adverse skin reactions to masks can cause an increased rate of inappropriate mask-wearing, face-touching during mask adjustment, and removal of the mask in the health care setting.²⁸ These acts of face-touching and PPE adjustment have been shown to increase microbial transmission and to reduce the efficacy of PPE in blocking pathogens.^29,30

Considering the mounting evidence that widespread use of masks effectively prevents viral transmission, it is crucial that all HCPs wear appropriate PPE when treating patients during the COVID-19 pandemic.^31,32 The recent surge in ACD and ICD among HCPs in response to wearing N95 masks creates a need to determine the underlying cause of these dermatoses and find methods of mitigating sensitization of HCPs to the offending agents. The current epidemiology of COVID-19 in the United States suggests that PPE will be necessary for much longer than originally anticipated and will continue to be worn for long hours by HCPs.

Formaldehyde-Free Alternatives?

Some researchers have proposed that using materials that are free of allergens like formaldehyde might be a long-term solution to the development of contact dermatitis.^15,33 Formaldehyde is used in the finishing process of N95 masks for wrinkle and crease resistance and to prevent mildew. It is possible that formaldehyde could be completely removed from the manufacturing process, although no studies on the effects of such alternatives on mask efficacy have been performed.

Formaldehyde-free alternatives that would confer similar properties on textiles have been explored; the most promising alternative to formaldehyde in cross-linking cellulose fibers is polycarboxylic acid in combination with sodium hypophosphite, which can help avoid the adverse health outcomes and environmental impact of formaldehyde.^34-36 Studies of such alternatives in the manufacturing of N95 masks would be needed to establish the efficacy and durability of formaldehyde-free PPE.

Final Thoughts

Additional studies are needed to confirm the presence of formaldehyde in N95 masks and to confirm that the mask material yields a positive patch test in sensitized individuals. The paucity of available studies that quantify formaldehyde or FRR content of N95 and surgical masks makes it difficult to establish an association between the chemical content of masks and the prevalence of mask dermatitis among HCPs; however, available reports of skin reactions, including contact dermatitis, from PPE suggest that formaldehyde sensitivity might be at least part of the problem. As such, we propose that manufacturers of N95 and surgical masks be required to reveal the chemical components of their products so that consumers can make educated purchasing decisions.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Not surprisingly, the pandemic has torn at the already fraying fabric of many families. Cooped up away from friends and the emotional relief valve of school, even children who had been relatively easy to manage in the past have posed disciplinary challenges beyond their parents’ abilities to cope.

In a recent study from the Parenting in Context Lab of the University of Michigan (“Child Discipline During the Covid-19 Pandemic,” Family Snapshots: Life During the Pandemic, American Academy of Pediatrics, June 8 2021) researchers found that one in six parents surveyed (n = 3,000 adults) admitted to spanking. Nearly half of the parents said that they had yelled at or threatened their children.

Five out of six parents reported using what the investigators described as less harsh “positive discipline measures.” Three-quarters of these parents used “explaining” as a strategy and nearly the same number used either time-outs or sent the children to their rooms.

Again, not surprisingly, parents who had experienced at least one adverse childhood experience (ACE) were more than twice as likely to spank. And parents who reported an episode of intimate partner violence (IPV) were more likely to resort to a harsh discipline strategy (yelling, threatening, or spanking).

Over my professional career I’ve spent a lot of time thinking about discipline and I have attempted to summarize my thoughts in a book titled, “How to Say No to Your Toddler” (Simon and Schuster, 2003), that has been published in four languages. Based on my observations, trying to explain to a misbehaving child the error of his ways is generally parental time not well spent. A well-structured time-out, preferably in a separate room with a door closed, is the most effective and safest discipline strategy.

However, as in all of my books, this advice on discipline was colored by the families in my practice and the audience for which I was writing, primarily middle class and upper middle class, reasonably affluent parents who buy books. These are usually folks who have homes in which children often have their own rooms, or where at least there are multiple rooms with doors – spaces to escape when tensions rise. Few of these parents have endured ACEs. Few have they experienced – nor have their children witnessed – IPV.

My advice that parents make only threats that can be safely carried, out such as time-out, and to always follow up on threats and promises, is valid regardless of a family’s socioeconomic situation. However, when it comes to choosing a consequence, my standard recommendation of a time-out can be difficult to follow for a family of six living in a three-room apartment, particularly during pandemic-dictated restrictions and lockdowns.

Of course there are alternatives to time-outs in a separate space, including an extended hug in a parental lap, but these responses require that the parents have been able to compose themselves well enough, and that they have the time. One of the important benefits of time-outs is that they can provide parents the time and space to reassess the situation and consider their role in the conflict. The bottom line is that a time-out is the safest and most effective form of discipline, but it requires space and a parent relatively unburdened of financial or emotional stress. Families without these luxuries are left with few alternatives other than physical or verbal abuse.

The AAP’s Family Snapshot concludes with the observation that “pediatricians and pediatric health care providers can continue to play an important role in supporting positive discipline strategies.” That is a difficult assignment even in prepandemic times, but for those of you working with families who lack the space and time to defuse disciplinary tensions, it is a heroic task.
 

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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

This month, JFP tackles a topic—work disability—that might, at first, seem a bit outside our usual wheelhouse of clinical review articles. Work disability is, however, a very important topic. The authors point out that “... primary care clinicians are asked to provide guidance about work activities in nearly 10% of their patient encounters; however, 25% of those clinicians thought they had little influence over work disability outcomes.” This statement suggests that we need to learn more about managing work-related disability and how to influence patients’ outcomes in a positive manner.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action. The authors of this article provide excellent information about how we can—and should—help ill and injured patients return to work.

As I read the article, I reflected on my own experience providing patients with advice about returning to work. Two points, in particular, struck a chord with me.

1. Many factors in the process are beyond our control. The physician’s role in helping patients return to work after an injury or illness is limited. The authors remind us that there are many patient and employer factors that are beyond our control and that influence patients’ successful return to work. Patient factors include motivation, mental health, and job satisfaction. Employer factors include job flexibility and disability benefits and policies. And of course, there are system factors that include laws governing work-related disability.

2. Our role, while limited, is important. By putting forth a positive attitude toward recovery and providing encouragement to patients, we can facilitate an earlier return to work.

I am cognizant of the pivotal role we can play with back injuries, a frequent cause of work disability. A great deal of excellent research over the past 20 years guides us regarding treatment and prognosis. Most back injuries are due to musculoskeletal injury and improve quickly during the first week, no matter what the therapy. By steering these patients clear of narcotics, telling them to remain as physically active as their pain will allow, and letting them know they will recover, we can pave the way for an early return to work.

Let us all take full advantage, then, of these important conversations with our patients. Armed with the strategies in this month’s article, we can increase the likelihood of our patients’ success.

This month, JFP tackles a topic—work disability—that might, at first, seem a bit outside our usual wheelhouse of clinical review articles. Work disability is, however, a very important topic. The authors point out that “... primary care clinicians are asked to provide guidance about work activities in nearly 10% of their patient encounters; however, 25% of those clinicians thought they had little influence over work disability outcomes.” This statement suggests that we need to learn more about managing work-related disability and how to influence patients’ outcomes in a positive manner.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action. The authors of this article provide excellent information about how we can—and should—help ill and injured patients return to work.

As I read the article, I reflected on my own experience providing patients with advice about returning to work. Two points, in particular, struck a chord with me.

1. Many factors in the process are beyond our control. The physician’s role in helping patients return to work after an injury or illness is limited. The authors remind us that there are many patient and employer factors that are beyond our control and that influence patients’ successful return to work. Patient factors include motivation, mental health, and job satisfaction. Employer factors include job flexibility and disability benefits and policies. And of course, there are system factors that include laws governing work-related disability.

2. Our role, while limited, is important. By putting forth a positive attitude toward recovery and providing encouragement to patients, we can facilitate an earlier return to work.

I am cognizant of the pivotal role we can play with back injuries, a frequent cause of work disability. A great deal of excellent research over the past 20 years guides us regarding treatment and prognosis. Most back injuries are due to musculoskeletal injury and improve quickly during the first week, no matter what the therapy. By steering these patients clear of narcotics, telling them to remain as physically active as their pain will allow, and letting them know they will recover, we can pave the way for an early return to work.

Let us all take full advantage, then, of these important conversations with our patients. Armed with the strategies in this month’s article, we can increase the likelihood of our patients’ success.

This month, JFP tackles a topic—work disability—that might, at first, seem a bit outside our usual wheelhouse of clinical review articles. Work disability is, however, a very important topic. The authors point out that “... primary care clinicians are asked to provide guidance about work activities in nearly 10% of their patient encounters; however, 25% of those clinicians thought they had little influence over work disability outcomes.” This statement suggests that we need to learn more about managing work-related disability and how to influence patients’ outcomes in a positive manner.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action.

I suspect that we tend to be pessimistic about our ability to influence patient outcomes because we are uncertain about the best course of action. The authors of this article provide excellent information about how we can—and should—help ill and injured patients return to work.

As I read the article, I reflected on my own experience providing patients with advice about returning to work. Two points, in particular, struck a chord with me.

1. Many factors in the process are beyond our control. The physician’s role in helping patients return to work after an injury or illness is limited. The authors remind us that there are many patient and employer factors that are beyond our control and that influence patients’ successful return to work. Patient factors include motivation, mental health, and job satisfaction. Employer factors include job flexibility and disability benefits and policies. And of course, there are system factors that include laws governing work-related disability.

2. Our role, while limited, is important. By putting forth a positive attitude toward recovery and providing encouragement to patients, we can facilitate an earlier return to work.

I am cognizant of the pivotal role we can play with back injuries, a frequent cause of work disability. A great deal of excellent research over the past 20 years guides us regarding treatment and prognosis. Most back injuries are due to musculoskeletal injury and improve quickly during the first week, no matter what the therapy. By steering these patients clear of narcotics, telling them to remain as physically active as their pain will allow, and letting them know they will recover, we can pave the way for an early return to work.

Let us all take full advantage, then, of these important conversations with our patients. Armed with the strategies in this month’s article, we can increase the likelihood of our patients’ success.

Over the next 2 months we will dedicate this column to some general tips and pearls from the perspective of a gynecologic oncologist to guide general obstetrician gynecologists in the workup and management of preinvasive or invasive gynecologic diseases. The goal of these recommendations is to minimize misdiagnosis or delayed diagnosis and avoid unnecessary or untimely referrals.

Perform biopsy, not Pap smears, on visible cervical and vaginal lesions

The purpose of the Pap smear is to screen asymptomatic patients for cervical dysplasia or microscopic invasive disease. Cytology is an unreliable diagnostic tool for visible, symptomatic lesions in large part because of sampling errors, and the lack of architectural information in cytologic versus histopathologic specimens. Invasive lesions can be mischaracterized as preinvasive on a Pap smear. This can result in delayed diagnosis and unnecessary diagnostic procedures. For example, if a visible, abnormal-appearing, cervical lesion is seen during a routine visit and a Pap smear is performed (rather than a biopsy of the mass), the patient may receive an incorrect preliminary diagnosis of “high-grade dysplasia, carcinoma in situ” as it can be difficult to distinguish invasive carcinoma from carcinoma in situ on cytology. If the patient and provider do not understand the limitations of Pap smears in diagnosing invasive cancers, they may be falsely reassured and possibly delay or abstain from follow-up for an excisional procedure. If she does return for the loop electrosurgical excision procedure (LEEP), there might still be unnecessary delays in making referrals and definitive treatment while waiting for results. Radical hysterectomy may not promptly follow because, if performed within 6 weeks of an excisional procedure, it is associated with a significantly higher risk for perioperative complication, and therefore, if the excisional procedure was unnecessary to begin with, there may be additional time lost that need not be.¹

Some clinicians avoid biopsy of visible lesions because they are concerned about bleeding complications that might arise in the office. Straightforward strategies to control bleeding are readily available in most gynecology offices, especially those already equipped for procedures such as LEEP and colposcopy. Prior to performing the biopsy, clinicians should ensure that they have supplies such as gauze sponges and ring forceps or packing forceps, silver nitrate, and ferric subsulfate solution (“Monsel’s solution”) close at hand. In the vast majority of cases, direct pressure for 5 minutes with gauze sponges and ferric subsulfate is highly effective at resolving most bleeding from a cervical or vaginal biopsy site. If this does not bring hemostasis, cautery devices or suture can be employed. If all else fails, be prepared to place vaginal packing (always with the insertion of a urinary Foley catheter to prevent urinary retention). In my experience, this is rarely needed.

Wherever possible, visible cervical or vaginal (or vulvar, see below) lesions should be biopsied for histopathology, sampling representative areas of the most concerning portion, in order to minimize misdiagnosis and expedite referral and definitive treatment. For necrotic-appearing lesions I recommend taking multiple samples of the tumor, as necrotic, nonviable tissue can prevent accurate diagnosis of a cancer. In general, Pap smears should be reserved as screening tests for asymptomatic women without visible pathology.
 

Don’t treat or refer low-grade dysplasia, even if persistent

Increasingly we are understanding that low-grade dysplasia of the lower genital tract (CIN I, VAIN I, VIN I) is less a precursor for cancer, and more a phenomenon of benign HPV-associated changes.² This HPV change may be chronically persistent, may require years of observation and serial Pap smears, and may be a general nuisance for the patient. However, current guidelines do not recommend intervention for low-grade dysplasia of the lower genital tract.² Interventions to resect these lesions can result in morbidity, including perineal pain, vaginal scarring, and cervical stenosis or insufficiency. Given the extremely low risk for progression to cancer, these morbidities do not outweigh any small potential benefit.

When I am conferring with patients who have chronic low-grade dysplasia I spend a great deal of time exploring their understanding of the diagnosis and its pathophysiology, their fears, and their expectation regarding “success” of treatment. I spend the time educating them that this is a sequela of chronic viral infection that will not be eradicated with local surgical excisions, that their cancer risk and need for surveillance would persist even if surgical intervention were offered, and that the side effects of treatment would outweigh any benefit from the small risk of cancer or high-grade dysplasia.

In summary, the treatment of choice for persistent low-grade dysplasia of the lower genital tract is comprehensive patient education, not surgical resection or referral to gynecologic oncology.
 

Repeat sampling if there’s a discordance between imaging and biopsy results

Delay in cancer diagnosis is one of the greatest concerns for front-line gynecology providers. One of the more modifiable strategies to avoid missed or delayed diagnosis is to ensure that there is concordance between clinical findings and testing results. Otherwise said: The results and findings should make sense in aggregate. An example was cited above in which a visible cervical mass demonstrated CIN III on cytologic testing. Another common example is a biopsy result of “scant benign endometrium” in a patient with postmenopausal bleeding and thickened endometrial stripe on ultrasound. In both of these cases there is clear discordance between physical findings and the results of pathology sampling. A pathology report, in all of its black and white certitude, seems like the most reliable source of information. However, always trust your clinical judgment. If the clinical picture is suggesting something far worse than these limited, often random or blind samplings, I recommend repeated or more extensive sampling (for example, dilation and curettage). At the very least, schedule close follow-up with repeated sampling if the symptom or finding persists. The emphasis here is on scheduled follow-up, rather than “p.r.n.,” because a patient who was given a “normal” pathology result to explain her abnormal symptoms may not volunteer that those symptoms are persistent as she may feel that anything sinister was already ruled out. Make certain that you explain the potential for misdiagnosis as the reason for why you would like to see her back shortly to ensure the issue has resolved.

Biopsy vulvar lesions, minimize empiric treatment

Vulvar cancer is notoriously associated with delayed diagnosis. Unfortunately, it is commonplace for gynecologic oncologists to see women who have vulvar cancers that have been empirically treated, sometimes for months or years, with steroids or other topical agents. If a lesion on the vulva is characteristically benign in appearance (such as condyloma or lichen sclerosis), it may be reasonable to start empiric treatment. However, all patients who are treated without biopsy should be rescheduled for a planned follow-up appointment in 2-3 months. If the lesion/area remains unchanged, or worse, the lesion should be biopsied before proceeding with a change in therapy or continued therapy. Once again, don’t rely on patients to return for evaluation if the lesion doesn’t improve. Many patients assume that our first empiric diagnosis is “gospel,” and therefore may not return if the treatment doesn’t work. Meanwhile, providers may assume that patients will know that there is uncertainty in our interpretation and that they will know to report if the initial treatment didn’t work. These assumptions are the recipe for delayed diagnosis. If there is too great a burden on the patient to schedule a return visit because of social or financial reasons then the patient should have a biopsy prior to initiation of treatment. As a rule, empiric treatment is not a good strategy for patients without good access to follow-up.

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

References

1. Sullivan S. et al Gynecol Oncol. 2017 Feb;144(2):294-8.

2. Perkins R .et al J Low Genit Tract Dis. 2020 Apr;24(2):102-31.

Over the next 2 months we will dedicate this column to some general tips and pearls from the perspective of a gynecologic oncologist to guide general obstetrician gynecologists in the workup and management of preinvasive or invasive gynecologic diseases. The goal of these recommendations is to minimize misdiagnosis or delayed diagnosis and avoid unnecessary or untimely referrals.

Perform biopsy, not Pap smears, on visible cervical and vaginal lesions

The purpose of the Pap smear is to screen asymptomatic patients for cervical dysplasia or microscopic invasive disease. Cytology is an unreliable diagnostic tool for visible, symptomatic lesions in large part because of sampling errors, and the lack of architectural information in cytologic versus histopathologic specimens. Invasive lesions can be mischaracterized as preinvasive on a Pap smear. This can result in delayed diagnosis and unnecessary diagnostic procedures. For example, if a visible, abnormal-appearing, cervical lesion is seen during a routine visit and a Pap smear is performed (rather than a biopsy of the mass), the patient may receive an incorrect preliminary diagnosis of “high-grade dysplasia, carcinoma in situ” as it can be difficult to distinguish invasive carcinoma from carcinoma in situ on cytology. If the patient and provider do not understand the limitations of Pap smears in diagnosing invasive cancers, they may be falsely reassured and possibly delay or abstain from follow-up for an excisional procedure. If she does return for the loop electrosurgical excision procedure (LEEP), there might still be unnecessary delays in making referrals and definitive treatment while waiting for results. Radical hysterectomy may not promptly follow because, if performed within 6 weeks of an excisional procedure, it is associated with a significantly higher risk for perioperative complication, and therefore, if the excisional procedure was unnecessary to begin with, there may be additional time lost that need not be.¹

Some clinicians avoid biopsy of visible lesions because they are concerned about bleeding complications that might arise in the office. Straightforward strategies to control bleeding are readily available in most gynecology offices, especially those already equipped for procedures such as LEEP and colposcopy. Prior to performing the biopsy, clinicians should ensure that they have supplies such as gauze sponges and ring forceps or packing forceps, silver nitrate, and ferric subsulfate solution (“Monsel’s solution”) close at hand. In the vast majority of cases, direct pressure for 5 minutes with gauze sponges and ferric subsulfate is highly effective at resolving most bleeding from a cervical or vaginal biopsy site. If this does not bring hemostasis, cautery devices or suture can be employed. If all else fails, be prepared to place vaginal packing (always with the insertion of a urinary Foley catheter to prevent urinary retention). In my experience, this is rarely needed.

Wherever possible, visible cervical or vaginal (or vulvar, see below) lesions should be biopsied for histopathology, sampling representative areas of the most concerning portion, in order to minimize misdiagnosis and expedite referral and definitive treatment. For necrotic-appearing lesions I recommend taking multiple samples of the tumor, as necrotic, nonviable tissue can prevent accurate diagnosis of a cancer. In general, Pap smears should be reserved as screening tests for asymptomatic women without visible pathology.
 

Don’t treat or refer low-grade dysplasia, even if persistent

Increasingly we are understanding that low-grade dysplasia of the lower genital tract (CIN I, VAIN I, VIN I) is less a precursor for cancer, and more a phenomenon of benign HPV-associated changes.² This HPV change may be chronically persistent, may require years of observation and serial Pap smears, and may be a general nuisance for the patient. However, current guidelines do not recommend intervention for low-grade dysplasia of the lower genital tract.² Interventions to resect these lesions can result in morbidity, including perineal pain, vaginal scarring, and cervical stenosis or insufficiency. Given the extremely low risk for progression to cancer, these morbidities do not outweigh any small potential benefit.

When I am conferring with patients who have chronic low-grade dysplasia I spend a great deal of time exploring their understanding of the diagnosis and its pathophysiology, their fears, and their expectation regarding “success” of treatment. I spend the time educating them that this is a sequela of chronic viral infection that will not be eradicated with local surgical excisions, that their cancer risk and need for surveillance would persist even if surgical intervention were offered, and that the side effects of treatment would outweigh any benefit from the small risk of cancer or high-grade dysplasia.

In summary, the treatment of choice for persistent low-grade dysplasia of the lower genital tract is comprehensive patient education, not surgical resection or referral to gynecologic oncology.
 

Repeat sampling if there’s a discordance between imaging and biopsy results

Delay in cancer diagnosis is one of the greatest concerns for front-line gynecology providers. One of the more modifiable strategies to avoid missed or delayed diagnosis is to ensure that there is concordance between clinical findings and testing results. Otherwise said: The results and findings should make sense in aggregate. An example was cited above in which a visible cervical mass demonstrated CIN III on cytologic testing. Another common example is a biopsy result of “scant benign endometrium” in a patient with postmenopausal bleeding and thickened endometrial stripe on ultrasound. In both of these cases there is clear discordance between physical findings and the results of pathology sampling. A pathology report, in all of its black and white certitude, seems like the most reliable source of information. However, always trust your clinical judgment. If the clinical picture is suggesting something far worse than these limited, often random or blind samplings, I recommend repeated or more extensive sampling (for example, dilation and curettage). At the very least, schedule close follow-up with repeated sampling if the symptom or finding persists. The emphasis here is on scheduled follow-up, rather than “p.r.n.,” because a patient who was given a “normal” pathology result to explain her abnormal symptoms may not volunteer that those symptoms are persistent as she may feel that anything sinister was already ruled out. Make certain that you explain the potential for misdiagnosis as the reason for why you would like to see her back shortly to ensure the issue has resolved.

Biopsy vulvar lesions, minimize empiric treatment

Vulvar cancer is notoriously associated with delayed diagnosis. Unfortunately, it is commonplace for gynecologic oncologists to see women who have vulvar cancers that have been empirically treated, sometimes for months or years, with steroids or other topical agents. If a lesion on the vulva is characteristically benign in appearance (such as condyloma or lichen sclerosis), it may be reasonable to start empiric treatment. However, all patients who are treated without biopsy should be rescheduled for a planned follow-up appointment in 2-3 months. If the lesion/area remains unchanged, or worse, the lesion should be biopsied before proceeding with a change in therapy or continued therapy. Once again, don’t rely on patients to return for evaluation if the lesion doesn’t improve. Many patients assume that our first empiric diagnosis is “gospel,” and therefore may not return if the treatment doesn’t work. Meanwhile, providers may assume that patients will know that there is uncertainty in our interpretation and that they will know to report if the initial treatment didn’t work. These assumptions are the recipe for delayed diagnosis. If there is too great a burden on the patient to schedule a return visit because of social or financial reasons then the patient should have a biopsy prior to initiation of treatment. As a rule, empiric treatment is not a good strategy for patients without good access to follow-up.

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

References

1. Sullivan S. et al Gynecol Oncol. 2017 Feb;144(2):294-8.

2. Perkins R .et al J Low Genit Tract Dis. 2020 Apr;24(2):102-31.

Over the next 2 months we will dedicate this column to some general tips and pearls from the perspective of a gynecologic oncologist to guide general obstetrician gynecologists in the workup and management of preinvasive or invasive gynecologic diseases. The goal of these recommendations is to minimize misdiagnosis or delayed diagnosis and avoid unnecessary or untimely referrals.

Perform biopsy, not Pap smears, on visible cervical and vaginal lesions

The purpose of the Pap smear is to screen asymptomatic patients for cervical dysplasia or microscopic invasive disease. Cytology is an unreliable diagnostic tool for visible, symptomatic lesions in large part because of sampling errors, and the lack of architectural information in cytologic versus histopathologic specimens. Invasive lesions can be mischaracterized as preinvasive on a Pap smear. This can result in delayed diagnosis and unnecessary diagnostic procedures. For example, if a visible, abnormal-appearing, cervical lesion is seen during a routine visit and a Pap smear is performed (rather than a biopsy of the mass), the patient may receive an incorrect preliminary diagnosis of “high-grade dysplasia, carcinoma in situ” as it can be difficult to distinguish invasive carcinoma from carcinoma in situ on cytology. If the patient and provider do not understand the limitations of Pap smears in diagnosing invasive cancers, they may be falsely reassured and possibly delay or abstain from follow-up for an excisional procedure. If she does return for the loop electrosurgical excision procedure (LEEP), there might still be unnecessary delays in making referrals and definitive treatment while waiting for results. Radical hysterectomy may not promptly follow because, if performed within 6 weeks of an excisional procedure, it is associated with a significantly higher risk for perioperative complication, and therefore, if the excisional procedure was unnecessary to begin with, there may be additional time lost that need not be.¹

Some clinicians avoid biopsy of visible lesions because they are concerned about bleeding complications that might arise in the office. Straightforward strategies to control bleeding are readily available in most gynecology offices, especially those already equipped for procedures such as LEEP and colposcopy. Prior to performing the biopsy, clinicians should ensure that they have supplies such as gauze sponges and ring forceps or packing forceps, silver nitrate, and ferric subsulfate solution (“Monsel’s solution”) close at hand. In the vast majority of cases, direct pressure for 5 minutes with gauze sponges and ferric subsulfate is highly effective at resolving most bleeding from a cervical or vaginal biopsy site. If this does not bring hemostasis, cautery devices or suture can be employed. If all else fails, be prepared to place vaginal packing (always with the insertion of a urinary Foley catheter to prevent urinary retention). In my experience, this is rarely needed.

Wherever possible, visible cervical or vaginal (or vulvar, see below) lesions should be biopsied for histopathology, sampling representative areas of the most concerning portion, in order to minimize misdiagnosis and expedite referral and definitive treatment. For necrotic-appearing lesions I recommend taking multiple samples of the tumor, as necrotic, nonviable tissue can prevent accurate diagnosis of a cancer. In general, Pap smears should be reserved as screening tests for asymptomatic women without visible pathology.
 

Don’t treat or refer low-grade dysplasia, even if persistent

Increasingly we are understanding that low-grade dysplasia of the lower genital tract (CIN I, VAIN I, VIN I) is less a precursor for cancer, and more a phenomenon of benign HPV-associated changes.² This HPV change may be chronically persistent, may require years of observation and serial Pap smears, and may be a general nuisance for the patient. However, current guidelines do not recommend intervention for low-grade dysplasia of the lower genital tract.² Interventions to resect these lesions can result in morbidity, including perineal pain, vaginal scarring, and cervical stenosis or insufficiency. Given the extremely low risk for progression to cancer, these morbidities do not outweigh any small potential benefit.

When I am conferring with patients who have chronic low-grade dysplasia I spend a great deal of time exploring their understanding of the diagnosis and its pathophysiology, their fears, and their expectation regarding “success” of treatment. I spend the time educating them that this is a sequela of chronic viral infection that will not be eradicated with local surgical excisions, that their cancer risk and need for surveillance would persist even if surgical intervention were offered, and that the side effects of treatment would outweigh any benefit from the small risk of cancer or high-grade dysplasia.

In summary, the treatment of choice for persistent low-grade dysplasia of the lower genital tract is comprehensive patient education, not surgical resection or referral to gynecologic oncology.
 

Repeat sampling if there’s a discordance between imaging and biopsy results

Delay in cancer diagnosis is one of the greatest concerns for front-line gynecology providers. One of the more modifiable strategies to avoid missed or delayed diagnosis is to ensure that there is concordance between clinical findings and testing results. Otherwise said: The results and findings should make sense in aggregate. An example was cited above in which a visible cervical mass demonstrated CIN III on cytologic testing. Another common example is a biopsy result of “scant benign endometrium” in a patient with postmenopausal bleeding and thickened endometrial stripe on ultrasound. In both of these cases there is clear discordance between physical findings and the results of pathology sampling. A pathology report, in all of its black and white certitude, seems like the most reliable source of information. However, always trust your clinical judgment. If the clinical picture is suggesting something far worse than these limited, often random or blind samplings, I recommend repeated or more extensive sampling (for example, dilation and curettage). At the very least, schedule close follow-up with repeated sampling if the symptom or finding persists. The emphasis here is on scheduled follow-up, rather than “p.r.n.,” because a patient who was given a “normal” pathology result to explain her abnormal symptoms may not volunteer that those symptoms are persistent as she may feel that anything sinister was already ruled out. Make certain that you explain the potential for misdiagnosis as the reason for why you would like to see her back shortly to ensure the issue has resolved.

Biopsy vulvar lesions, minimize empiric treatment

Vulvar cancer is notoriously associated with delayed diagnosis. Unfortunately, it is commonplace for gynecologic oncologists to see women who have vulvar cancers that have been empirically treated, sometimes for months or years, with steroids or other topical agents. If a lesion on the vulva is characteristically benign in appearance (such as condyloma or lichen sclerosis), it may be reasonable to start empiric treatment. However, all patients who are treated without biopsy should be rescheduled for a planned follow-up appointment in 2-3 months. If the lesion/area remains unchanged, or worse, the lesion should be biopsied before proceeding with a change in therapy or continued therapy. Once again, don’t rely on patients to return for evaluation if the lesion doesn’t improve. Many patients assume that our first empiric diagnosis is “gospel,” and therefore may not return if the treatment doesn’t work. Meanwhile, providers may assume that patients will know that there is uncertainty in our interpretation and that they will know to report if the initial treatment didn’t work. These assumptions are the recipe for delayed diagnosis. If there is too great a burden on the patient to schedule a return visit because of social or financial reasons then the patient should have a biopsy prior to initiation of treatment. As a rule, empiric treatment is not a good strategy for patients without good access to follow-up.

Dr. Rossi is assistant professor in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. She has no relevant financial disclosures. Email her at obnews@mdedge.com.

References

1. Sullivan S. et al Gynecol Oncol. 2017 Feb;144(2):294-8.

2. Perkins R .et al J Low Genit Tract Dis. 2020 Apr;24(2):102-31.

Two chronic gynecologic conditions notably affect a woman’s quality of life (QoL), including fertility – one is endometriosis, and the other is a fibroid uterus. For a benign tumor, fibroids have an impressive prevalence found in approximately 50%-60% of women during their reproductive years. By menopause, it is estimated that 70% of woman have a fibroid, yet the true incidence is unknown given that only 25% of women experience symptoms bothersome enough to warrant intervention. This month’s article reviews the burden of fibroids and the latest management options that may potentially avoid surgery.

Background

Fibroids are monoclonal tumors of uterine smooth muscle that originate from the myometrium. Risk factors include family history, being premenopausal, increasing time since last delivery, obesity, and hypertension (ACOG Practice Bulletin no. 228 Jun 2021: Obstet Gynecol. 2021 Jun 1;137[6]:e100-e15) but oral hormonal contraception, depot medroxyprogesterone acetate (MPA), and increased parity reduce the risk of fibroids. Compared with White women, Black women have a 2-3 times higher prevalence of fibroids, develop them at a younger age, and present with larger fibroids.

The FIGO leiomyoma classification is the agreed upon system for identifying fibroid location. Symptoms are all too familiar to gynecologists, with life-threatening hemorrhage with severe anemia being the most feared, particularly for FIGO types 1-5. Transvaginal ultrasound is the simplest imaging tool for evaluation.

Adapted from Int J Gynecol Obstet. 2011;113:3-13.

Fibroids and fertility

Fibroids can impair fertility in several ways: alteration of local anatomy, including the detrimental effects of abnormal uterine bleeding; functional changes by increasing uterine contractions and impairing endometrium and myometrial blood supply; and changes to the local hormonal environment that could impair egg/sperm transport, or embryo implantation (Hum Reprod Update. 2017;22:665-86).

Prior to consideration of surgery, saline infusion sonogram can determine the degree of impact on the endometrium, which is most applicable to the infertility patient, but can also allow guidance toward the appropriate surgical approach.
 

Treatment options – medical

Management of fibroids is based on a woman’s age, desire for fertility, symptoms, and location of the fibroid(s). Expectant observation of a woman with fibroids may be a reasonable approach, provided the lack of symptoms impairing QoL and of anemia. Typically, there is no change in fibroid size during the short term, considered less than 1 year. Regarding fertility, studies are heterogeneous so there is no definitive conclusion that fibroids impair natural fertility (Reprod Biomed Online. 2021;43:100-10). Spontaneous regression, defined by a reduction in fibroid volume of greater than 20%, has been noted to occur in 7.0% of fibroids (Curr Obstet Gynecol Rep. 2018;7[3]:117-21).

When fertility is not desired, medical management of fibroids is the initial conservative approach. GnRH agonists have been utilized for temporary relief of menometrorrhagia because of fibroids and to reduce their volume, particularly preoperatively. However, extended treatment can induce bone mineral density loss. Add-back therapy (tibolone, raloxifene, estriol, and ipriflavone) is of value in reducing bone loss while MPA and tibolone may manage vasomotor symptoms. More recently, the use of a GnRH antagonist (elagolix) along with add-back therapy has been approved for up to 24 months by the Food and Drug Administration and has demonstrated a more than 50% amenorrhea rate at 12 months (Obstet Gynecol. 2020;135:1313-26).

Progesterone plays an important role in fibroid growth, but the mechanism is unclear. Although not FDA approved, selective progesterone receptor modulators (SPRM) act directly on fibroid size reduction at the level of the pituitary to induce amenorrhea through inhibition of ovulation. Also, more than one course of SPRMs can provide benefit for bleeding control and volume reduction. The SPRM ulipristal acetate for four courses of 3 months demonstrated 73.5% of patients experienced a fibroid volume reduction of greater than 25% and were amenorrheic (Fertil Steril. 2017;108:416-25). GnRH agonists or SPRMs may benefit women if the fibroid is larger than 3 cm or anemia exists, thereby precluding immediate surgery.

Other medication options include the levonorgestrel IUD, combined hormonal contraceptives, and tranexamic acid – all of which have limited data on effective results of treating abnormal uterine bleeding.
 

Treatment options – surgical

Fibroids are the most common reason for hysterectomy as they are the contributing indication in approximately one-third of surgeries. When future fertility is desired, current surgical options include hysteroscopic and laparoscopic (including robotic) myomectomy. Hysteroscopy is the standard approach for FIGO type 1 fibroids and can also manage some type 2 fibroids provided they are less than 3 cm and the latter is greater than 5 mm from the serosa. Type 2 fibroids may benefit from a “two-step” removal to allow the myometrium to contract and extrude the fibroid. In light of the risk of fluid overload with nonelectrolyte solutions that enable the use of monopolar cautery, many procedures are now performed with bipolar cautery or morcellators.

Laparoscopy (including robotic) has outcomes similar to those of laparotomy although the risk of uterine rupture with the former requires careful attention to thorough closure of the myometrial defect. Robotic myomectomy has outcomes similar to those of standard laparoscopy with less blood loss, but operating times may be prolonged (Best Pract Res Clin Obstet Gynaecol. 2018;46:113-9).

The rate of myomectomy is reported to be 9.2 per 10,000 woman-years in Black women and 1.3 per 10,000 woman years in White women (Fertil Steril 2017;108;416-25). The rate of recurrence after myomectomy can be as great as 60% when patients are followed up to 5 years. Intramural fibroids greater than 2.85 cm and not distorting the uterine cavity may decrease in vitro fertilization (IVF) success (Fertil Steril 2014;101:716-21).
 

Noninvasive treatment modalities

Uterine artery embolization (UAE) is the most popular minimally invasive alternative to surgical myomectomy. Risks include postembolization syndrome (pain, fever, nausea, leukocytosis, and occasionally malaise), infection, and damage to fertility. Rarely, loss of ovarian function can occur, particularly in women above age 45. Because of the disruption of uterine blood flow, UAE increases the risk of accelerating ovarian aging and infertility as well as atrophic endometrium. In addition, pregnancy complications are increased including miscarriage, preterm labor, and postpartum hemorrhage. There is debate regarding the need for cesarean section at time of delivery given the potential for weakening of the uterine wall following UAE.

High-intensity focused ultrasound (HIFU) is guided by ultrasound or MRI and involves a high-energy-density ultrasound wave passing through the skin. The wave is absorbed and transformed into heat, causing the tissue protein to coagulate, and to be absorbed by the body. The procedure is scarless, carries a minimal risk of infection, and offers less pain compared with traditional approaches. However, HIFU is time consuming, and skin burns and unintentional tissue injury are a risk. A meta-analysis demonstrated improved symptoms of fibroids at 6 and 12 months (J Min Invasive Gynecol. 2021 in press).

Ultrasound-guided microwave ablation (MWA) uses an ablative electrode that is directly inserted into the target tissue via transcutaneous or transcervical approach via ultrasound guidance using microwave to produce heat for tissue coagulation necrosis. The advantages of MWA compared with HIFU and RFA are a higher tissue temperature, larger ablation volume, shorter operating time, less pain and no adverse major events (J Min Invasive Gynecol. 2021, in press).
 

Conclusion

The current literature cannot conclude that fibroids reduce the likelihood of achieving pregnancy with or without fertility treatment, based on a specific size, number, or location (not including submucosal or cavity-distorting intramural fibroids). Definitive evidence on the efficacy of myomectomy to improve fertility remains limited. Hysteroscopic myomectomy presumably improves pregnancy rates, but there is uncertainty as to its role in reducing miscarriage. Novel nonsurgical modalities are available and are expected to continue being developed but clarity on fertility outcomes is needed.
 

Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts of interests. Please contact him at obnews@mdedge.com.

Two chronic gynecologic conditions notably affect a woman’s quality of life (QoL), including fertility – one is endometriosis, and the other is a fibroid uterus. For a benign tumor, fibroids have an impressive prevalence found in approximately 50%-60% of women during their reproductive years. By menopause, it is estimated that 70% of woman have a fibroid, yet the true incidence is unknown given that only 25% of women experience symptoms bothersome enough to warrant intervention. This month’s article reviews the burden of fibroids and the latest management options that may potentially avoid surgery.

Background

Fibroids are monoclonal tumors of uterine smooth muscle that originate from the myometrium. Risk factors include family history, being premenopausal, increasing time since last delivery, obesity, and hypertension (ACOG Practice Bulletin no. 228 Jun 2021: Obstet Gynecol. 2021 Jun 1;137[6]:e100-e15) but oral hormonal contraception, depot medroxyprogesterone acetate (MPA), and increased parity reduce the risk of fibroids. Compared with White women, Black women have a 2-3 times higher prevalence of fibroids, develop them at a younger age, and present with larger fibroids.

The FIGO leiomyoma classification is the agreed upon system for identifying fibroid location. Symptoms are all too familiar to gynecologists, with life-threatening hemorrhage with severe anemia being the most feared, particularly for FIGO types 1-5. Transvaginal ultrasound is the simplest imaging tool for evaluation.

Adapted from Int J Gynecol Obstet. 2011;113:3-13.

Fibroids and fertility

Fibroids can impair fertility in several ways: alteration of local anatomy, including the detrimental effects of abnormal uterine bleeding; functional changes by increasing uterine contractions and impairing endometrium and myometrial blood supply; and changes to the local hormonal environment that could impair egg/sperm transport, or embryo implantation (Hum Reprod Update. 2017;22:665-86).

Prior to consideration of surgery, saline infusion sonogram can determine the degree of impact on the endometrium, which is most applicable to the infertility patient, but can also allow guidance toward the appropriate surgical approach.
 

Treatment options – medical

Management of fibroids is based on a woman’s age, desire for fertility, symptoms, and location of the fibroid(s). Expectant observation of a woman with fibroids may be a reasonable approach, provided the lack of symptoms impairing QoL and of anemia. Typically, there is no change in fibroid size during the short term, considered less than 1 year. Regarding fertility, studies are heterogeneous so there is no definitive conclusion that fibroids impair natural fertility (Reprod Biomed Online. 2021;43:100-10). Spontaneous regression, defined by a reduction in fibroid volume of greater than 20%, has been noted to occur in 7.0% of fibroids (Curr Obstet Gynecol Rep. 2018;7[3]:117-21).

When fertility is not desired, medical management of fibroids is the initial conservative approach. GnRH agonists have been utilized for temporary relief of menometrorrhagia because of fibroids and to reduce their volume, particularly preoperatively. However, extended treatment can induce bone mineral density loss. Add-back therapy (tibolone, raloxifene, estriol, and ipriflavone) is of value in reducing bone loss while MPA and tibolone may manage vasomotor symptoms. More recently, the use of a GnRH antagonist (elagolix) along with add-back therapy has been approved for up to 24 months by the Food and Drug Administration and has demonstrated a more than 50% amenorrhea rate at 12 months (Obstet Gynecol. 2020;135:1313-26).

Progesterone plays an important role in fibroid growth, but the mechanism is unclear. Although not FDA approved, selective progesterone receptor modulators (SPRM) act directly on fibroid size reduction at the level of the pituitary to induce amenorrhea through inhibition of ovulation. Also, more than one course of SPRMs can provide benefit for bleeding control and volume reduction. The SPRM ulipristal acetate for four courses of 3 months demonstrated 73.5% of patients experienced a fibroid volume reduction of greater than 25% and were amenorrheic (Fertil Steril. 2017;108:416-25). GnRH agonists or SPRMs may benefit women if the fibroid is larger than 3 cm or anemia exists, thereby precluding immediate surgery.

Other medication options include the levonorgestrel IUD, combined hormonal contraceptives, and tranexamic acid – all of which have limited data on effective results of treating abnormal uterine bleeding.
 

Treatment options – surgical

Fibroids are the most common reason for hysterectomy as they are the contributing indication in approximately one-third of surgeries. When future fertility is desired, current surgical options include hysteroscopic and laparoscopic (including robotic) myomectomy. Hysteroscopy is the standard approach for FIGO type 1 fibroids and can also manage some type 2 fibroids provided they are less than 3 cm and the latter is greater than 5 mm from the serosa. Type 2 fibroids may benefit from a “two-step” removal to allow the myometrium to contract and extrude the fibroid. In light of the risk of fluid overload with nonelectrolyte solutions that enable the use of monopolar cautery, many procedures are now performed with bipolar cautery or morcellators.

Laparoscopy (including robotic) has outcomes similar to those of laparotomy although the risk of uterine rupture with the former requires careful attention to thorough closure of the myometrial defect. Robotic myomectomy has outcomes similar to those of standard laparoscopy with less blood loss, but operating times may be prolonged (Best Pract Res Clin Obstet Gynaecol. 2018;46:113-9).

The rate of myomectomy is reported to be 9.2 per 10,000 woman-years in Black women and 1.3 per 10,000 woman years in White women (Fertil Steril 2017;108;416-25). The rate of recurrence after myomectomy can be as great as 60% when patients are followed up to 5 years. Intramural fibroids greater than 2.85 cm and not distorting the uterine cavity may decrease in vitro fertilization (IVF) success (Fertil Steril 2014;101:716-21).
 

Noninvasive treatment modalities

Uterine artery embolization (UAE) is the most popular minimally invasive alternative to surgical myomectomy. Risks include postembolization syndrome (pain, fever, nausea, leukocytosis, and occasionally malaise), infection, and damage to fertility. Rarely, loss of ovarian function can occur, particularly in women above age 45. Because of the disruption of uterine blood flow, UAE increases the risk of accelerating ovarian aging and infertility as well as atrophic endometrium. In addition, pregnancy complications are increased including miscarriage, preterm labor, and postpartum hemorrhage. There is debate regarding the need for cesarean section at time of delivery given the potential for weakening of the uterine wall following UAE.

High-intensity focused ultrasound (HIFU) is guided by ultrasound or MRI and involves a high-energy-density ultrasound wave passing through the skin. The wave is absorbed and transformed into heat, causing the tissue protein to coagulate, and to be absorbed by the body. The procedure is scarless, carries a minimal risk of infection, and offers less pain compared with traditional approaches. However, HIFU is time consuming, and skin burns and unintentional tissue injury are a risk. A meta-analysis demonstrated improved symptoms of fibroids at 6 and 12 months (J Min Invasive Gynecol. 2021 in press).

Ultrasound-guided microwave ablation (MWA) uses an ablative electrode that is directly inserted into the target tissue via transcutaneous or transcervical approach via ultrasound guidance using microwave to produce heat for tissue coagulation necrosis. The advantages of MWA compared with HIFU and RFA are a higher tissue temperature, larger ablation volume, shorter operating time, less pain and no adverse major events (J Min Invasive Gynecol. 2021, in press).
 

Conclusion

The current literature cannot conclude that fibroids reduce the likelihood of achieving pregnancy with or without fertility treatment, based on a specific size, number, or location (not including submucosal or cavity-distorting intramural fibroids). Definitive evidence on the efficacy of myomectomy to improve fertility remains limited. Hysteroscopic myomectomy presumably improves pregnancy rates, but there is uncertainty as to its role in reducing miscarriage. Novel nonsurgical modalities are available and are expected to continue being developed but clarity on fertility outcomes is needed.
 

Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts of interests. Please contact him at obnews@mdedge.com.

Two chronic gynecologic conditions notably affect a woman’s quality of life (QoL), including fertility – one is endometriosis, and the other is a fibroid uterus. For a benign tumor, fibroids have an impressive prevalence found in approximately 50%-60% of women during their reproductive years. By menopause, it is estimated that 70% of woman have a fibroid, yet the true incidence is unknown given that only 25% of women experience symptoms bothersome enough to warrant intervention. This month’s article reviews the burden of fibroids and the latest management options that may potentially avoid surgery.

Background

Fibroids are monoclonal tumors of uterine smooth muscle that originate from the myometrium. Risk factors include family history, being premenopausal, increasing time since last delivery, obesity, and hypertension (ACOG Practice Bulletin no. 228 Jun 2021: Obstet Gynecol. 2021 Jun 1;137[6]:e100-e15) but oral hormonal contraception, depot medroxyprogesterone acetate (MPA), and increased parity reduce the risk of fibroids. Compared with White women, Black women have a 2-3 times higher prevalence of fibroids, develop them at a younger age, and present with larger fibroids.

The FIGO leiomyoma classification is the agreed upon system for identifying fibroid location. Symptoms are all too familiar to gynecologists, with life-threatening hemorrhage with severe anemia being the most feared, particularly for FIGO types 1-5. Transvaginal ultrasound is the simplest imaging tool for evaluation.

Adapted from Int J Gynecol Obstet. 2011;113:3-13.

Fibroids and fertility

Fibroids can impair fertility in several ways: alteration of local anatomy, including the detrimental effects of abnormal uterine bleeding; functional changes by increasing uterine contractions and impairing endometrium and myometrial blood supply; and changes to the local hormonal environment that could impair egg/sperm transport, or embryo implantation (Hum Reprod Update. 2017;22:665-86).

Prior to consideration of surgery, saline infusion sonogram can determine the degree of impact on the endometrium, which is most applicable to the infertility patient, but can also allow guidance toward the appropriate surgical approach.
 

Treatment options – medical

Management of fibroids is based on a woman’s age, desire for fertility, symptoms, and location of the fibroid(s). Expectant observation of a woman with fibroids may be a reasonable approach, provided the lack of symptoms impairing QoL and of anemia. Typically, there is no change in fibroid size during the short term, considered less than 1 year. Regarding fertility, studies are heterogeneous so there is no definitive conclusion that fibroids impair natural fertility (Reprod Biomed Online. 2021;43:100-10). Spontaneous regression, defined by a reduction in fibroid volume of greater than 20%, has been noted to occur in 7.0% of fibroids (Curr Obstet Gynecol Rep. 2018;7[3]:117-21).

When fertility is not desired, medical management of fibroids is the initial conservative approach. GnRH agonists have been utilized for temporary relief of menometrorrhagia because of fibroids and to reduce their volume, particularly preoperatively. However, extended treatment can induce bone mineral density loss. Add-back therapy (tibolone, raloxifene, estriol, and ipriflavone) is of value in reducing bone loss while MPA and tibolone may manage vasomotor symptoms. More recently, the use of a GnRH antagonist (elagolix) along with add-back therapy has been approved for up to 24 months by the Food and Drug Administration and has demonstrated a more than 50% amenorrhea rate at 12 months (Obstet Gynecol. 2020;135:1313-26).

Progesterone plays an important role in fibroid growth, but the mechanism is unclear. Although not FDA approved, selective progesterone receptor modulators (SPRM) act directly on fibroid size reduction at the level of the pituitary to induce amenorrhea through inhibition of ovulation. Also, more than one course of SPRMs can provide benefit for bleeding control and volume reduction. The SPRM ulipristal acetate for four courses of 3 months demonstrated 73.5% of patients experienced a fibroid volume reduction of greater than 25% and were amenorrheic (Fertil Steril. 2017;108:416-25). GnRH agonists or SPRMs may benefit women if the fibroid is larger than 3 cm or anemia exists, thereby precluding immediate surgery.

Other medication options include the levonorgestrel IUD, combined hormonal contraceptives, and tranexamic acid – all of which have limited data on effective results of treating abnormal uterine bleeding.
 

Treatment options – surgical

Fibroids are the most common reason for hysterectomy as they are the contributing indication in approximately one-third of surgeries. When future fertility is desired, current surgical options include hysteroscopic and laparoscopic (including robotic) myomectomy. Hysteroscopy is the standard approach for FIGO type 1 fibroids and can also manage some type 2 fibroids provided they are less than 3 cm and the latter is greater than 5 mm from the serosa. Type 2 fibroids may benefit from a “two-step” removal to allow the myometrium to contract and extrude the fibroid. In light of the risk of fluid overload with nonelectrolyte solutions that enable the use of monopolar cautery, many procedures are now performed with bipolar cautery or morcellators.

Laparoscopy (including robotic) has outcomes similar to those of laparotomy although the risk of uterine rupture with the former requires careful attention to thorough closure of the myometrial defect. Robotic myomectomy has outcomes similar to those of standard laparoscopy with less blood loss, but operating times may be prolonged (Best Pract Res Clin Obstet Gynaecol. 2018;46:113-9).

The rate of myomectomy is reported to be 9.2 per 10,000 woman-years in Black women and 1.3 per 10,000 woman years in White women (Fertil Steril 2017;108;416-25). The rate of recurrence after myomectomy can be as great as 60% when patients are followed up to 5 years. Intramural fibroids greater than 2.85 cm and not distorting the uterine cavity may decrease in vitro fertilization (IVF) success (Fertil Steril 2014;101:716-21).
 

Noninvasive treatment modalities

Uterine artery embolization (UAE) is the most popular minimally invasive alternative to surgical myomectomy. Risks include postembolization syndrome (pain, fever, nausea, leukocytosis, and occasionally malaise), infection, and damage to fertility. Rarely, loss of ovarian function can occur, particularly in women above age 45. Because of the disruption of uterine blood flow, UAE increases the risk of accelerating ovarian aging and infertility as well as atrophic endometrium. In addition, pregnancy complications are increased including miscarriage, preterm labor, and postpartum hemorrhage. There is debate regarding the need for cesarean section at time of delivery given the potential for weakening of the uterine wall following UAE.

High-intensity focused ultrasound (HIFU) is guided by ultrasound or MRI and involves a high-energy-density ultrasound wave passing through the skin. The wave is absorbed and transformed into heat, causing the tissue protein to coagulate, and to be absorbed by the body. The procedure is scarless, carries a minimal risk of infection, and offers less pain compared with traditional approaches. However, HIFU is time consuming, and skin burns and unintentional tissue injury are a risk. A meta-analysis demonstrated improved symptoms of fibroids at 6 and 12 months (J Min Invasive Gynecol. 2021 in press).

Ultrasound-guided microwave ablation (MWA) uses an ablative electrode that is directly inserted into the target tissue via transcutaneous or transcervical approach via ultrasound guidance using microwave to produce heat for tissue coagulation necrosis. The advantages of MWA compared with HIFU and RFA are a higher tissue temperature, larger ablation volume, shorter operating time, less pain and no adverse major events (J Min Invasive Gynecol. 2021, in press).
 

Conclusion

The current literature cannot conclude that fibroids reduce the likelihood of achieving pregnancy with or without fertility treatment, based on a specific size, number, or location (not including submucosal or cavity-distorting intramural fibroids). Definitive evidence on the efficacy of myomectomy to improve fertility remains limited. Hysteroscopic myomectomy presumably improves pregnancy rates, but there is uncertainty as to its role in reducing miscarriage. Novel nonsurgical modalities are available and are expected to continue being developed but clarity on fertility outcomes is needed.
 

Dr. Trolice is director of Fertility CARE – The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando. He has no conflicts of interests. Please contact him at obnews@mdedge.com.

The 4-year-old boy and his grandmother are out for stroll around the neighborhood, walking hand in hand.

“Let’s sit on the bench and talk,” the boy says.

“Okay,” says the grandmother and they climb up onto the high bench and look out across the quiet road to a small garden beyond.

“What would you like to talk about?” his grandmother asks.

“You first,” he says.

“Okay, let’s see ... the grandmother and the grandson are out for a walk and they see a bench to sit on. They climb up and look around. They see the daffodils and the white clouds in the blue sky. The breeze is blowing gently. It is a happy day. Your turn; what would you like to talk about?”

“Nanna and Papa.”

“Do you miss Papa?”

“Yes.”

“It has been a whole year since he died.”

“A long, long time.”

“He loved you very much.”

“Yes,” the boy replies.

“Nanna must miss him very much. She must be lonely without him.”

The boy nods.

They sit on for a while, watching the occasional car and the occasional bird pass by. The boy and the grandmother are quiet and contemplative.

“Okay, let’s go,” he says and jumps down, ready to continue their walk.
 

The Friendship Bench

It must have been such an experience that gave Dixon Chibanda, MD, MPH, PhD, a psychiatrist from Zimbabwe, his brilliant idea. He trained grandmothers in evidence-based talk therapy and sat them on a bench in the park with his patients.^1,2 He founded the Friendship Bench in 2006 in the Harare township of Mbare with 14 grandmothers. There are more than 300 grandmothers sitting on benches, listening, and providing cognitive-behavioral therapy–informed interventions because he could find no therapists in the community and he found that, with a little training, these grandmothers could provide effective culturally sensitive interventions.

Originally, the sessions were conducted in Shona, the predominant native language in Zimbabwe, but since 2017, the sessions are also in English. By 2017, the Friendship Bench had helped more than 30,000 people. The method has been empirically vetted and expanded to countries beyond, including the United States. Dr. Chibanda’s Friendship Bench serves as a blueprint for any community interested in bringing affordable, accessible, and highly effective mental health services to its residents. Dr. Chibanda said: “Imagine if we could create a global network of grandmothers in every major city in the world.”³The Friendship Bench is also used with other illnesses, such as HIV, to improve medication compliance.⁴ Participants in this study reported that the Friendship Bench had a critical role in helping them accept their HIV status, citing the grandmothers’ empathic attitude, their normalization of the reality of living with HIV, and their encouragement of young people to socialize with peers and be free of guilt. Many recipients also described enhanced health and well-being.
 

Why grandmothers?

Have you heard of the evolutionary importance of grandmothers? The grandmother hypothesis is an adaptationist explanation for the fact that the human female lifespan extends beyond the period of fertility. A third of the average human female life span is post menopause. Does such a long female postreproductive life span have a reason, inquired Mwenza Blell, PhD.⁵

Peter B. Medawar, PhD,6 and Kristen Hawkes, PhD,⁷ suggested that grandparents influence their own fitness by their actions toward their grandchildren. International fieldwork has revealed that the situation is less clear than their hypothesis. In industrialized countries, grandmaternal support is often financial or emotional. Two meta-analyses of largely the same group of studies investigating grandmother effects have come up with differing conclusions. Rebecca Sear, PhD, and Ruth Mace, PhD, conclude that grandmothers are “almost universally” beneficial, while acknowledging some variation in the effects of paternal grandmothers.⁸ Maternal grandparents appear to invest more in their grandchildren than paternal grandparents. Beverly I. Strassmann, PhD, and Wendy M. Garrard, PhD, concluded that, in patrilineal societies, survival of maternal grandparents is associated with survival of grandchildren and suggest this may represent covert matriliny.⁹

Examining specific time periods, maternal grandmothers may have greatest effect on survival of grandchildren at the time of weaning, a time when increased pathogenic exposure is a threat to survival. Paternal grandmothers may influence the survival of grandchildren during the early period of life (1-12 months) and to influence the condition of their daughters-in-law during pregnancy. The fact that grandmothers share one X chromosome with their sons’ daughters, none with their sons’ sons, and have a 50% chance of sharing an X chromosome with their daughters’ children is suggested to explain the patterns of survival observed in these studies than a simple maternal/paternal division.

In low- and middle-income countries, grandmothers and older women are seen as owners of traditional knowledge, and influence many decisions about childcare, help with domestic work, and emotional support and advice.¹⁰ Studies find a significant positive impact on breastfeeding when grandmothers of the infants had their own breastfeeding experience or were positively inclined toward breastfeeding, although one Chinese study found that highly educated grandmothers were associated with decreased exclusive breastfeeding.¹¹ Despite this, most health programs target individual new mothers, without an understanding of the family and who else influences decisions.

Grandchildren and grandparents benefit from intergenerational activities with improved health and well-being of both generations. When older adults are involved in raising children, there is a significant reduction in the incidence of behavioral problems in childhood and adolescence. Grandparents improve grandchild outcomes, when measured by coresidence, caregiving, financial, and other support. The grandchild outcomes include physical health, socioemotional well-being, and cognitive development.¹²

Are there ‘grandparent genes?’

Flavio Schwarz, PhD, and colleagues think that variants of APOE and CD33 protect against heart disease and Alzheimer’s disease, allowing older people to live longer with better functioning hearts and brains – thus enabling transfer of wisdom from older to younger generations.¹³ While this logic may be a bit of a stretch, it does lead to a more interesting question: What has wisdom got to do with it?

When I ask psychiatrists what they think about wisdom, they give a variety of answers. Dilip Jeste, MD, a geriatric psychiatrist who studies successful aging, helped develop a measurable vision of wisdom.¹⁴ Wisdom is defined as a “multidimensional human trait that includes good social decision-making and pragmatic knowledge of life, prosocial attitudes and behaviors such as empathy and compassion, emotional homeostasis with a tendency to favor positive emotions, reflection and self-understanding, acknowledgment of and coping effectively with uncertainty, and decisiveness.”¹⁵ Others suggest that they include spirituality, openness to new experience, and a sense of humor.¹⁶ A scale called the San Diego Wisdom scale (SD-WISE) was created, using 524 community-dwelling adults aged 25-104 years. These subjects comprised a high proportion of White adults and individuals with a higher education, thus lacking diversity. Lack of diversity perpetuates generalizations, and like all sociocultural constructs, truth is specific to the population studied. High scores on the SD-WISE are positively correlated with good mental health, self-ratings of successful aging, mastery, resilience, happiness, and satisfaction with life.

Which brings us back to the grandmothers on the bench: Can someone please give them the SD-WISE scale and confirm several hypotheses? I would like to know whether a pragmatic knowledge of life is a recognized grandmotherly quality, suitable for the bench.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

References

1. Chibanda D. Bull World Health Organ. 2018 Jun 196(6):376-7.

2. Cavanaugh R. Lancet Psychiatry. 2017 Nov. doi: 10.1016/S2215-0366(17)30420-0.

3. Nuwer R. “How a bench and a team of grandmothers can tackle depression.” BBC. 2020 May 27.

4. Ouansafi I et al. PLoS One. 2021 Apr 22;16(4):e0250074.

5. Blell M. “Grandmother hypothesis, grandmother effect, and residence patterns.” Int Encyclopedia Anthropol. John Wiley & Sons, 2018.

6. Medawar PB. An Unsolved Problem of Biology. Routledge, 1957.

7. Hawkes K et al. Proc Nat Acad Sci. 1998 Feb 395(3):1336-9.

8. Sear R and Mace R. Evol Hum Behav. 2008;29(1):1-18.

9. Strassmann B and Garrard WM. Hum Nat. 2011 Jul;22(1-2):201-22.

10. Aubel J. BMJ Glob Health. 2021;6(2). doi 10.1136/bmjgh-2020-003808.

11. Negin J et al. BMJ Pregnancy Childbirth. 2016 Apr 7. doi: 10.1186/s12884-016-0880-5.

12. Sadruddin AFA. Soc Sci Med. 2019 Aug;239(4):112476.

13. Schwarz F et al. Proc Nat Acad Sci. 2016 Jan 5;113(1):74-9.

14. Jeste DV et al. Psychol Inquiry. 2020 Jun 22;31(2):134-43.

15. Meeks TW and Jeste DV. Arch Gen Psychiatry. 2009 Apr;66(4):355-65.

16. Bangen KJ et al. Am J Geriatr Psychiatry. 2013 Dec;21(12):1254-66.

The 4-year-old boy and his grandmother are out for stroll around the neighborhood, walking hand in hand.

“Let’s sit on the bench and talk,” the boy says.

“Okay,” says the grandmother and they climb up onto the high bench and look out across the quiet road to a small garden beyond.

“What would you like to talk about?” his grandmother asks.

“You first,” he says.

“Okay, let’s see ... the grandmother and the grandson are out for a walk and they see a bench to sit on. They climb up and look around. They see the daffodils and the white clouds in the blue sky. The breeze is blowing gently. It is a happy day. Your turn; what would you like to talk about?”

“Nanna and Papa.”

“Do you miss Papa?”

“Yes.”

“It has been a whole year since he died.”

“A long, long time.”

“He loved you very much.”

“Yes,” the boy replies.

“Nanna must miss him very much. She must be lonely without him.”

The boy nods.

They sit on for a while, watching the occasional car and the occasional bird pass by. The boy and the grandmother are quiet and contemplative.

“Okay, let’s go,” he says and jumps down, ready to continue their walk.
 

The Friendship Bench

It must have been such an experience that gave Dixon Chibanda, MD, MPH, PhD, a psychiatrist from Zimbabwe, his brilliant idea. He trained grandmothers in evidence-based talk therapy and sat them on a bench in the park with his patients.^1,2 He founded the Friendship Bench in 2006 in the Harare township of Mbare with 14 grandmothers. There are more than 300 grandmothers sitting on benches, listening, and providing cognitive-behavioral therapy–informed interventions because he could find no therapists in the community and he found that, with a little training, these grandmothers could provide effective culturally sensitive interventions.

Originally, the sessions were conducted in Shona, the predominant native language in Zimbabwe, but since 2017, the sessions are also in English. By 2017, the Friendship Bench had helped more than 30,000 people. The method has been empirically vetted and expanded to countries beyond, including the United States. Dr. Chibanda’s Friendship Bench serves as a blueprint for any community interested in bringing affordable, accessible, and highly effective mental health services to its residents. Dr. Chibanda said: “Imagine if we could create a global network of grandmothers in every major city in the world.”³The Friendship Bench is also used with other illnesses, such as HIV, to improve medication compliance.⁴ Participants in this study reported that the Friendship Bench had a critical role in helping them accept their HIV status, citing the grandmothers’ empathic attitude, their normalization of the reality of living with HIV, and their encouragement of young people to socialize with peers and be free of guilt. Many recipients also described enhanced health and well-being.
 

Why grandmothers?

Have you heard of the evolutionary importance of grandmothers? The grandmother hypothesis is an adaptationist explanation for the fact that the human female lifespan extends beyond the period of fertility. A third of the average human female life span is post menopause. Does such a long female postreproductive life span have a reason, inquired Mwenza Blell, PhD.⁵

Peter B. Medawar, PhD,6 and Kristen Hawkes, PhD,⁷ suggested that grandparents influence their own fitness by their actions toward their grandchildren. International fieldwork has revealed that the situation is less clear than their hypothesis. In industrialized countries, grandmaternal support is often financial or emotional. Two meta-analyses of largely the same group of studies investigating grandmother effects have come up with differing conclusions. Rebecca Sear, PhD, and Ruth Mace, PhD, conclude that grandmothers are “almost universally” beneficial, while acknowledging some variation in the effects of paternal grandmothers.⁸ Maternal grandparents appear to invest more in their grandchildren than paternal grandparents. Beverly I. Strassmann, PhD, and Wendy M. Garrard, PhD, concluded that, in patrilineal societies, survival of maternal grandparents is associated with survival of grandchildren and suggest this may represent covert matriliny.⁹

Examining specific time periods, maternal grandmothers may have greatest effect on survival of grandchildren at the time of weaning, a time when increased pathogenic exposure is a threat to survival. Paternal grandmothers may influence the survival of grandchildren during the early period of life (1-12 months) and to influence the condition of their daughters-in-law during pregnancy. The fact that grandmothers share one X chromosome with their sons’ daughters, none with their sons’ sons, and have a 50% chance of sharing an X chromosome with their daughters’ children is suggested to explain the patterns of survival observed in these studies than a simple maternal/paternal division.

In low- and middle-income countries, grandmothers and older women are seen as owners of traditional knowledge, and influence many decisions about childcare, help with domestic work, and emotional support and advice.¹⁰ Studies find a significant positive impact on breastfeeding when grandmothers of the infants had their own breastfeeding experience or were positively inclined toward breastfeeding, although one Chinese study found that highly educated grandmothers were associated with decreased exclusive breastfeeding.¹¹ Despite this, most health programs target individual new mothers, without an understanding of the family and who else influences decisions.

Grandchildren and grandparents benefit from intergenerational activities with improved health and well-being of both generations. When older adults are involved in raising children, there is a significant reduction in the incidence of behavioral problems in childhood and adolescence. Grandparents improve grandchild outcomes, when measured by coresidence, caregiving, financial, and other support. The grandchild outcomes include physical health, socioemotional well-being, and cognitive development.¹²

Are there ‘grandparent genes?’

Flavio Schwarz, PhD, and colleagues think that variants of APOE and CD33 protect against heart disease and Alzheimer’s disease, allowing older people to live longer with better functioning hearts and brains – thus enabling transfer of wisdom from older to younger generations.¹³ While this logic may be a bit of a stretch, it does lead to a more interesting question: What has wisdom got to do with it?

When I ask psychiatrists what they think about wisdom, they give a variety of answers. Dilip Jeste, MD, a geriatric psychiatrist who studies successful aging, helped develop a measurable vision of wisdom.¹⁴ Wisdom is defined as a “multidimensional human trait that includes good social decision-making and pragmatic knowledge of life, prosocial attitudes and behaviors such as empathy and compassion, emotional homeostasis with a tendency to favor positive emotions, reflection and self-understanding, acknowledgment of and coping effectively with uncertainty, and decisiveness.”¹⁵ Others suggest that they include spirituality, openness to new experience, and a sense of humor.¹⁶ A scale called the San Diego Wisdom scale (SD-WISE) was created, using 524 community-dwelling adults aged 25-104 years. These subjects comprised a high proportion of White adults and individuals with a higher education, thus lacking diversity. Lack of diversity perpetuates generalizations, and like all sociocultural constructs, truth is specific to the population studied. High scores on the SD-WISE are positively correlated with good mental health, self-ratings of successful aging, mastery, resilience, happiness, and satisfaction with life.

Which brings us back to the grandmothers on the bench: Can someone please give them the SD-WISE scale and confirm several hypotheses? I would like to know whether a pragmatic knowledge of life is a recognized grandmotherly quality, suitable for the bench.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

References

1. Chibanda D. Bull World Health Organ. 2018 Jun 196(6):376-7.

2. Cavanaugh R. Lancet Psychiatry. 2017 Nov. doi: 10.1016/S2215-0366(17)30420-0.

3. Nuwer R. “How a bench and a team of grandmothers can tackle depression.” BBC. 2020 May 27.

4. Ouansafi I et al. PLoS One. 2021 Apr 22;16(4):e0250074.

5. Blell M. “Grandmother hypothesis, grandmother effect, and residence patterns.” Int Encyclopedia Anthropol. John Wiley & Sons, 2018.

6. Medawar PB. An Unsolved Problem of Biology. Routledge, 1957.

7. Hawkes K et al. Proc Nat Acad Sci. 1998 Feb 395(3):1336-9.

8. Sear R and Mace R. Evol Hum Behav. 2008;29(1):1-18.

9. Strassmann B and Garrard WM. Hum Nat. 2011 Jul;22(1-2):201-22.

10. Aubel J. BMJ Glob Health. 2021;6(2). doi 10.1136/bmjgh-2020-003808.

11. Negin J et al. BMJ Pregnancy Childbirth. 2016 Apr 7. doi: 10.1186/s12884-016-0880-5.

12. Sadruddin AFA. Soc Sci Med. 2019 Aug;239(4):112476.

13. Schwarz F et al. Proc Nat Acad Sci. 2016 Jan 5;113(1):74-9.

14. Jeste DV et al. Psychol Inquiry. 2020 Jun 22;31(2):134-43.

15. Meeks TW and Jeste DV. Arch Gen Psychiatry. 2009 Apr;66(4):355-65.

16. Bangen KJ et al. Am J Geriatr Psychiatry. 2013 Dec;21(12):1254-66.

The 4-year-old boy and his grandmother are out for stroll around the neighborhood, walking hand in hand.

“Let’s sit on the bench and talk,” the boy says.

“Okay,” says the grandmother and they climb up onto the high bench and look out across the quiet road to a small garden beyond.

“What would you like to talk about?” his grandmother asks.

“You first,” he says.

“Okay, let’s see ... the grandmother and the grandson are out for a walk and they see a bench to sit on. They climb up and look around. They see the daffodils and the white clouds in the blue sky. The breeze is blowing gently. It is a happy day. Your turn; what would you like to talk about?”

“Nanna and Papa.”

“Do you miss Papa?”

“Yes.”

“It has been a whole year since he died.”

“A long, long time.”

“He loved you very much.”

“Yes,” the boy replies.

“Nanna must miss him very much. She must be lonely without him.”

The boy nods.

They sit on for a while, watching the occasional car and the occasional bird pass by. The boy and the grandmother are quiet and contemplative.

“Okay, let’s go,” he says and jumps down, ready to continue their walk.
 

The Friendship Bench

It must have been such an experience that gave Dixon Chibanda, MD, MPH, PhD, a psychiatrist from Zimbabwe, his brilliant idea. He trained grandmothers in evidence-based talk therapy and sat them on a bench in the park with his patients.^1,2 He founded the Friendship Bench in 2006 in the Harare township of Mbare with 14 grandmothers. There are more than 300 grandmothers sitting on benches, listening, and providing cognitive-behavioral therapy–informed interventions because he could find no therapists in the community and he found that, with a little training, these grandmothers could provide effective culturally sensitive interventions.

Originally, the sessions were conducted in Shona, the predominant native language in Zimbabwe, but since 2017, the sessions are also in English. By 2017, the Friendship Bench had helped more than 30,000 people. The method has been empirically vetted and expanded to countries beyond, including the United States. Dr. Chibanda’s Friendship Bench serves as a blueprint for any community interested in bringing affordable, accessible, and highly effective mental health services to its residents. Dr. Chibanda said: “Imagine if we could create a global network of grandmothers in every major city in the world.”³The Friendship Bench is also used with other illnesses, such as HIV, to improve medication compliance.⁴ Participants in this study reported that the Friendship Bench had a critical role in helping them accept their HIV status, citing the grandmothers’ empathic attitude, their normalization of the reality of living with HIV, and their encouragement of young people to socialize with peers and be free of guilt. Many recipients also described enhanced health and well-being.
 

Why grandmothers?

Have you heard of the evolutionary importance of grandmothers? The grandmother hypothesis is an adaptationist explanation for the fact that the human female lifespan extends beyond the period of fertility. A third of the average human female life span is post menopause. Does such a long female postreproductive life span have a reason, inquired Mwenza Blell, PhD.⁵

Peter B. Medawar, PhD,6 and Kristen Hawkes, PhD,⁷ suggested that grandparents influence their own fitness by their actions toward their grandchildren. International fieldwork has revealed that the situation is less clear than their hypothesis. In industrialized countries, grandmaternal support is often financial or emotional. Two meta-analyses of largely the same group of studies investigating grandmother effects have come up with differing conclusions. Rebecca Sear, PhD, and Ruth Mace, PhD, conclude that grandmothers are “almost universally” beneficial, while acknowledging some variation in the effects of paternal grandmothers.⁸ Maternal grandparents appear to invest more in their grandchildren than paternal grandparents. Beverly I. Strassmann, PhD, and Wendy M. Garrard, PhD, concluded that, in patrilineal societies, survival of maternal grandparents is associated with survival of grandchildren and suggest this may represent covert matriliny.⁹

Examining specific time periods, maternal grandmothers may have greatest effect on survival of grandchildren at the time of weaning, a time when increased pathogenic exposure is a threat to survival. Paternal grandmothers may influence the survival of grandchildren during the early period of life (1-12 months) and to influence the condition of their daughters-in-law during pregnancy. The fact that grandmothers share one X chromosome with their sons’ daughters, none with their sons’ sons, and have a 50% chance of sharing an X chromosome with their daughters’ children is suggested to explain the patterns of survival observed in these studies than a simple maternal/paternal division.

In low- and middle-income countries, grandmothers and older women are seen as owners of traditional knowledge, and influence many decisions about childcare, help with domestic work, and emotional support and advice.¹⁰ Studies find a significant positive impact on breastfeeding when grandmothers of the infants had their own breastfeeding experience or were positively inclined toward breastfeeding, although one Chinese study found that highly educated grandmothers were associated with decreased exclusive breastfeeding.¹¹ Despite this, most health programs target individual new mothers, without an understanding of the family and who else influences decisions.

Grandchildren and grandparents benefit from intergenerational activities with improved health and well-being of both generations. When older adults are involved in raising children, there is a significant reduction in the incidence of behavioral problems in childhood and adolescence. Grandparents improve grandchild outcomes, when measured by coresidence, caregiving, financial, and other support. The grandchild outcomes include physical health, socioemotional well-being, and cognitive development.¹²

Are there ‘grandparent genes?’

Flavio Schwarz, PhD, and colleagues think that variants of APOE and CD33 protect against heart disease and Alzheimer’s disease, allowing older people to live longer with better functioning hearts and brains – thus enabling transfer of wisdom from older to younger generations.¹³ While this logic may be a bit of a stretch, it does lead to a more interesting question: What has wisdom got to do with it?

When I ask psychiatrists what they think about wisdom, they give a variety of answers. Dilip Jeste, MD, a geriatric psychiatrist who studies successful aging, helped develop a measurable vision of wisdom.¹⁴ Wisdom is defined as a “multidimensional human trait that includes good social decision-making and pragmatic knowledge of life, prosocial attitudes and behaviors such as empathy and compassion, emotional homeostasis with a tendency to favor positive emotions, reflection and self-understanding, acknowledgment of and coping effectively with uncertainty, and decisiveness.”¹⁵ Others suggest that they include spirituality, openness to new experience, and a sense of humor.¹⁶ A scale called the San Diego Wisdom scale (SD-WISE) was created, using 524 community-dwelling adults aged 25-104 years. These subjects comprised a high proportion of White adults and individuals with a higher education, thus lacking diversity. Lack of diversity perpetuates generalizations, and like all sociocultural constructs, truth is specific to the population studied. High scores on the SD-WISE are positively correlated with good mental health, self-ratings of successful aging, mastery, resilience, happiness, and satisfaction with life.

Which brings us back to the grandmothers on the bench: Can someone please give them the SD-WISE scale and confirm several hypotheses? I would like to know whether a pragmatic knowledge of life is a recognized grandmotherly quality, suitable for the bench.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest.

References

1. Chibanda D. Bull World Health Organ. 2018 Jun 196(6):376-7.

2. Cavanaugh R. Lancet Psychiatry. 2017 Nov. doi: 10.1016/S2215-0366(17)30420-0.

3. Nuwer R. “How a bench and a team of grandmothers can tackle depression.” BBC. 2020 May 27.

4. Ouansafi I et al. PLoS One. 2021 Apr 22;16(4):e0250074.

5. Blell M. “Grandmother hypothesis, grandmother effect, and residence patterns.” Int Encyclopedia Anthropol. John Wiley & Sons, 2018.

6. Medawar PB. An Unsolved Problem of Biology. Routledge, 1957.

7. Hawkes K et al. Proc Nat Acad Sci. 1998 Feb 395(3):1336-9.

8. Sear R and Mace R. Evol Hum Behav. 2008;29(1):1-18.

9. Strassmann B and Garrard WM. Hum Nat. 2011 Jul;22(1-2):201-22.

10. Aubel J. BMJ Glob Health. 2021;6(2). doi 10.1136/bmjgh-2020-003808.

11. Negin J et al. BMJ Pregnancy Childbirth. 2016 Apr 7. doi: 10.1186/s12884-016-0880-5.

12. Sadruddin AFA. Soc Sci Med. 2019 Aug;239(4):112476.

13. Schwarz F et al. Proc Nat Acad Sci. 2016 Jan 5;113(1):74-9.

14. Jeste DV et al. Psychol Inquiry. 2020 Jun 22;31(2):134-43.

15. Meeks TW and Jeste DV. Arch Gen Psychiatry. 2009 Apr;66(4):355-65.

16. Bangen KJ et al. Am J Geriatr Psychiatry. 2013 Dec;21(12):1254-66.

For me, vacation planning brings with it a bit of anxiety and stress – particularly as we navigate the many uncertainties around COVID-19.

Courtesy Danielle M. Scott

Not only must my husband and I think about our own safety, we also have to make sure that our beloved dog, Samson, gets the proper care while we are away.

My husband adopted Samson, an 11-year-old mixed-breed rescue, when he was just a year old. He’s an important part of our family.

So, when booking our hotel room and flights, we also had to find someone we trust to care for Samson in our absence. Family members are not always an option, so we often rely on pet-sitting apps. We looked through profile after profile, contacted sitters, and interrogated them as if we were looking for care for a tiny human.

Eventually, we found a service that allows owners to use a mobile app that provides updates about how their pets are faring. While we were away, the sitter sent daily photos and videos of Samson that put our minds at ease.

As a registered nurse who works in an ICU, my own anxiety about leaving Samson reminded me about my patients’ reservations about leaving their pets during hospitalizations. Many of them share the same kinds of anxieties when they are separated from their beloved pets. Hospital visits are rarely planned. I have cared for patients who expressed concerns about their pets being home alone and needing to coordinate pet care. In some cases – to alleviate those patients’ anxieties – I have helped them contact friends and family members to assist with care.
 

Pets’ popularity grows in U.S.

According to the 2019-2020 National Pet Owners Survey, about 67% of U.S. households own a pet – which translates to about 84.9 million homes. During the height of COVID, Americans also acquired a greater number of smaller pets.¹ In addition, when social restrictions increased, the demand for dog adoptions and the desire to serve as foster owners rose significantly.² Last Chance Animal Rescue of Waldorf, Md., reportedly saw the adoption of dogs rise from 30%-40% in 2020. Another animal rescue operation, Lucky Dog, of Arlington, Va., in 2020 helped about 3,385 pets find adoption, up from about 1,800 in 2019.³ About two-thirds of all American households and roughly half of elderly individuals own pets.⁴

I am not surprised by those numbers. In my nursing practice, I face many stress-related factors, such as alternating day and night shifts, 12-hour shifts, strenuous physical work, and the psychological strain of attending to ill and dying patients. Interacting with Samson helps relieve that stress. The motion of petting Samson helps calm my heart rate and decreases my anxiety. In addition, Samson makes me smile – and excites almost all the people I interact with while he’s around. Of course, I’m not objective, but I view Samson’s impact on people as a symbol of the power of animal-assisted therapy (AAT).

AAT, defined as “the positive interaction between an animal and a patient within a therapeutic framework,”has proven to be an effective intervention for adults with intellectual disabilities who experience anxiety in an observational study.⁵ The intervention also has helped reduce cortisol levels in a study of nurses in physical medicine, internal medicine, and long-term care.⁶ Since most patient hospital stays are unplanned, there is a need to introduce AAT into hospital care. This would lessen anxiety in patients concerning their pets’ welfare.

We know that long-term hospital stays often cause adverse psychosocial effects on patients. Such stays can result in “hospitalization syndrome,” which is characterized by a gradual loss of cognition and orientation, an unwillingness to maintain contact with others or to engage in group therapy, and a loss of interest in their surroundings.⁷ The common causes for this syndrome are infection, medication, isolation, response to surgery, and dehydration. A consequence can be a permanent change in cognitive function or psychological impairment. However, my experience of practicing nursing for years has led me to discover that pets as an external stimulus can prevent the syndrome’s onset. This is because a large percentage of hospitalized patients have pets, and contact with a pet reminds them of home and the memories they share at home.

Introducing animal therapy into health care facilities could boost patients’ mental health – and ease their anxiety – by acting as a bridge between their present circumstances and the lives they have outside the establishment.
 

References

1. American Pet Owners Association. Will the COVID Pet Spike Last? State of the industry presentation. 2021 Mar 24.

2. Morgan L et al. Humanit Soc Sci Comm. 2020 Nov 24;7(144). doi: 10.1057/S41599-020-00649-x.

3. Hedgpeth D. So many pets have been adopted during the pandemic that shelters are running out. Washington Post. 2021 Jan 6.

4. Cherniack EP and Cherniack AR. Curr Gerontol Geriatr Res. 2014. doi: 10.1155/2014/623203.

5. Giuliani F and Jacquemettaz M. Eur J Integ Med. 2017 Sep;14;13-9.

6. Machová K et al. Int J Environ Res and Public Health. 2019 Oct;16(19):3670.

7. Machová K et al. Int J Environ Res Public Health. 2012 Apr;16(8):1362.

Ms. Scott is a registered nurse specializing in critical care and also has experience in nursing leadership. She has 8 years of experience in cardiothoracic ICUs. Ms. Scott received a bachelor of science in nursing degree from Queens University of Charlotte (N.C.), and a master of business administration in health care administration from the University of North Alabama, Florence. She has no conflicts of interest.

For me, vacation planning brings with it a bit of anxiety and stress – particularly as we navigate the many uncertainties around COVID-19.

Courtesy Danielle M. Scott

Not only must my husband and I think about our own safety, we also have to make sure that our beloved dog, Samson, gets the proper care while we are away.

My husband adopted Samson, an 11-year-old mixed-breed rescue, when he was just a year old. He’s an important part of our family.

So, when booking our hotel room and flights, we also had to find someone we trust to care for Samson in our absence. Family members are not always an option, so we often rely on pet-sitting apps. We looked through profile after profile, contacted sitters, and interrogated them as if we were looking for care for a tiny human.

Eventually, we found a service that allows owners to use a mobile app that provides updates about how their pets are faring. While we were away, the sitter sent daily photos and videos of Samson that put our minds at ease.

As a registered nurse who works in an ICU, my own anxiety about leaving Samson reminded me about my patients’ reservations about leaving their pets during hospitalizations. Many of them share the same kinds of anxieties when they are separated from their beloved pets. Hospital visits are rarely planned. I have cared for patients who expressed concerns about their pets being home alone and needing to coordinate pet care. In some cases – to alleviate those patients’ anxieties – I have helped them contact friends and family members to assist with care.
 

Pets’ popularity grows in U.S.

According to the 2019-2020 National Pet Owners Survey, about 67% of U.S. households own a pet – which translates to about 84.9 million homes. During the height of COVID, Americans also acquired a greater number of smaller pets.¹ In addition, when social restrictions increased, the demand for dog adoptions and the desire to serve as foster owners rose significantly.² Last Chance Animal Rescue of Waldorf, Md., reportedly saw the adoption of dogs rise from 30%-40% in 2020. Another animal rescue operation, Lucky Dog, of Arlington, Va., in 2020 helped about 3,385 pets find adoption, up from about 1,800 in 2019.³ About two-thirds of all American households and roughly half of elderly individuals own pets.⁴

I am not surprised by those numbers. In my nursing practice, I face many stress-related factors, such as alternating day and night shifts, 12-hour shifts, strenuous physical work, and the psychological strain of attending to ill and dying patients. Interacting with Samson helps relieve that stress. The motion of petting Samson helps calm my heart rate and decreases my anxiety. In addition, Samson makes me smile – and excites almost all the people I interact with while he’s around. Of course, I’m not objective, but I view Samson’s impact on people as a symbol of the power of animal-assisted therapy (AAT).

AAT, defined as “the positive interaction between an animal and a patient within a therapeutic framework,”has proven to be an effective intervention for adults with intellectual disabilities who experience anxiety in an observational study.⁵ The intervention also has helped reduce cortisol levels in a study of nurses in physical medicine, internal medicine, and long-term care.⁶ Since most patient hospital stays are unplanned, there is a need to introduce AAT into hospital care. This would lessen anxiety in patients concerning their pets’ welfare.

We know that long-term hospital stays often cause adverse psychosocial effects on patients. Such stays can result in “hospitalization syndrome,” which is characterized by a gradual loss of cognition and orientation, an unwillingness to maintain contact with others or to engage in group therapy, and a loss of interest in their surroundings.⁷ The common causes for this syndrome are infection, medication, isolation, response to surgery, and dehydration. A consequence can be a permanent change in cognitive function or psychological impairment. However, my experience of practicing nursing for years has led me to discover that pets as an external stimulus can prevent the syndrome’s onset. This is because a large percentage of hospitalized patients have pets, and contact with a pet reminds them of home and the memories they share at home.

Introducing animal therapy into health care facilities could boost patients’ mental health – and ease their anxiety – by acting as a bridge between their present circumstances and the lives they have outside the establishment.
 

References

1. American Pet Owners Association. Will the COVID Pet Spike Last? State of the industry presentation. 2021 Mar 24.

2. Morgan L et al. Humanit Soc Sci Comm. 2020 Nov 24;7(144). doi: 10.1057/S41599-020-00649-x.

3. Hedgpeth D. So many pets have been adopted during the pandemic that shelters are running out. Washington Post. 2021 Jan 6.

4. Cherniack EP and Cherniack AR. Curr Gerontol Geriatr Res. 2014. doi: 10.1155/2014/623203.

5. Giuliani F and Jacquemettaz M. Eur J Integ Med. 2017 Sep;14;13-9.

6. Machová K et al. Int J Environ Res and Public Health. 2019 Oct;16(19):3670.

7. Machová K et al. Int J Environ Res Public Health. 2012 Apr;16(8):1362.

Ms. Scott is a registered nurse specializing in critical care and also has experience in nursing leadership. She has 8 years of experience in cardiothoracic ICUs. Ms. Scott received a bachelor of science in nursing degree from Queens University of Charlotte (N.C.), and a master of business administration in health care administration from the University of North Alabama, Florence. She has no conflicts of interest.

For me, vacation planning brings with it a bit of anxiety and stress – particularly as we navigate the many uncertainties around COVID-19.

Courtesy Danielle M. Scott

Not only must my husband and I think about our own safety, we also have to make sure that our beloved dog, Samson, gets the proper care while we are away.

My husband adopted Samson, an 11-year-old mixed-breed rescue, when he was just a year old. He’s an important part of our family.

So, when booking our hotel room and flights, we also had to find someone we trust to care for Samson in our absence. Family members are not always an option, so we often rely on pet-sitting apps. We looked through profile after profile, contacted sitters, and interrogated them as if we were looking for care for a tiny human.

Eventually, we found a service that allows owners to use a mobile app that provides updates about how their pets are faring. While we were away, the sitter sent daily photos and videos of Samson that put our minds at ease.

As a registered nurse who works in an ICU, my own anxiety about leaving Samson reminded me about my patients’ reservations about leaving their pets during hospitalizations. Many of them share the same kinds of anxieties when they are separated from their beloved pets. Hospital visits are rarely planned. I have cared for patients who expressed concerns about their pets being home alone and needing to coordinate pet care. In some cases – to alleviate those patients’ anxieties – I have helped them contact friends and family members to assist with care.
 

Pets’ popularity grows in U.S.

According to the 2019-2020 National Pet Owners Survey, about 67% of U.S. households own a pet – which translates to about 84.9 million homes. During the height of COVID, Americans also acquired a greater number of smaller pets.¹ In addition, when social restrictions increased, the demand for dog adoptions and the desire to serve as foster owners rose significantly.² Last Chance Animal Rescue of Waldorf, Md., reportedly saw the adoption of dogs rise from 30%-40% in 2020. Another animal rescue operation, Lucky Dog, of Arlington, Va., in 2020 helped about 3,385 pets find adoption, up from about 1,800 in 2019.³ About two-thirds of all American households and roughly half of elderly individuals own pets.⁴

I am not surprised by those numbers. In my nursing practice, I face many stress-related factors, such as alternating day and night shifts, 12-hour shifts, strenuous physical work, and the psychological strain of attending to ill and dying patients. Interacting with Samson helps relieve that stress. The motion of petting Samson helps calm my heart rate and decreases my anxiety. In addition, Samson makes me smile – and excites almost all the people I interact with while he’s around. Of course, I’m not objective, but I view Samson’s impact on people as a symbol of the power of animal-assisted therapy (AAT).

AAT, defined as “the positive interaction between an animal and a patient within a therapeutic framework,”has proven to be an effective intervention for adults with intellectual disabilities who experience anxiety in an observational study.⁵ The intervention also has helped reduce cortisol levels in a study of nurses in physical medicine, internal medicine, and long-term care.⁶ Since most patient hospital stays are unplanned, there is a need to introduce AAT into hospital care. This would lessen anxiety in patients concerning their pets’ welfare.

We know that long-term hospital stays often cause adverse psychosocial effects on patients. Such stays can result in “hospitalization syndrome,” which is characterized by a gradual loss of cognition and orientation, an unwillingness to maintain contact with others or to engage in group therapy, and a loss of interest in their surroundings.⁷ The common causes for this syndrome are infection, medication, isolation, response to surgery, and dehydration. A consequence can be a permanent change in cognitive function or psychological impairment. However, my experience of practicing nursing for years has led me to discover that pets as an external stimulus can prevent the syndrome’s onset. This is because a large percentage of hospitalized patients have pets, and contact with a pet reminds them of home and the memories they share at home.

Introducing animal therapy into health care facilities could boost patients’ mental health – and ease their anxiety – by acting as a bridge between their present circumstances and the lives they have outside the establishment.
 

References

1. American Pet Owners Association. Will the COVID Pet Spike Last? State of the industry presentation. 2021 Mar 24.

2. Morgan L et al. Humanit Soc Sci Comm. 2020 Nov 24;7(144). doi: 10.1057/S41599-020-00649-x.

3. Hedgpeth D. So many pets have been adopted during the pandemic that shelters are running out. Washington Post. 2021 Jan 6.

4. Cherniack EP and Cherniack AR. Curr Gerontol Geriatr Res. 2014. doi: 10.1155/2014/623203.

5. Giuliani F and Jacquemettaz M. Eur J Integ Med. 2017 Sep;14;13-9.

6. Machová K et al. Int J Environ Res and Public Health. 2019 Oct;16(19):3670.

7. Machová K et al. Int J Environ Res Public Health. 2012 Apr;16(8):1362.

Ms. Scott is a registered nurse specializing in critical care and also has experience in nursing leadership. She has 8 years of experience in cardiothoracic ICUs. Ms. Scott received a bachelor of science in nursing degree from Queens University of Charlotte (N.C.), and a master of business administration in health care administration from the University of North Alabama, Florence. She has no conflicts of interest.