Commentary

The world of telemedicine—especially teledermatology—had been a sleepy underutilized afterthought for most physicians until we were faced with a global pandemic the likes of which none of us had seen in our lifetimes. And just like that, teledermatology went from an afterthought to part of the “new normal.” Although those of us already practicing telemedicine knew of potential pitfalls and concerns, this great social experiment of throwing everyone into unexplored territory led to a great deal of frustration with technology and workflows that were not optimized for dermatology visits. The process is still changing, and the technical aspects of conducting teledermatology visits will no doubt improve, but what about the bigger question of reimbursement? Without adequate payments and financial models, the long-term future of telemedicine is uncertain, so an understanding of the current and likely future landscape of telemedicine reimbursement is critical.

Waivers During the Public Health Emergency

The declaration of a public health emergency (PHE)allowed for significant flexibility by the Centers for Medicare & Medicaid Services (CMS) during the coronavirus disease 2019 (COVID-19) pandemic. Importantly, the CMS was permitted to act quickly to allow telehealth to flourish during the worst of the pandemic and throughout the declared PHE, which has been extended several times already. Currently, the PHE is set to expire on April 20, 2021, but may be extended again if the pandemic is ongoing. The most important of these waivers was probably the removal of both the originating site and geographic requirements for telehealth services.¹ Prior to the COVID-19 PHE, a patient would have to travel to a doctor’s office, hospital, or skilled nursing facility to receive telehealth care (originating site requirement), and even then this was only allowed in defined rural areas of the country (geographic requirement). Both of these requirements were waived, allowing for any patient to receive telehealth services within their own homes. Concurrently, the requirement that patients must have an established relationship with the provider (ie, telehealth could not be used to provide care to new patients) also was waived.¹

In the spirit of expanding access to care and providing reasonable reimbursement for medical services, other changes were made for which the CMS should be commended. In acknowledging that many Medicare/Medicaid beneficiaries may not have access to devices that permit real-time, 2-way audio/video communication, which previously were necessary to qualify for a telehealth encounter, the CMS decided to cover telephone visits and provide reimbursement at the level of an established visit.¹ They also changed the billing structure to remove the place of service (POS) designation for telehealth (POS 02) and replace it with the normal physician’s office POS designation (usually POS 11), bringing back a telehealth modifier (modifier -95) in the process. The benefit of this change is solely to increase reimbursement for these services, as telehealth POS services generally are covered at lower facility rates, whereas POS 11 codes are reimbursed at the full level of a nonfacility physician’s office rate.

Finally, other waivers such as the Office of Civil Rights’ decision to waive HIPAA (Health Insurance Portability and Accountability Act) violations for telehealth platforms during the PHE allowed offices to take on telemedicine quickly without having to implement a new infrastructure.² Numerous codes were added to the list of covered services for telehealth, but these generally are not relevant for dermatologists. The CMS also allowed physicians’ offices to waive the patient responsibility/co-pay during the COVID-19 PHE, which previously was not allowed due to concerns about the anti-kickback statute.¹ These co-pay waivers were intended to remove another barrier to care for patients who were hesitant to participate in virtual visits. For the most part, the waiver of state licensing requirements is a bit less useful. As part of the CMS waiver, providers technically are allowed to see out-of-state Medicare/Medicaid beneficiaries, but state licensing laws are still in effect; thus, in the absence of a blanket state-level waiver (which some states enacted, modeled after the Uniform Emergency Volunteer Health Practitioner Act of 2006³), providers still cannot see most out-of-state patients from a legal and malpractice coverage standpoint.

An important flexibility during the COVID-19 PHE is one that often is underrecognized. The CMS has been clear about the ability to provide direct supervision for advanced practice providers (APPs) and residents via telehealth during the PHE, which allows for incident-to billing for APPs at remote sites given that the supervising physician is immediately available via an interactive, 2-way, live audio/video telecommunications method. It also allows for direct supervision of APPs and residents using such technology. For dermatology, which does not have a primary care waiver, an attending must still directly supervise each patient and see the patient via a live audio/video modality but does not have to be on-site to do so. This is a very interesting concept that, if extended, could truly impact practice management for the long-term.

Response From Commercial Insurance Carriers

Tracking along with the CMS waivers and flexibilities during the PHE, most commercial carriers quickly adopted similar policies to cover telehealth services. It should be noted that for most commercial insurance carriers, the coverage was already broader than Medicare/Medicaid coverage for telehealth prior to the PHE, so in many ways it is an extension of that concept and acceptance of telemedicine as a whole. What is sometimes confusing, though, is that various policies and requirements around billing exist; for example, while most carriers emulated the POS requirements that the CMS adopted, some carriers still stuck with the telemedicine POS but paid full in-office visit rates for those codes. Some carriers adopted higher reimbursement rates for telephone visits, similar to the CMS, while others instructed providers to just bill for the established office visit codes and allowed for telephone-only visits to qualify for these billing codes. Some carriers also waived co-pays for telehealth visits for their members (whether related to COVID-19 or not). It is beyond the scope of this article to delve into the specifics, which may vary not only by carrier but by region and plan. However, it is important to stay on top of one’s insurance carriers to find out what their latest directives are for billing for telehealth.

Postpandemic Teledermatology

What about the future of teledermatology? Although many dermatologists have adopted telehealth services out of necessity during the COVID-19 PHE, the jury is still out on the long-term forecast for telemedicine in dermatology. Concerns about liability/malpractice and technology issues abound, and for many, the headaches of teledermatology—such as trying to focus on a blurry photograph of a nevus that the patient is concerned about—make it unappealing. Some of these issues will be addressed by better technology, but the reimbursement structure must continue for teledermatology to remain in widespread use.

Currently, the biggest question facing telehealth is whether the waivers for originating site and geographic requirements will be able to continue. The CMS itself does not have the statutory authority to make these changes permanent and was only allowed to act due to a waiver under section 1135 of the Social Security Act during a PHE. It would take an act of Congress to change the law to allow for this specific expansion of telehealth services. A number of federal bills, including S 2741 (Creating Opportunities Now for Necessary and Effective Care Technologies [CONNECT] for Health Act of 2019) and S 4796 (Fair Care Act of 2020) from the Senate, contain such provisions, but none have been passed at the time of writing. There does seem to be broad support of the concept of expanding telemedicine access, such as noted by New York State Governor Andrew Cuomo in his 2021 State of the State address,⁴ but it remains to be seen when action will come.

Some regulations, such as the HIPAA waiver and the ability to waive co-pays, are not slated to continue after the pandemic. The ability to supervise residents via telehealth (real-time audio/video) has been made permanent, but only in rural areas. Direct supervision of APPs via telehealth will continue through the end of the calendar year of the PHE or the end of 2021, whichever comes later, but it remains to be seen whether remote supervision will continue. The CMS has stated in its comments that it is looking at this issue closely and may establish certain guardrails to ensure quality of care is maintained.¹ Telephone/audio-only visits also may come under further scrutiny, but research has supported the concept that patients who are more likely to gain access through audio-only modalities are older, Medicare/Medicaid (vs commercial), and Black (vs White) patients,⁵ so it would indeed introduce an unfair barrier to access if such coverage was rolled back.

Final Thoughts

Overall, we have made much progress in teledermatology. Once utilized by a small fraction of dermatologists, the vast majority of us turned to teledermatology to sustain our practices during the COVID-19 pandemic. Moving forward, there are 2 critical factors to consider: continued technological innovation and permanent coverage for telehealth reimbursement at in-office visit levels. With these challenges resolved, we can move forward and consider novel models that may be able to deliver dermatologic care to a broader patient population, thereby solving the critical issue of access to care for so many patients in need in our country.

The world of telemedicine—especially teledermatology—had been a sleepy underutilized afterthought for most physicians until we were faced with a global pandemic the likes of which none of us had seen in our lifetimes. And just like that, teledermatology went from an afterthought to part of the “new normal.” Although those of us already practicing telemedicine knew of potential pitfalls and concerns, this great social experiment of throwing everyone into unexplored territory led to a great deal of frustration with technology and workflows that were not optimized for dermatology visits. The process is still changing, and the technical aspects of conducting teledermatology visits will no doubt improve, but what about the bigger question of reimbursement? Without adequate payments and financial models, the long-term future of telemedicine is uncertain, so an understanding of the current and likely future landscape of telemedicine reimbursement is critical.

Waivers During the Public Health Emergency

The declaration of a public health emergency (PHE)allowed for significant flexibility by the Centers for Medicare & Medicaid Services (CMS) during the coronavirus disease 2019 (COVID-19) pandemic. Importantly, the CMS was permitted to act quickly to allow telehealth to flourish during the worst of the pandemic and throughout the declared PHE, which has been extended several times already. Currently, the PHE is set to expire on April 20, 2021, but may be extended again if the pandemic is ongoing. The most important of these waivers was probably the removal of both the originating site and geographic requirements for telehealth services.¹ Prior to the COVID-19 PHE, a patient would have to travel to a doctor’s office, hospital, or skilled nursing facility to receive telehealth care (originating site requirement), and even then this was only allowed in defined rural areas of the country (geographic requirement). Both of these requirements were waived, allowing for any patient to receive telehealth services within their own homes. Concurrently, the requirement that patients must have an established relationship with the provider (ie, telehealth could not be used to provide care to new patients) also was waived.¹

In the spirit of expanding access to care and providing reasonable reimbursement for medical services, other changes were made for which the CMS should be commended. In acknowledging that many Medicare/Medicaid beneficiaries may not have access to devices that permit real-time, 2-way audio/video communication, which previously were necessary to qualify for a telehealth encounter, the CMS decided to cover telephone visits and provide reimbursement at the level of an established visit.¹ They also changed the billing structure to remove the place of service (POS) designation for telehealth (POS 02) and replace it with the normal physician’s office POS designation (usually POS 11), bringing back a telehealth modifier (modifier -95) in the process. The benefit of this change is solely to increase reimbursement for these services, as telehealth POS services generally are covered at lower facility rates, whereas POS 11 codes are reimbursed at the full level of a nonfacility physician’s office rate.

Finally, other waivers such as the Office of Civil Rights’ decision to waive HIPAA (Health Insurance Portability and Accountability Act) violations for telehealth platforms during the PHE allowed offices to take on telemedicine quickly without having to implement a new infrastructure.² Numerous codes were added to the list of covered services for telehealth, but these generally are not relevant for dermatologists. The CMS also allowed physicians’ offices to waive the patient responsibility/co-pay during the COVID-19 PHE, which previously was not allowed due to concerns about the anti-kickback statute.¹ These co-pay waivers were intended to remove another barrier to care for patients who were hesitant to participate in virtual visits. For the most part, the waiver of state licensing requirements is a bit less useful. As part of the CMS waiver, providers technically are allowed to see out-of-state Medicare/Medicaid beneficiaries, but state licensing laws are still in effect; thus, in the absence of a blanket state-level waiver (which some states enacted, modeled after the Uniform Emergency Volunteer Health Practitioner Act of 2006³), providers still cannot see most out-of-state patients from a legal and malpractice coverage standpoint.

An important flexibility during the COVID-19 PHE is one that often is underrecognized. The CMS has been clear about the ability to provide direct supervision for advanced practice providers (APPs) and residents via telehealth during the PHE, which allows for incident-to billing for APPs at remote sites given that the supervising physician is immediately available via an interactive, 2-way, live audio/video telecommunications method. It also allows for direct supervision of APPs and residents using such technology. For dermatology, which does not have a primary care waiver, an attending must still directly supervise each patient and see the patient via a live audio/video modality but does not have to be on-site to do so. This is a very interesting concept that, if extended, could truly impact practice management for the long-term.

Response From Commercial Insurance Carriers

Tracking along with the CMS waivers and flexibilities during the PHE, most commercial carriers quickly adopted similar policies to cover telehealth services. It should be noted that for most commercial insurance carriers, the coverage was already broader than Medicare/Medicaid coverage for telehealth prior to the PHE, so in many ways it is an extension of that concept and acceptance of telemedicine as a whole. What is sometimes confusing, though, is that various policies and requirements around billing exist; for example, while most carriers emulated the POS requirements that the CMS adopted, some carriers still stuck with the telemedicine POS but paid full in-office visit rates for those codes. Some carriers adopted higher reimbursement rates for telephone visits, similar to the CMS, while others instructed providers to just bill for the established office visit codes and allowed for telephone-only visits to qualify for these billing codes. Some carriers also waived co-pays for telehealth visits for their members (whether related to COVID-19 or not). It is beyond the scope of this article to delve into the specifics, which may vary not only by carrier but by region and plan. However, it is important to stay on top of one’s insurance carriers to find out what their latest directives are for billing for telehealth.

Postpandemic Teledermatology

What about the future of teledermatology? Although many dermatologists have adopted telehealth services out of necessity during the COVID-19 PHE, the jury is still out on the long-term forecast for telemedicine in dermatology. Concerns about liability/malpractice and technology issues abound, and for many, the headaches of teledermatology—such as trying to focus on a blurry photograph of a nevus that the patient is concerned about—make it unappealing. Some of these issues will be addressed by better technology, but the reimbursement structure must continue for teledermatology to remain in widespread use.

Currently, the biggest question facing telehealth is whether the waivers for originating site and geographic requirements will be able to continue. The CMS itself does not have the statutory authority to make these changes permanent and was only allowed to act due to a waiver under section 1135 of the Social Security Act during a PHE. It would take an act of Congress to change the law to allow for this specific expansion of telehealth services. A number of federal bills, including S 2741 (Creating Opportunities Now for Necessary and Effective Care Technologies [CONNECT] for Health Act of 2019) and S 4796 (Fair Care Act of 2020) from the Senate, contain such provisions, but none have been passed at the time of writing. There does seem to be broad support of the concept of expanding telemedicine access, such as noted by New York State Governor Andrew Cuomo in his 2021 State of the State address,⁴ but it remains to be seen when action will come.

Some regulations, such as the HIPAA waiver and the ability to waive co-pays, are not slated to continue after the pandemic. The ability to supervise residents via telehealth (real-time audio/video) has been made permanent, but only in rural areas. Direct supervision of APPs via telehealth will continue through the end of the calendar year of the PHE or the end of 2021, whichever comes later, but it remains to be seen whether remote supervision will continue. The CMS has stated in its comments that it is looking at this issue closely and may establish certain guardrails to ensure quality of care is maintained.¹ Telephone/audio-only visits also may come under further scrutiny, but research has supported the concept that patients who are more likely to gain access through audio-only modalities are older, Medicare/Medicaid (vs commercial), and Black (vs White) patients,⁵ so it would indeed introduce an unfair barrier to access if such coverage was rolled back.

Final Thoughts

Overall, we have made much progress in teledermatology. Once utilized by a small fraction of dermatologists, the vast majority of us turned to teledermatology to sustain our practices during the COVID-19 pandemic. Moving forward, there are 2 critical factors to consider: continued technological innovation and permanent coverage for telehealth reimbursement at in-office visit levels. With these challenges resolved, we can move forward and consider novel models that may be able to deliver dermatologic care to a broader patient population, thereby solving the critical issue of access to care for so many patients in need in our country.

The world of telemedicine—especially teledermatology—had been a sleepy underutilized afterthought for most physicians until we were faced with a global pandemic the likes of which none of us had seen in our lifetimes. And just like that, teledermatology went from an afterthought to part of the “new normal.” Although those of us already practicing telemedicine knew of potential pitfalls and concerns, this great social experiment of throwing everyone into unexplored territory led to a great deal of frustration with technology and workflows that were not optimized for dermatology visits. The process is still changing, and the technical aspects of conducting teledermatology visits will no doubt improve, but what about the bigger question of reimbursement? Without adequate payments and financial models, the long-term future of telemedicine is uncertain, so an understanding of the current and likely future landscape of telemedicine reimbursement is critical.

Waivers During the Public Health Emergency

The declaration of a public health emergency (PHE)allowed for significant flexibility by the Centers for Medicare & Medicaid Services (CMS) during the coronavirus disease 2019 (COVID-19) pandemic. Importantly, the CMS was permitted to act quickly to allow telehealth to flourish during the worst of the pandemic and throughout the declared PHE, which has been extended several times already. Currently, the PHE is set to expire on April 20, 2021, but may be extended again if the pandemic is ongoing. The most important of these waivers was probably the removal of both the originating site and geographic requirements for telehealth services.¹ Prior to the COVID-19 PHE, a patient would have to travel to a doctor’s office, hospital, or skilled nursing facility to receive telehealth care (originating site requirement), and even then this was only allowed in defined rural areas of the country (geographic requirement). Both of these requirements were waived, allowing for any patient to receive telehealth services within their own homes. Concurrently, the requirement that patients must have an established relationship with the provider (ie, telehealth could not be used to provide care to new patients) also was waived.¹

In the spirit of expanding access to care and providing reasonable reimbursement for medical services, other changes were made for which the CMS should be commended. In acknowledging that many Medicare/Medicaid beneficiaries may not have access to devices that permit real-time, 2-way audio/video communication, which previously were necessary to qualify for a telehealth encounter, the CMS decided to cover telephone visits and provide reimbursement at the level of an established visit.¹ They also changed the billing structure to remove the place of service (POS) designation for telehealth (POS 02) and replace it with the normal physician’s office POS designation (usually POS 11), bringing back a telehealth modifier (modifier -95) in the process. The benefit of this change is solely to increase reimbursement for these services, as telehealth POS services generally are covered at lower facility rates, whereas POS 11 codes are reimbursed at the full level of a nonfacility physician’s office rate.

Finally, other waivers such as the Office of Civil Rights’ decision to waive HIPAA (Health Insurance Portability and Accountability Act) violations for telehealth platforms during the PHE allowed offices to take on telemedicine quickly without having to implement a new infrastructure.² Numerous codes were added to the list of covered services for telehealth, but these generally are not relevant for dermatologists. The CMS also allowed physicians’ offices to waive the patient responsibility/co-pay during the COVID-19 PHE, which previously was not allowed due to concerns about the anti-kickback statute.¹ These co-pay waivers were intended to remove another barrier to care for patients who were hesitant to participate in virtual visits. For the most part, the waiver of state licensing requirements is a bit less useful. As part of the CMS waiver, providers technically are allowed to see out-of-state Medicare/Medicaid beneficiaries, but state licensing laws are still in effect; thus, in the absence of a blanket state-level waiver (which some states enacted, modeled after the Uniform Emergency Volunteer Health Practitioner Act of 2006³), providers still cannot see most out-of-state patients from a legal and malpractice coverage standpoint.

An important flexibility during the COVID-19 PHE is one that often is underrecognized. The CMS has been clear about the ability to provide direct supervision for advanced practice providers (APPs) and residents via telehealth during the PHE, which allows for incident-to billing for APPs at remote sites given that the supervising physician is immediately available via an interactive, 2-way, live audio/video telecommunications method. It also allows for direct supervision of APPs and residents using such technology. For dermatology, which does not have a primary care waiver, an attending must still directly supervise each patient and see the patient via a live audio/video modality but does not have to be on-site to do so. This is a very interesting concept that, if extended, could truly impact practice management for the long-term.

Response From Commercial Insurance Carriers

Tracking along with the CMS waivers and flexibilities during the PHE, most commercial carriers quickly adopted similar policies to cover telehealth services. It should be noted that for most commercial insurance carriers, the coverage was already broader than Medicare/Medicaid coverage for telehealth prior to the PHE, so in many ways it is an extension of that concept and acceptance of telemedicine as a whole. What is sometimes confusing, though, is that various policies and requirements around billing exist; for example, while most carriers emulated the POS requirements that the CMS adopted, some carriers still stuck with the telemedicine POS but paid full in-office visit rates for those codes. Some carriers adopted higher reimbursement rates for telephone visits, similar to the CMS, while others instructed providers to just bill for the established office visit codes and allowed for telephone-only visits to qualify for these billing codes. Some carriers also waived co-pays for telehealth visits for their members (whether related to COVID-19 or not). It is beyond the scope of this article to delve into the specifics, which may vary not only by carrier but by region and plan. However, it is important to stay on top of one’s insurance carriers to find out what their latest directives are for billing for telehealth.

Postpandemic Teledermatology

What about the future of teledermatology? Although many dermatologists have adopted telehealth services out of necessity during the COVID-19 PHE, the jury is still out on the long-term forecast for telemedicine in dermatology. Concerns about liability/malpractice and technology issues abound, and for many, the headaches of teledermatology—such as trying to focus on a blurry photograph of a nevus that the patient is concerned about—make it unappealing. Some of these issues will be addressed by better technology, but the reimbursement structure must continue for teledermatology to remain in widespread use.

Currently, the biggest question facing telehealth is whether the waivers for originating site and geographic requirements will be able to continue. The CMS itself does not have the statutory authority to make these changes permanent and was only allowed to act due to a waiver under section 1135 of the Social Security Act during a PHE. It would take an act of Congress to change the law to allow for this specific expansion of telehealth services. A number of federal bills, including S 2741 (Creating Opportunities Now for Necessary and Effective Care Technologies [CONNECT] for Health Act of 2019) and S 4796 (Fair Care Act of 2020) from the Senate, contain such provisions, but none have been passed at the time of writing. There does seem to be broad support of the concept of expanding telemedicine access, such as noted by New York State Governor Andrew Cuomo in his 2021 State of the State address,⁴ but it remains to be seen when action will come.

Some regulations, such as the HIPAA waiver and the ability to waive co-pays, are not slated to continue after the pandemic. The ability to supervise residents via telehealth (real-time audio/video) has been made permanent, but only in rural areas. Direct supervision of APPs via telehealth will continue through the end of the calendar year of the PHE or the end of 2021, whichever comes later, but it remains to be seen whether remote supervision will continue. The CMS has stated in its comments that it is looking at this issue closely and may establish certain guardrails to ensure quality of care is maintained.¹ Telephone/audio-only visits also may come under further scrutiny, but research has supported the concept that patients who are more likely to gain access through audio-only modalities are older, Medicare/Medicaid (vs commercial), and Black (vs White) patients,⁵ so it would indeed introduce an unfair barrier to access if such coverage was rolled back.

Final Thoughts

Overall, we have made much progress in teledermatology. Once utilized by a small fraction of dermatologists, the vast majority of us turned to teledermatology to sustain our practices during the COVID-19 pandemic. Moving forward, there are 2 critical factors to consider: continued technological innovation and permanent coverage for telehealth reimbursement at in-office visit levels. With these challenges resolved, we can move forward and consider novel models that may be able to deliver dermatologic care to a broader patient population, thereby solving the critical issue of access to care for so many patients in need in our country.

I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.

This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.

The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.

Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.

I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.

This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.

The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.

Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.

I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.

This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.

The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.

Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.

The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.

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

The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.

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

The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.

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

We would like to describe the case of a patient we treated who developed neuropsychiatric symptoms secondary to recreational use of nitrous oxide (N₂O).

Mr. N, a 24-year-old military veteran, presented to the emergency department (ED) with symptoms of numbness, tingling of his entire body, and difficulty walking for the past 3 days. His family recently became concerned when they noted changes in his personality and behavior, including increased irritability, verbal aggression, and paranoia. The family reported that before the recent changes, Mr. N had typically been calm and had a pleasant temperament. When Mr. N’s symptoms progressed to difficulty ambulating, his family brought him to the ED for evaluation.

During his interview, Mr. N reported that he started using N₂O 2 years ago for recreational purposes because he learned it is legal to purchase and undetectable on a urine drug screen. He said he had been using >100 N₂O canisters per day and had spent approximately $15,000 over the past few months. His use had increasingly escalated up to 3 days before his visit to the ED, which was the last day he used N₂O.

Mr. N was admitted to the inpatient medical service. Laboratory testing revealed a low-normal vitamin B12 level of 254 pg/mL (normal range: 200 to 900 pg/mL), an elevated methylmalonic acid blood level of 2,491 nmol/L (normal range: 73 to 376 nmol/L), and an elevated homocysteine blood level of 22.4 μmol/L (normal range: 0 to 15 μmol/L). Magnetic resonance imaging studies showed hyperintensity regions on his cervical spine from the C1 to C6 levels. These changes suggested demyelination due to vitamin B12 deficiency from N₂O abuse.

Mr. N was started on vitamin B12 injections and physical therapy, which led to the resolution of his concerning neurologic symptoms. A few weeks after admission, he was discharged with outpatient follow-up services. Unfortunately, he was lost to follow-up.

Approximately 1 year later, Mr. N returned to the ED with anxiety and paranoid ideation. Medical workup at the time was normal (including vitamin B12 and methylmalonic acid blood levels). He denied any recent substance use and was admitted voluntarily to the psychiatric unit. He declined the recommended treatment of risperidone. Because he showed no signs or symptoms that warranted involuntary retention, he was discharged. Over the next few months, he had 4 visits to the ED with similar concerns and poor adherence to outpatient treatment.

On Mr. N’s fourth admission, he agreed to a course of long-acting injectable paliperidone and escitalopram to target his psychotic and anxious symptoms. These treatments stabilized him, and he was discharged. Neuropsychological testing later showed impairment across several cognitive domains, including memory, processing speed, attention, and executive functioning.

Continue to: Identifying N₂O use

Identifying N₂O use. N₂O is not detected on routine drug screen panels. Obtaining a careful psychiatric and substance use history, as well as conducting a neurologic assessment, are helpful to identify N₂O use. Both acute and chronic inhalation of N₂O can result in vitamin B12 deficiency with hematologic (megaloblastic anemia), neurologic (subacute combined degeneration of spinal cord, motor-sensory polyneuropathy), and psychiatric sequelae (memory loss, depression, hypomania, transient psychosis).¹ Patients who exhibit these changes warrant workup for vitamin B12 deficiency, which includes testing for B12, homocysteine, and methylmalonic acid blood levels. Magnetic resonance imaging should be considered for patients who exhibit neurologic symptoms.

The means by which N₂O causes neuropsychiatric changes have been explored in the literature. There is general consensus that part of N₂O’s deleterious effects is due to the inactivation of vitamin B12 by the irreversible oxidation of Cob(I)alamin to Cob(III)alamin.¹

Treatment. The recommended treatment is high-dose oral or parenteral vitamin B12.¹ Repletion of vitamin B12 is believed to reverse the course of illness. However, our patient’s symptoms of paranoia and delusions persisted despite resolution of his neurologic symptoms after the underlying vitamin B12 deficiency was corrected.

Due to N₂O’s wide availability and growing recreational use, it is important for clinicians to ask their patients about their use of this substance. The abuse of N₂O remains an important topic that requires further research, particularly in adolescents, who are still undergoing significant brain development.^2,3

Daniel Roberts, MD, MSW
PGY-3 Psychiatric Resident
Department of Psychiatry
New York University Grossman School of Medicine
New York, New York

Pantea Farahmand, MA, MD
Assistant Professor
Department of Psychiatry
New York University Grossman School of Medicine
Inpatient Psychiatrist
Veterans Administration New York Harbor Healthcare System
New York, New York

Adam Wolkin, MD
Associate Professor and Vice Chair
New York University Grossman School of Medicine
Associate Chief of Staff for Mental Health
Veterans Administration New York Harbor Healthcare System
New York, New York

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We would like to describe the case of a patient we treated who developed neuropsychiatric symptoms secondary to recreational use of nitrous oxide (N₂O).

Mr. N, a 24-year-old military veteran, presented to the emergency department (ED) with symptoms of numbness, tingling of his entire body, and difficulty walking for the past 3 days. His family recently became concerned when they noted changes in his personality and behavior, including increased irritability, verbal aggression, and paranoia. The family reported that before the recent changes, Mr. N had typically been calm and had a pleasant temperament. When Mr. N’s symptoms progressed to difficulty ambulating, his family brought him to the ED for evaluation.

During his interview, Mr. N reported that he started using N₂O 2 years ago for recreational purposes because he learned it is legal to purchase and undetectable on a urine drug screen. He said he had been using >100 N₂O canisters per day and had spent approximately $15,000 over the past few months. His use had increasingly escalated up to 3 days before his visit to the ED, which was the last day he used N₂O.

Mr. N was admitted to the inpatient medical service. Laboratory testing revealed a low-normal vitamin B12 level of 254 pg/mL (normal range: 200 to 900 pg/mL), an elevated methylmalonic acid blood level of 2,491 nmol/L (normal range: 73 to 376 nmol/L), and an elevated homocysteine blood level of 22.4 μmol/L (normal range: 0 to 15 μmol/L). Magnetic resonance imaging studies showed hyperintensity regions on his cervical spine from the C1 to C6 levels. These changes suggested demyelination due to vitamin B12 deficiency from N₂O abuse.

Mr. N was started on vitamin B12 injections and physical therapy, which led to the resolution of his concerning neurologic symptoms. A few weeks after admission, he was discharged with outpatient follow-up services. Unfortunately, he was lost to follow-up.

Approximately 1 year later, Mr. N returned to the ED with anxiety and paranoid ideation. Medical workup at the time was normal (including vitamin B12 and methylmalonic acid blood levels). He denied any recent substance use and was admitted voluntarily to the psychiatric unit. He declined the recommended treatment of risperidone. Because he showed no signs or symptoms that warranted involuntary retention, he was discharged. Over the next few months, he had 4 visits to the ED with similar concerns and poor adherence to outpatient treatment.

On Mr. N’s fourth admission, he agreed to a course of long-acting injectable paliperidone and escitalopram to target his psychotic and anxious symptoms. These treatments stabilized him, and he was discharged. Neuropsychological testing later showed impairment across several cognitive domains, including memory, processing speed, attention, and executive functioning.

Continue to: Identifying N₂O use

Identifying N₂O use. N₂O is not detected on routine drug screen panels. Obtaining a careful psychiatric and substance use history, as well as conducting a neurologic assessment, are helpful to identify N₂O use. Both acute and chronic inhalation of N₂O can result in vitamin B12 deficiency with hematologic (megaloblastic anemia), neurologic (subacute combined degeneration of spinal cord, motor-sensory polyneuropathy), and psychiatric sequelae (memory loss, depression, hypomania, transient psychosis).¹ Patients who exhibit these changes warrant workup for vitamin B12 deficiency, which includes testing for B12, homocysteine, and methylmalonic acid blood levels. Magnetic resonance imaging should be considered for patients who exhibit neurologic symptoms.

The means by which N₂O causes neuropsychiatric changes have been explored in the literature. There is general consensus that part of N₂O’s deleterious effects is due to the inactivation of vitamin B12 by the irreversible oxidation of Cob(I)alamin to Cob(III)alamin.¹

Treatment. The recommended treatment is high-dose oral or parenteral vitamin B12.¹ Repletion of vitamin B12 is believed to reverse the course of illness. However, our patient’s symptoms of paranoia and delusions persisted despite resolution of his neurologic symptoms after the underlying vitamin B12 deficiency was corrected.

Due to N₂O’s wide availability and growing recreational use, it is important for clinicians to ask their patients about their use of this substance. The abuse of N₂O remains an important topic that requires further research, particularly in adolescents, who are still undergoing significant brain development.^2,3

Daniel Roberts, MD, MSW
PGY-3 Psychiatric Resident
Department of Psychiatry
New York University Grossman School of Medicine
New York, New York

Pantea Farahmand, MA, MD
Assistant Professor
Department of Psychiatry
New York University Grossman School of Medicine
Inpatient Psychiatrist
Veterans Administration New York Harbor Healthcare System
New York, New York

Adam Wolkin, MD
Associate Professor and Vice Chair
New York University Grossman School of Medicine
Associate Chief of Staff for Mental Health
Veterans Administration New York Harbor Healthcare System
New York, New York

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We would like to describe the case of a patient we treated who developed neuropsychiatric symptoms secondary to recreational use of nitrous oxide (N₂O).

Mr. N, a 24-year-old military veteran, presented to the emergency department (ED) with symptoms of numbness, tingling of his entire body, and difficulty walking for the past 3 days. His family recently became concerned when they noted changes in his personality and behavior, including increased irritability, verbal aggression, and paranoia. The family reported that before the recent changes, Mr. N had typically been calm and had a pleasant temperament. When Mr. N’s symptoms progressed to difficulty ambulating, his family brought him to the ED for evaluation.

During his interview, Mr. N reported that he started using N₂O 2 years ago for recreational purposes because he learned it is legal to purchase and undetectable on a urine drug screen. He said he had been using >100 N₂O canisters per day and had spent approximately $15,000 over the past few months. His use had increasingly escalated up to 3 days before his visit to the ED, which was the last day he used N₂O.

Mr. N was admitted to the inpatient medical service. Laboratory testing revealed a low-normal vitamin B12 level of 254 pg/mL (normal range: 200 to 900 pg/mL), an elevated methylmalonic acid blood level of 2,491 nmol/L (normal range: 73 to 376 nmol/L), and an elevated homocysteine blood level of 22.4 μmol/L (normal range: 0 to 15 μmol/L). Magnetic resonance imaging studies showed hyperintensity regions on his cervical spine from the C1 to C6 levels. These changes suggested demyelination due to vitamin B12 deficiency from N₂O abuse.

Mr. N was started on vitamin B12 injections and physical therapy, which led to the resolution of his concerning neurologic symptoms. A few weeks after admission, he was discharged with outpatient follow-up services. Unfortunately, he was lost to follow-up.

Approximately 1 year later, Mr. N returned to the ED with anxiety and paranoid ideation. Medical workup at the time was normal (including vitamin B12 and methylmalonic acid blood levels). He denied any recent substance use and was admitted voluntarily to the psychiatric unit. He declined the recommended treatment of risperidone. Because he showed no signs or symptoms that warranted involuntary retention, he was discharged. Over the next few months, he had 4 visits to the ED with similar concerns and poor adherence to outpatient treatment.

On Mr. N’s fourth admission, he agreed to a course of long-acting injectable paliperidone and escitalopram to target his psychotic and anxious symptoms. These treatments stabilized him, and he was discharged. Neuropsychological testing later showed impairment across several cognitive domains, including memory, processing speed, attention, and executive functioning.

Continue to: Identifying N₂O use

Identifying N₂O use. N₂O is not detected on routine drug screen panels. Obtaining a careful psychiatric and substance use history, as well as conducting a neurologic assessment, are helpful to identify N₂O use. Both acute and chronic inhalation of N₂O can result in vitamin B12 deficiency with hematologic (megaloblastic anemia), neurologic (subacute combined degeneration of spinal cord, motor-sensory polyneuropathy), and psychiatric sequelae (memory loss, depression, hypomania, transient psychosis).¹ Patients who exhibit these changes warrant workup for vitamin B12 deficiency, which includes testing for B12, homocysteine, and methylmalonic acid blood levels. Magnetic resonance imaging should be considered for patients who exhibit neurologic symptoms.

The means by which N₂O causes neuropsychiatric changes have been explored in the literature. There is general consensus that part of N₂O’s deleterious effects is due to the inactivation of vitamin B12 by the irreversible oxidation of Cob(I)alamin to Cob(III)alamin.¹

Treatment. The recommended treatment is high-dose oral or parenteral vitamin B12.¹ Repletion of vitamin B12 is believed to reverse the course of illness. However, our patient’s symptoms of paranoia and delusions persisted despite resolution of his neurologic symptoms after the underlying vitamin B12 deficiency was corrected.

Due to N₂O’s wide availability and growing recreational use, it is important for clinicians to ask their patients about their use of this substance. The abuse of N₂O remains an important topic that requires further research, particularly in adolescents, who are still undergoing significant brain development.^2,3

Daniel Roberts, MD, MSW
PGY-3 Psychiatric Resident
Department of Psychiatry
New York University Grossman School of Medicine
New York, New York

Pantea Farahmand, MA, MD
Assistant Professor
Department of Psychiatry
New York University Grossman School of Medicine
Inpatient Psychiatrist
Veterans Administration New York Harbor Healthcare System
New York, New York

Adam Wolkin, MD
Associate Professor and Vice Chair
New York University Grossman School of Medicine
Associate Chief of Staff for Mental Health
Veterans Administration New York Harbor Healthcare System
New York, New York

Disclosures: The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

As we struggle to gradually emerge from the horrid coronavirus disease 2019 (COVID-19) pandemic that has disrupted our lives and killed hundreds of thousands of people in the United States, we harbor the hope that life will return to “normal.” But while it will certainly be a great relief to put this deadly virus behind us, many other epidemics will continue to plague our society and taint our culture.

Scientific ingenuity has led to the development of several vaccines in record time (aka “warp speed”) that will help defeat the deadly scourge of COVID-19. The pandemic is likely to peter out 2 years after its onset. We will all be grateful for such a rapid resolution of the worst health crisis the world has faced in a century, which will enable medical, economic, and social recovery. But as we eventually resume our lives and rejoice in resuming the pursuit of happiness, we will quickly realize that all is not well in our society just because the viral pandemic is gone.

Perhaps the ordeal of the COVID-19 pandemic, and the agony that was universally shared, will open our collective eyes to a jarring reality: many other epidemics will continue to permeate society and cause endless grief and suffering to many of our fellow humans. And thanks to our training as psychiatric physicians, we have developed extra “receptors” to the darker side of the human condition. As we help many of our psychiatric patients rendered sicker under the unbearable stress of the pandemic, we must not overlook the plight of so many others who do not show up in our clinics for health care, yet suffer enormously but imperceptibly. And no vaccine can come to the rescue of those who continue to live in quiet desperation.

Long-standing epidemics

It is truly unfortunate that many of the epidemics I am referring to have persisted for so long that they have become “fixtures” of contemporary societies. They have become “endemic epidemics” with no urgency to squelch them, as with the COVID-19 pandemic. The benign neglect that perpetuates these serious epidemics has had a malignant effect of “grudging resignation” that nothing can be done to reverse them. Unlike the viral epidemic that engulfed everyone around the world and triggered a massive and unified push to defeat the virus, these long-standing epidemics continue to afflict subgroups who are left to fend for themselves. These individuals deserve our empathy and warrant our determination to lift them from their miserable existence.

Consider some of the widespread epidemics that preceded the pandemic and will, in all likelihood, persist after the pandemic’s burden is lifted:

• millions of people living in poverty and hunger
• widespread racism
• smoldering social injustice
• appalling human trafficking, especially targeting children and women
• child abuse and neglect that leads to psychosis, depression, and suicide in adulthood
• gun violence, which kills many innocent people
• domestic violence that inflicts both physical and mental harm on families
• suicide, both attempts and completions, which continues to increase annually
• the festering stigma of mental illness that adds insult to injury for psychiatric patients
• alcohol and drug addictions, which destroy lives and corrode the fabric of society
• lack of access to mental health care for millions of people who need it
• lack of parity for psychiatric disorders, which is so unjust for our patients
• venomous political hatred and hyperpartisanship, which permeates our culture and can lead to violence, as we recently witnessed
• physician burnout, due to many causes, even before the stresses of COVID-19
• the ongoing agony of wars and terrorism, including dangerous cyberattacks
• the deleterious effect of social media on everyone, especially children.

Most of these epidemics claim thousands of lives each year, and yet no concerted public health effort is being mounted to counteract them, as we are seeing with the COVID-19 pandemic. Much is being written about each of them, but there has been little tangible action, so they persist. They have become a perpetual underbelly of our society that is essentially ignored or simply given the usual lip service.

It will take a herculean effort by policymakers, the judicial system, the medical establishment, and faith organizations to put an end to these life-threatening epidemics. It may appear too daunting to mount a war on so many fronts, but that should not deter us all from launching a strategic plan to create meaningful tactics and solutions. And just as was done with the COVID-19 pandemic, both mitigation measures as well as effective interventions must be employed in this campaign against the epidemic “hydra.”

Continue to: It is tragic...

It is tragic that so many fellow humans are allowed to suffer or die while the rest of us watch, or worse, turn a blind eye and never get involved. A civilized society must never neglect so many of its suffering citizens. As psychiatrists, we are aware of those human travesties around us, but we are often so overwhelmed with our work and personal responsibilities that few of us are passionately advocating or setting aside some time for those victimized by one or more of these endemic pandemics. And unless we all decide to be actively, meaningfully involved, many lives will continue to be lost every day, but without the daily “casualty count” displayed on television screens, as is the case with COVID-19 causalities.

Regrettably, maybe that old saw is true: out of sight, out of mind.

As we struggle to gradually emerge from the horrid coronavirus disease 2019 (COVID-19) pandemic that has disrupted our lives and killed hundreds of thousands of people in the United States, we harbor the hope that life will return to “normal.” But while it will certainly be a great relief to put this deadly virus behind us, many other epidemics will continue to plague our society and taint our culture.

Scientific ingenuity has led to the development of several vaccines in record time (aka “warp speed”) that will help defeat the deadly scourge of COVID-19. The pandemic is likely to peter out 2 years after its onset. We will all be grateful for such a rapid resolution of the worst health crisis the world has faced in a century, which will enable medical, economic, and social recovery. But as we eventually resume our lives and rejoice in resuming the pursuit of happiness, we will quickly realize that all is not well in our society just because the viral pandemic is gone.

Perhaps the ordeal of the COVID-19 pandemic, and the agony that was universally shared, will open our collective eyes to a jarring reality: many other epidemics will continue to permeate society and cause endless grief and suffering to many of our fellow humans. And thanks to our training as psychiatric physicians, we have developed extra “receptors” to the darker side of the human condition. As we help many of our psychiatric patients rendered sicker under the unbearable stress of the pandemic, we must not overlook the plight of so many others who do not show up in our clinics for health care, yet suffer enormously but imperceptibly. And no vaccine can come to the rescue of those who continue to live in quiet desperation.

Long-standing epidemics

It is truly unfortunate that many of the epidemics I am referring to have persisted for so long that they have become “fixtures” of contemporary societies. They have become “endemic epidemics” with no urgency to squelch them, as with the COVID-19 pandemic. The benign neglect that perpetuates these serious epidemics has had a malignant effect of “grudging resignation” that nothing can be done to reverse them. Unlike the viral epidemic that engulfed everyone around the world and triggered a massive and unified push to defeat the virus, these long-standing epidemics continue to afflict subgroups who are left to fend for themselves. These individuals deserve our empathy and warrant our determination to lift them from their miserable existence.

Consider some of the widespread epidemics that preceded the pandemic and will, in all likelihood, persist after the pandemic’s burden is lifted:

• millions of people living in poverty and hunger
• widespread racism
• smoldering social injustice
• appalling human trafficking, especially targeting children and women
• child abuse and neglect that leads to psychosis, depression, and suicide in adulthood
• gun violence, which kills many innocent people
• domestic violence that inflicts both physical and mental harm on families
• suicide, both attempts and completions, which continues to increase annually
• the festering stigma of mental illness that adds insult to injury for psychiatric patients
• alcohol and drug addictions, which destroy lives and corrode the fabric of society
• lack of access to mental health care for millions of people who need it
• lack of parity for psychiatric disorders, which is so unjust for our patients
• venomous political hatred and hyperpartisanship, which permeates our culture and can lead to violence, as we recently witnessed
• physician burnout, due to many causes, even before the stresses of COVID-19
• the ongoing agony of wars and terrorism, including dangerous cyberattacks
• the deleterious effect of social media on everyone, especially children.

Most of these epidemics claim thousands of lives each year, and yet no concerted public health effort is being mounted to counteract them, as we are seeing with the COVID-19 pandemic. Much is being written about each of them, but there has been little tangible action, so they persist. They have become a perpetual underbelly of our society that is essentially ignored or simply given the usual lip service.

It will take a herculean effort by policymakers, the judicial system, the medical establishment, and faith organizations to put an end to these life-threatening epidemics. It may appear too daunting to mount a war on so many fronts, but that should not deter us all from launching a strategic plan to create meaningful tactics and solutions. And just as was done with the COVID-19 pandemic, both mitigation measures as well as effective interventions must be employed in this campaign against the epidemic “hydra.”

Continue to: It is tragic...

It is tragic that so many fellow humans are allowed to suffer or die while the rest of us watch, or worse, turn a blind eye and never get involved. A civilized society must never neglect so many of its suffering citizens. As psychiatrists, we are aware of those human travesties around us, but we are often so overwhelmed with our work and personal responsibilities that few of us are passionately advocating or setting aside some time for those victimized by one or more of these endemic pandemics. And unless we all decide to be actively, meaningfully involved, many lives will continue to be lost every day, but without the daily “casualty count” displayed on television screens, as is the case with COVID-19 causalities.

Regrettably, maybe that old saw is true: out of sight, out of mind.

As we struggle to gradually emerge from the horrid coronavirus disease 2019 (COVID-19) pandemic that has disrupted our lives and killed hundreds of thousands of people in the United States, we harbor the hope that life will return to “normal.” But while it will certainly be a great relief to put this deadly virus behind us, many other epidemics will continue to plague our society and taint our culture.

Scientific ingenuity has led to the development of several vaccines in record time (aka “warp speed”) that will help defeat the deadly scourge of COVID-19. The pandemic is likely to peter out 2 years after its onset. We will all be grateful for such a rapid resolution of the worst health crisis the world has faced in a century, which will enable medical, economic, and social recovery. But as we eventually resume our lives and rejoice in resuming the pursuit of happiness, we will quickly realize that all is not well in our society just because the viral pandemic is gone.

Perhaps the ordeal of the COVID-19 pandemic, and the agony that was universally shared, will open our collective eyes to a jarring reality: many other epidemics will continue to permeate society and cause endless grief and suffering to many of our fellow humans. And thanks to our training as psychiatric physicians, we have developed extra “receptors” to the darker side of the human condition. As we help many of our psychiatric patients rendered sicker under the unbearable stress of the pandemic, we must not overlook the plight of so many others who do not show up in our clinics for health care, yet suffer enormously but imperceptibly. And no vaccine can come to the rescue of those who continue to live in quiet desperation.

Long-standing epidemics

It is truly unfortunate that many of the epidemics I am referring to have persisted for so long that they have become “fixtures” of contemporary societies. They have become “endemic epidemics” with no urgency to squelch them, as with the COVID-19 pandemic. The benign neglect that perpetuates these serious epidemics has had a malignant effect of “grudging resignation” that nothing can be done to reverse them. Unlike the viral epidemic that engulfed everyone around the world and triggered a massive and unified push to defeat the virus, these long-standing epidemics continue to afflict subgroups who are left to fend for themselves. These individuals deserve our empathy and warrant our determination to lift them from their miserable existence.

Consider some of the widespread epidemics that preceded the pandemic and will, in all likelihood, persist after the pandemic’s burden is lifted:

• millions of people living in poverty and hunger
• widespread racism
• smoldering social injustice
• appalling human trafficking, especially targeting children and women
• child abuse and neglect that leads to psychosis, depression, and suicide in adulthood
• gun violence, which kills many innocent people
• domestic violence that inflicts both physical and mental harm on families
• suicide, both attempts and completions, which continues to increase annually
• the festering stigma of mental illness that adds insult to injury for psychiatric patients
• alcohol and drug addictions, which destroy lives and corrode the fabric of society
• lack of access to mental health care for millions of people who need it
• lack of parity for psychiatric disorders, which is so unjust for our patients
• venomous political hatred and hyperpartisanship, which permeates our culture and can lead to violence, as we recently witnessed
• physician burnout, due to many causes, even before the stresses of COVID-19
• the ongoing agony of wars and terrorism, including dangerous cyberattacks
• the deleterious effect of social media on everyone, especially children.

Most of these epidemics claim thousands of lives each year, and yet no concerted public health effort is being mounted to counteract them, as we are seeing with the COVID-19 pandemic. Much is being written about each of them, but there has been little tangible action, so they persist. They have become a perpetual underbelly of our society that is essentially ignored or simply given the usual lip service.

It will take a herculean effort by policymakers, the judicial system, the medical establishment, and faith organizations to put an end to these life-threatening epidemics. It may appear too daunting to mount a war on so many fronts, but that should not deter us all from launching a strategic plan to create meaningful tactics and solutions. And just as was done with the COVID-19 pandemic, both mitigation measures as well as effective interventions must be employed in this campaign against the epidemic “hydra.”

Continue to: It is tragic...

It is tragic that so many fellow humans are allowed to suffer or die while the rest of us watch, or worse, turn a blind eye and never get involved. A civilized society must never neglect so many of its suffering citizens. As psychiatrists, we are aware of those human travesties around us, but we are often so overwhelmed with our work and personal responsibilities that few of us are passionately advocating or setting aside some time for those victimized by one or more of these endemic pandemics. And unless we all decide to be actively, meaningfully involved, many lives will continue to be lost every day, but without the daily “casualty count” displayed on television screens, as is the case with COVID-19 causalities.

Regrettably, maybe that old saw is true: out of sight, out of mind.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed our way of life. It has affected everything from how we go to the grocery store, attend school, worship, and spend time with our loved ones. As vaccinations are becoming available, there’s hope for a time when we can all enjoy a mask-free life again. Despite this, many of us are beginning to sense that the precautions and technology employed in response to COVID-19, and some of the lessons learned as a result, are likely to stay in place long after the virus has been controlled.

Victor Rendon, DO, MPA

Working remotely through audio and visual synchronous communication is now becoming the norm throughout the American workplace and educational system. Hospitals and graduate medical education programs are not exempt from this trend. For at least the foreseeable future, gone are the days of “unsocially distanced” bedside rounds in which 5 to 10 residents and medical students gather around with their attending as a case is presented in front of an agreeable patient.

My experience with ‘virtual’ supervision

Telemedicine has played a key role in the practice of health care during this pandemic, but little has been written about “telesupervision” of residents in the hospital setting. An unprecedented virtual approach to supervising emergency medicine residents was trialed at the University of Alabama a few months prior to my experience with it. This was found to be quite effective and well-received by all involved parties.¹

I am a PGY-2 psychiatry resident at ChristianaCare, a large multisite hospital system with more than 1,200 beds that serves the health care needs of Delaware and the surrounding areas. I recently had a novel educational experience working on a busy addiction medicine consult service. On the first day of this rotation, I met with my attending, Dr. Terry Horton, to discuss how the month would proceed. Together we developed a strategy for him to supervise me virtually.

Our arrangement was efficient and simple: I began each day by donning my surgical mask and protective eyewear and reviewing patients that had been placed on the consult list. Dr. Horton and I would have a conversation via telephone early in the morning to discuss the tasks that needed to be completed for the day. I would see and evaluate patients in the standard face-to-face way. After developing a treatment strategy, I contacted Dr. Horton on the phone, presented the patient, shared my plan, and gained information from his experienced perspective.

Then we saw the patient “together.” We used an iPad and Microsoft Teams video conferencing software. The information shared was protected using Microsoft Teams accounts, which were secured with profiles created by our institutional accounts. The iPad was placed on a rolling tripod, and the patient was able to converse with Dr. Horton as though he was physically in the room. I was there to facilitate the call, address any technical issues, and conduct any aspects of a physical exam that could only be done in person. After discussing any other changes to the treatment plan, I placed all medication orders, shared relevant details with nursing staff and other clinicians, wrote my progress note, and rolled my “attending on a stick” over to the next patient. Meanwhile, Dr. Horton was free to respond to pages or any other issues while I worked.

This description of my workflow is not very different from life before the virus. Based on informal feedback gathered from patients, the experience was overall positive. A physician is present; patients feel well cared for, and they look forward to visits and a virtual presence. This virtual approach not only spared unnecessary physical contact, reducing the risk of COVID-19 exposure, it also promoted efficiency.

Continue to: Fortunately, our hospital...

Certain psychosocial implications of the pandemic, including (but not limited to)social isolation and financial hardship, are often associated with increased substance use, and early data support the hypothesis that substance use has increased during this period.² Delaware seems to be included in the national trend. As such, our already-busy service is being stretched even further. Dr. Horton receives calls and is providing critical recommendations continuously throughout the day for multiple hospitals as well as for his outpatient practice. He used to spend a great deal of time traveling between different sites. With increasing need for his expertise, this model became increasingly difficult to practice. Our new model of attending supervision is welcomed in some settings because the attending can virtually be in multiple places at the same time.

For me, this experience has been positive. For a physician in training, virtual rounding can provide a critical balance of autonomy and support. I felt free on the rotation to make my own decisions, but I also did not feel like I was left to care for complicated cases on my own. Furthermore, my education did not suffer. In actuality, the experience enabled me to excel in my training. An attending physician was there for the important steps of plan formulation, but solo problem-solving opportunities were more readily available without his physical presence.

Aside from the medical lessons learned, I believe the participation has given me a glimpse of the future of medical training, health care delivery, and life in the increasingly digital post−COVID-19 world.

Hopefully, my experience will be helpful for other hospital systems as they continue to provide high-quality care to patients and education/training to their resident physicians in the face of the pandemic and the changing landscape of health care.

Acknowledgment

The author thanks Mustafa Mufti, MD, ChristianaCare Psychiatry Residency Program Director; Rachel Bronsther, MD, ChristianaCare Psychiatry Residency Associate Program Director; and Terry Horton, MD, ChristianaCare Addiction Medicine, for their assistance with this article.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed our way of life. It has affected everything from how we go to the grocery store, attend school, worship, and spend time with our loved ones. As vaccinations are becoming available, there’s hope for a time when we can all enjoy a mask-free life again. Despite this, many of us are beginning to sense that the precautions and technology employed in response to COVID-19, and some of the lessons learned as a result, are likely to stay in place long after the virus has been controlled.

Victor Rendon, DO, MPA

Working remotely through audio and visual synchronous communication is now becoming the norm throughout the American workplace and educational system. Hospitals and graduate medical education programs are not exempt from this trend. For at least the foreseeable future, gone are the days of “unsocially distanced” bedside rounds in which 5 to 10 residents and medical students gather around with their attending as a case is presented in front of an agreeable patient.

My experience with ‘virtual’ supervision

Telemedicine has played a key role in the practice of health care during this pandemic, but little has been written about “telesupervision” of residents in the hospital setting. An unprecedented virtual approach to supervising emergency medicine residents was trialed at the University of Alabama a few months prior to my experience with it. This was found to be quite effective and well-received by all involved parties.¹

I am a PGY-2 psychiatry resident at ChristianaCare, a large multisite hospital system with more than 1,200 beds that serves the health care needs of Delaware and the surrounding areas. I recently had a novel educational experience working on a busy addiction medicine consult service. On the first day of this rotation, I met with my attending, Dr. Terry Horton, to discuss how the month would proceed. Together we developed a strategy for him to supervise me virtually.

Our arrangement was efficient and simple: I began each day by donning my surgical mask and protective eyewear and reviewing patients that had been placed on the consult list. Dr. Horton and I would have a conversation via telephone early in the morning to discuss the tasks that needed to be completed for the day. I would see and evaluate patients in the standard face-to-face way. After developing a treatment strategy, I contacted Dr. Horton on the phone, presented the patient, shared my plan, and gained information from his experienced perspective.

Then we saw the patient “together.” We used an iPad and Microsoft Teams video conferencing software. The information shared was protected using Microsoft Teams accounts, which were secured with profiles created by our institutional accounts. The iPad was placed on a rolling tripod, and the patient was able to converse with Dr. Horton as though he was physically in the room. I was there to facilitate the call, address any technical issues, and conduct any aspects of a physical exam that could only be done in person. After discussing any other changes to the treatment plan, I placed all medication orders, shared relevant details with nursing staff and other clinicians, wrote my progress note, and rolled my “attending on a stick” over to the next patient. Meanwhile, Dr. Horton was free to respond to pages or any other issues while I worked.

This description of my workflow is not very different from life before the virus. Based on informal feedback gathered from patients, the experience was overall positive. A physician is present; patients feel well cared for, and they look forward to visits and a virtual presence. This virtual approach not only spared unnecessary physical contact, reducing the risk of COVID-19 exposure, it also promoted efficiency.

Continue to: Fortunately, our hospital...

Certain psychosocial implications of the pandemic, including (but not limited to)social isolation and financial hardship, are often associated with increased substance use, and early data support the hypothesis that substance use has increased during this period.² Delaware seems to be included in the national trend. As such, our already-busy service is being stretched even further. Dr. Horton receives calls and is providing critical recommendations continuously throughout the day for multiple hospitals as well as for his outpatient practice. He used to spend a great deal of time traveling between different sites. With increasing need for his expertise, this model became increasingly difficult to practice. Our new model of attending supervision is welcomed in some settings because the attending can virtually be in multiple places at the same time.

For me, this experience has been positive. For a physician in training, virtual rounding can provide a critical balance of autonomy and support. I felt free on the rotation to make my own decisions, but I also did not feel like I was left to care for complicated cases on my own. Furthermore, my education did not suffer. In actuality, the experience enabled me to excel in my training. An attending physician was there for the important steps of plan formulation, but solo problem-solving opportunities were more readily available without his physical presence.

Aside from the medical lessons learned, I believe the participation has given me a glimpse of the future of medical training, health care delivery, and life in the increasingly digital post−COVID-19 world.

Hopefully, my experience will be helpful for other hospital systems as they continue to provide high-quality care to patients and education/training to their resident physicians in the face of the pandemic and the changing landscape of health care.

Acknowledgment

The author thanks Mustafa Mufti, MD, ChristianaCare Psychiatry Residency Program Director; Rachel Bronsther, MD, ChristianaCare Psychiatry Residency Associate Program Director; and Terry Horton, MD, ChristianaCare Addiction Medicine, for their assistance with this article.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed our way of life. It has affected everything from how we go to the grocery store, attend school, worship, and spend time with our loved ones. As vaccinations are becoming available, there’s hope for a time when we can all enjoy a mask-free life again. Despite this, many of us are beginning to sense that the precautions and technology employed in response to COVID-19, and some of the lessons learned as a result, are likely to stay in place long after the virus has been controlled.

Victor Rendon, DO, MPA

Working remotely through audio and visual synchronous communication is now becoming the norm throughout the American workplace and educational system. Hospitals and graduate medical education programs are not exempt from this trend. For at least the foreseeable future, gone are the days of “unsocially distanced” bedside rounds in which 5 to 10 residents and medical students gather around with their attending as a case is presented in front of an agreeable patient.

My experience with ‘virtual’ supervision

Telemedicine has played a key role in the practice of health care during this pandemic, but little has been written about “telesupervision” of residents in the hospital setting. An unprecedented virtual approach to supervising emergency medicine residents was trialed at the University of Alabama a few months prior to my experience with it. This was found to be quite effective and well-received by all involved parties.¹

I am a PGY-2 psychiatry resident at ChristianaCare, a large multisite hospital system with more than 1,200 beds that serves the health care needs of Delaware and the surrounding areas. I recently had a novel educational experience working on a busy addiction medicine consult service. On the first day of this rotation, I met with my attending, Dr. Terry Horton, to discuss how the month would proceed. Together we developed a strategy for him to supervise me virtually.

Our arrangement was efficient and simple: I began each day by donning my surgical mask and protective eyewear and reviewing patients that had been placed on the consult list. Dr. Horton and I would have a conversation via telephone early in the morning to discuss the tasks that needed to be completed for the day. I would see and evaluate patients in the standard face-to-face way. After developing a treatment strategy, I contacted Dr. Horton on the phone, presented the patient, shared my plan, and gained information from his experienced perspective.

Then we saw the patient “together.” We used an iPad and Microsoft Teams video conferencing software. The information shared was protected using Microsoft Teams accounts, which were secured with profiles created by our institutional accounts. The iPad was placed on a rolling tripod, and the patient was able to converse with Dr. Horton as though he was physically in the room. I was there to facilitate the call, address any technical issues, and conduct any aspects of a physical exam that could only be done in person. After discussing any other changes to the treatment plan, I placed all medication orders, shared relevant details with nursing staff and other clinicians, wrote my progress note, and rolled my “attending on a stick” over to the next patient. Meanwhile, Dr. Horton was free to respond to pages or any other issues while I worked.

This description of my workflow is not very different from life before the virus. Based on informal feedback gathered from patients, the experience was overall positive. A physician is present; patients feel well cared for, and they look forward to visits and a virtual presence. This virtual approach not only spared unnecessary physical contact, reducing the risk of COVID-19 exposure, it also promoted efficiency.

Continue to: Fortunately, our hospital...

Certain psychosocial implications of the pandemic, including (but not limited to)social isolation and financial hardship, are often associated with increased substance use, and early data support the hypothesis that substance use has increased during this period.² Delaware seems to be included in the national trend. As such, our already-busy service is being stretched even further. Dr. Horton receives calls and is providing critical recommendations continuously throughout the day for multiple hospitals as well as for his outpatient practice. He used to spend a great deal of time traveling between different sites. With increasing need for his expertise, this model became increasingly difficult to practice. Our new model of attending supervision is welcomed in some settings because the attending can virtually be in multiple places at the same time.

For me, this experience has been positive. For a physician in training, virtual rounding can provide a critical balance of autonomy and support. I felt free on the rotation to make my own decisions, but I also did not feel like I was left to care for complicated cases on my own. Furthermore, my education did not suffer. In actuality, the experience enabled me to excel in my training. An attending physician was there for the important steps of plan formulation, but solo problem-solving opportunities were more readily available without his physical presence.

Aside from the medical lessons learned, I believe the participation has given me a glimpse of the future of medical training, health care delivery, and life in the increasingly digital post−COVID-19 world.

Hopefully, my experience will be helpful for other hospital systems as they continue to provide high-quality care to patients and education/training to their resident physicians in the face of the pandemic and the changing landscape of health care.

Acknowledgment

The author thanks Mustafa Mufti, MD, ChristianaCare Psychiatry Residency Program Director; Rachel Bronsther, MD, ChristianaCare Psychiatry Residency Associate Program Director; and Terry Horton, MD, ChristianaCare Addiction Medicine, for their assistance with this article.

On my third day as a PGY-4 junior attending on the inpatient psychiatric ward, 2 new PGY-1 residents, 2 medical students, and I stood in the wee hours of the morning, preparing to meet with our attending to begin rounds. I took the opportunity to discuss potential antipsychotic selection for one of our patients. I questioned the students to gauge their level of knowledge on antipsychotics in general, and did some “thinking out loud” about what our possible options could be. We discussed which antipsychotics are considered “weight-neutral” and which ones require caloric intake for adequate absorption. We discussed what other laboratory tests we should consider upon initiating the hypothetical medication. While discussing these things, I was suddenly taken aback to see that every member of my team was diligently taking notes and hanging on my every word!

Lessons from my teaching experiences

Taking on the role of junior attending has made me reflect on a few things about the transition that I will undergo at the end of this year, from resident to attending. First, teaching makes me keen to really sharpen my own knowledge, so that I can provide accurate information with confidence and ease. Making valid clinical decisions is a basic attending skill, but eloquently explaining clinical decisions to trainees with varying levels of background knowledge is a unique teaching attending necessity.

Second, I had this amazing feeling of helping patients beyond those currently in my care, since disseminating useful clinical information will allow trainees to better prepare to treat their own patients later. Random hypothetical situations presented by my attendings through the years may have seemed tangentially related to rounds at the time, but were meant to prepare me for actual future decisions (for example, “What would you change if this patient’s renal impairment were more severe?”). These teaching moments strengthen problem-solving skills and help us get as much benefit as possible from each case. The service to future patients extends to students who aren’t pursuing careers in psychiatry, because the skills they learn during a psychiatry rotation will help them connect with patients in any setting.

Third, I realized that teaching has the power to actively shape the future of medicine. What my attendings have taught me through the years is echoed and amplified in my teaching, and supplemented with my own readings and practice patterns.

Fourth, I noted what a privilege it is to be in a field with such attentive and eager trainees; as teachers in medicine, we truly get to work with the cream of the crop, which is a joy and a great responsibility. Working with such highly motivated and attentive students can be intimidating, but as I realized later in the morning, when asked about the complete indications for gabapentin, I realized I’m comfortable saying, “I don’t know, let’s look it up together!”

My fifth and final realization from this exciting teaching experience was that as an attending, I will need to help manage the wellness and growth of my trainees. Attendings must strike a balance between pushing learners to gain mastery while protecting them from excessive stress. I am so grateful for the perceptiveness of my attendings and their ability to adapt to the demands of a clinical environment while maintaining a strong focus on teaching. I have often told PGY-1 residents, when they face feelings of inadequacy for early mistakes, “You have 4 whole years to learn how to do this job!”

These are the moments that make me appreciate the fulfillment that can come from teaching residents and medical students, and really put into perspective how far I’ve come as a trainee. Not long ago, I was one of those medical students scribbling notes while my attending effortlessly spouted medical knowledge, and I was worried I’d never learn the difference between clonidine and clozapine.

On my third day as a PGY-4 junior attending on the inpatient psychiatric ward, 2 new PGY-1 residents, 2 medical students, and I stood in the wee hours of the morning, preparing to meet with our attending to begin rounds. I took the opportunity to discuss potential antipsychotic selection for one of our patients. I questioned the students to gauge their level of knowledge on antipsychotics in general, and did some “thinking out loud” about what our possible options could be. We discussed which antipsychotics are considered “weight-neutral” and which ones require caloric intake for adequate absorption. We discussed what other laboratory tests we should consider upon initiating the hypothetical medication. While discussing these things, I was suddenly taken aback to see that every member of my team was diligently taking notes and hanging on my every word!

Lessons from my teaching experiences

Taking on the role of junior attending has made me reflect on a few things about the transition that I will undergo at the end of this year, from resident to attending. First, teaching makes me keen to really sharpen my own knowledge, so that I can provide accurate information with confidence and ease. Making valid clinical decisions is a basic attending skill, but eloquently explaining clinical decisions to trainees with varying levels of background knowledge is a unique teaching attending necessity.

Second, I had this amazing feeling of helping patients beyond those currently in my care, since disseminating useful clinical information will allow trainees to better prepare to treat their own patients later. Random hypothetical situations presented by my attendings through the years may have seemed tangentially related to rounds at the time, but were meant to prepare me for actual future decisions (for example, “What would you change if this patient’s renal impairment were more severe?”). These teaching moments strengthen problem-solving skills and help us get as much benefit as possible from each case. The service to future patients extends to students who aren’t pursuing careers in psychiatry, because the skills they learn during a psychiatry rotation will help them connect with patients in any setting.

Third, I realized that teaching has the power to actively shape the future of medicine. What my attendings have taught me through the years is echoed and amplified in my teaching, and supplemented with my own readings and practice patterns.

Fourth, I noted what a privilege it is to be in a field with such attentive and eager trainees; as teachers in medicine, we truly get to work with the cream of the crop, which is a joy and a great responsibility. Working with such highly motivated and attentive students can be intimidating, but as I realized later in the morning, when asked about the complete indications for gabapentin, I realized I’m comfortable saying, “I don’t know, let’s look it up together!”

My fifth and final realization from this exciting teaching experience was that as an attending, I will need to help manage the wellness and growth of my trainees. Attendings must strike a balance between pushing learners to gain mastery while protecting them from excessive stress. I am so grateful for the perceptiveness of my attendings and their ability to adapt to the demands of a clinical environment while maintaining a strong focus on teaching. I have often told PGY-1 residents, when they face feelings of inadequacy for early mistakes, “You have 4 whole years to learn how to do this job!”

These are the moments that make me appreciate the fulfillment that can come from teaching residents and medical students, and really put into perspective how far I’ve come as a trainee. Not long ago, I was one of those medical students scribbling notes while my attending effortlessly spouted medical knowledge, and I was worried I’d never learn the difference between clonidine and clozapine.

On my third day as a PGY-4 junior attending on the inpatient psychiatric ward, 2 new PGY-1 residents, 2 medical students, and I stood in the wee hours of the morning, preparing to meet with our attending to begin rounds. I took the opportunity to discuss potential antipsychotic selection for one of our patients. I questioned the students to gauge their level of knowledge on antipsychotics in general, and did some “thinking out loud” about what our possible options could be. We discussed which antipsychotics are considered “weight-neutral” and which ones require caloric intake for adequate absorption. We discussed what other laboratory tests we should consider upon initiating the hypothetical medication. While discussing these things, I was suddenly taken aback to see that every member of my team was diligently taking notes and hanging on my every word!

Lessons from my teaching experiences

Taking on the role of junior attending has made me reflect on a few things about the transition that I will undergo at the end of this year, from resident to attending. First, teaching makes me keen to really sharpen my own knowledge, so that I can provide accurate information with confidence and ease. Making valid clinical decisions is a basic attending skill, but eloquently explaining clinical decisions to trainees with varying levels of background knowledge is a unique teaching attending necessity.

Second, I had this amazing feeling of helping patients beyond those currently in my care, since disseminating useful clinical information will allow trainees to better prepare to treat their own patients later. Random hypothetical situations presented by my attendings through the years may have seemed tangentially related to rounds at the time, but were meant to prepare me for actual future decisions (for example, “What would you change if this patient’s renal impairment were more severe?”). These teaching moments strengthen problem-solving skills and help us get as much benefit as possible from each case. The service to future patients extends to students who aren’t pursuing careers in psychiatry, because the skills they learn during a psychiatry rotation will help them connect with patients in any setting.

Third, I realized that teaching has the power to actively shape the future of medicine. What my attendings have taught me through the years is echoed and amplified in my teaching, and supplemented with my own readings and practice patterns.

Fourth, I noted what a privilege it is to be in a field with such attentive and eager trainees; as teachers in medicine, we truly get to work with the cream of the crop, which is a joy and a great responsibility. Working with such highly motivated and attentive students can be intimidating, but as I realized later in the morning, when asked about the complete indications for gabapentin, I realized I’m comfortable saying, “I don’t know, let’s look it up together!”

My fifth and final realization from this exciting teaching experience was that as an attending, I will need to help manage the wellness and growth of my trainees. Attendings must strike a balance between pushing learners to gain mastery while protecting them from excessive stress. I am so grateful for the perceptiveness of my attendings and their ability to adapt to the demands of a clinical environment while maintaining a strong focus on teaching. I have often told PGY-1 residents, when they face feelings of inadequacy for early mistakes, “You have 4 whole years to learn how to do this job!”

These are the moments that make me appreciate the fulfillment that can come from teaching residents and medical students, and really put into perspective how far I’ve come as a trainee. Not long ago, I was one of those medical students scribbling notes while my attending effortlessly spouted medical knowledge, and I was worried I’d never learn the difference between clonidine and clozapine.

I am composing this editorial 4 days after the U.S. Capitol was invaded and 10 days before the presidential inauguration. It is impossible to ignore what is happening in our country, but I hesitate to add my thoughts to the overwhelming sea of opinions circulating in standard media, social media, and the dark web. I hope, as do many, that we return to a civil discourse, recognize the voices of all people, respect each other, and return to a belief in science and facts.

SARS-CoV-2 has devastated the world and will continue to cause preventable deaths until we adopt stricter mitigation measures, vaccinate most people, and develop widespread immunity. We are gaining immense knowledge about this virus, and as gastroenterologists, we are on the front lines in many aspects. A recent article in American Journal of Gastroenterology, among others, emphasized that mild GI symptoms may be the only presenting complaint for people with COVID-19. Responses to COVID-19, such as limits on elective procedures and social distancing, have upended our endoscopic processes and even altered the business models of GI practice. We will never go back to pre-COVID models.

The front page of this month’s GI & Hepatology News features important articles for our practice. One article delves into an extensive guideline from the American Gastroenterological Association on medical management of colonic diverticulitis. In another article, they also describe how efforts to encourage our patients with nonalcoholic fatty liver disease to exercise and manage their diet can make a real difference in their health. Finally, another explores how and why your immunocompromised patients (including those with inflammatory bowel disease) should and can be safely vaccinated for COVID-19.

Meanwhile, we need civility, science, and community. Without common purpose, we will experience the William Forster Lloyd’s Tragedy of the Commons. Incivility has economic and emotional costs, according to the Harvard Business Review. “Weathering,” the deterioration of Black women’s health over time that’s related to continued socioeconomic disadvantage, has multigenerational impacts; for example the Department of Health & Human Services reports that infant mortality among African American women is 2.3 times that of non-Hispanic Whites. Late effects of redlining continue to cause economic, health, and emotional harms (Badger E. “How Redlining’s Racist Effects Lasted for Decades” The New York Times. 2017 Aug 24).

“If Men were angels, no government would be necessary,” James Madison wrote. “In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed; and the next place, oblige it to control itself.”

John I. Allen, MD, MBA, AGAF
Editor in Chief

I am composing this editorial 4 days after the U.S. Capitol was invaded and 10 days before the presidential inauguration. It is impossible to ignore what is happening in our country, but I hesitate to add my thoughts to the overwhelming sea of opinions circulating in standard media, social media, and the dark web. I hope, as do many, that we return to a civil discourse, recognize the voices of all people, respect each other, and return to a belief in science and facts.

SARS-CoV-2 has devastated the world and will continue to cause preventable deaths until we adopt stricter mitigation measures, vaccinate most people, and develop widespread immunity. We are gaining immense knowledge about this virus, and as gastroenterologists, we are on the front lines in many aspects. A recent article in American Journal of Gastroenterology, among others, emphasized that mild GI symptoms may be the only presenting complaint for people with COVID-19. Responses to COVID-19, such as limits on elective procedures and social distancing, have upended our endoscopic processes and even altered the business models of GI practice. We will never go back to pre-COVID models.

The front page of this month’s GI & Hepatology News features important articles for our practice. One article delves into an extensive guideline from the American Gastroenterological Association on medical management of colonic diverticulitis. In another article, they also describe how efforts to encourage our patients with nonalcoholic fatty liver disease to exercise and manage their diet can make a real difference in their health. Finally, another explores how and why your immunocompromised patients (including those with inflammatory bowel disease) should and can be safely vaccinated for COVID-19.

Meanwhile, we need civility, science, and community. Without common purpose, we will experience the William Forster Lloyd’s Tragedy of the Commons. Incivility has economic and emotional costs, according to the Harvard Business Review. “Weathering,” the deterioration of Black women’s health over time that’s related to continued socioeconomic disadvantage, has multigenerational impacts; for example the Department of Health & Human Services reports that infant mortality among African American women is 2.3 times that of non-Hispanic Whites. Late effects of redlining continue to cause economic, health, and emotional harms (Badger E. “How Redlining’s Racist Effects Lasted for Decades” The New York Times. 2017 Aug 24).

“If Men were angels, no government would be necessary,” James Madison wrote. “In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed; and the next place, oblige it to control itself.”

John I. Allen, MD, MBA, AGAF
Editor in Chief

I am composing this editorial 4 days after the U.S. Capitol was invaded and 10 days before the presidential inauguration. It is impossible to ignore what is happening in our country, but I hesitate to add my thoughts to the overwhelming sea of opinions circulating in standard media, social media, and the dark web. I hope, as do many, that we return to a civil discourse, recognize the voices of all people, respect each other, and return to a belief in science and facts.

SARS-CoV-2 has devastated the world and will continue to cause preventable deaths until we adopt stricter mitigation measures, vaccinate most people, and develop widespread immunity. We are gaining immense knowledge about this virus, and as gastroenterologists, we are on the front lines in many aspects. A recent article in American Journal of Gastroenterology, among others, emphasized that mild GI symptoms may be the only presenting complaint for people with COVID-19. Responses to COVID-19, such as limits on elective procedures and social distancing, have upended our endoscopic processes and even altered the business models of GI practice. We will never go back to pre-COVID models.

The front page of this month’s GI & Hepatology News features important articles for our practice. One article delves into an extensive guideline from the American Gastroenterological Association on medical management of colonic diverticulitis. In another article, they also describe how efforts to encourage our patients with nonalcoholic fatty liver disease to exercise and manage their diet can make a real difference in their health. Finally, another explores how and why your immunocompromised patients (including those with inflammatory bowel disease) should and can be safely vaccinated for COVID-19.

Meanwhile, we need civility, science, and community. Without common purpose, we will experience the William Forster Lloyd’s Tragedy of the Commons. Incivility has economic and emotional costs, according to the Harvard Business Review. “Weathering,” the deterioration of Black women’s health over time that’s related to continued socioeconomic disadvantage, has multigenerational impacts; for example the Department of Health & Human Services reports that infant mortality among African American women is 2.3 times that of non-Hispanic Whites. Late effects of redlining continue to cause economic, health, and emotional harms (Badger E. “How Redlining’s Racist Effects Lasted for Decades” The New York Times. 2017 Aug 24).

“If Men were angels, no government would be necessary,” James Madison wrote. “In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed; and the next place, oblige it to control itself.”

John I. Allen, MD, MBA, AGAF
Editor in Chief

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at jfp.eic@gmail.com.

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at jfp.eic@gmail.com.

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

This month’s editorial was jointly written by the editors of 10 prominent family medicine publications, including JFP, and is being published simultaneously in all 10 publications. In addition to this statement, each editor has developed action steps for their respective journals. At JFP, we plan to take the steps detailed here to help eliminate systemic racism. We will:

• continue to seek Black, Latino, and Native American physicians to serve on the JFP editorial advisory board.
• solicit manuscripts from these underrepresented groups of physicians.
• recruit peer reviewers from underrepresented communities.
• re-evaluate the thoroughness of manuscripts; where there are racial or ethnic differences in presentation of diseases or treatment outcomes, we will ensure that these differences are highlighted.

If you are interested in helping us to achieve these goals, I encourage you to contact me at jfp.eic@gmail.com.

We must all band together to eliminate disparities and biases in medical education and medical care so that all people receive the same high standard of respect and care that every human being deserves.

The Hospital “Saint Louis” was founded in 1607 by King Henry IV of France to relieve overcrowding of Parisian hospitals during the plague epidemic of 1605-1606. He named it Saint-Louis in memory of his grandfather, King Louis IX.

Today, the Hospital Saint-Louis, a registered historic monument, is used for administrative activities.

Saint-Louis Hospital, Paris

Saint-Louis Hospital, Paris

Saint-Louis Hospital is known for its long tradition in hematology; it is the site of the first successful allogeneic bone marrow transplant in 1958, performed by Georges Mathé, MD, Professor Jean Bernard, and one of the recipients of the 1980 Nobel Prize in Medicine, Professor Jean Dausset. The hospital is known for not only its activity in dermatology care and research (such as oncodermatology and inflammatory diseases) but also its long tradition of teaching in dermatology and venereology.

Over the last four centuries, great physicians have practiced their art here and many professors, and clinicians at Saint-Louis Hospital have authored publications and developed manuals of dermatology that have been translated across five continents. Many diseases and semiology signs in dermatology were first described by physicians from this hospital, their names familiar to dermatologists worldwide: Jean-Louis-Marc Alibert, MD; Jean Guillaume Auguste Lugol, MD; Laurent-Théodore Biett, MD; Pierre-Antoine-Ernest Bazin, MD; Pierre Louis Alphée Cazenave, MD; François Henri Hallopeau, MD; Léon Lortat-Jacob, MD; Henri-Alexandre Danlos, MD; Ernest Besnier, MD; Jean Baptiste Emile Vidal, MD; Ferdinand-Jean Darier, MD; Louis Brocq, MD; Bernard Felix Duperrat, MD; Gaston Auguste Milian, MD; Albert Sézary, MD; Achille Civatte, MD; Raymond Sabouraud, MD; Henri Gougerot, MD; Albert Touraine, MD; Arnault Tzanck, MD; and Robert Degos, MD, among others.

Saint-Louis Hospital, Paris

Anonymous, free screening services are available at the Sexually Transmitted Diseases Center through “CeGIDD,” a free center for HIV/AIDS screening and specialized consultations in venereology and mucosal pathologies.

The surgical activity of the department is provided in the Center of Dermo-Surgery. Dedicated medical and paramedical consultations ensure the management of ulcers and therapeutic baths for patients and families with refractory scabies.

The technical platform includes an allergology consultation, a phototherapy center, a Fotofinder diagnosis, a photodynamic therapy unit, and a confocal microscopy unit. The department, completed in September 2019 with a laser center with four devices, also works in close collaboration with the Sabouraud Center, created by Dr. Sabouraud and dedicated to the investigation and treatment of scalp diseases.

We are absolutely aware that working in a hospital so rich in past personalities and discoveries and part of the history of dermatology is not only a huge honor requiring a special commitment to continue the tradition of research and excellence in dermatology initiated hundreds of years ago, but also an important responsibility to focus all our efforts on teaching dermatology to next generations in France and around the world. It is also our responsibility to pursue this historic tradition of excellence by developing dynamic translational research activities that lead to innovations in the field of dermatology.

Professor Bagot is head of the dermatology department of University Hospital Saint-Louis, Paris. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris and is a member of the Dermatology News editorial board. Write to them at dermnews@mdedge.com.

The Hospital “Saint Louis” was founded in 1607 by King Henry IV of France to relieve overcrowding of Parisian hospitals during the plague epidemic of 1605-1606. He named it Saint-Louis in memory of his grandfather, King Louis IX.

Today, the Hospital Saint-Louis, a registered historic monument, is used for administrative activities.

Saint-Louis Hospital, Paris

Saint-Louis Hospital, Paris

Saint-Louis Hospital is known for its long tradition in hematology; it is the site of the first successful allogeneic bone marrow transplant in 1958, performed by Georges Mathé, MD, Professor Jean Bernard, and one of the recipients of the 1980 Nobel Prize in Medicine, Professor Jean Dausset. The hospital is known for not only its activity in dermatology care and research (such as oncodermatology and inflammatory diseases) but also its long tradition of teaching in dermatology and venereology.

Over the last four centuries, great physicians have practiced their art here and many professors, and clinicians at Saint-Louis Hospital have authored publications and developed manuals of dermatology that have been translated across five continents. Many diseases and semiology signs in dermatology were first described by physicians from this hospital, their names familiar to dermatologists worldwide: Jean-Louis-Marc Alibert, MD; Jean Guillaume Auguste Lugol, MD; Laurent-Théodore Biett, MD; Pierre-Antoine-Ernest Bazin, MD; Pierre Louis Alphée Cazenave, MD; François Henri Hallopeau, MD; Léon Lortat-Jacob, MD; Henri-Alexandre Danlos, MD; Ernest Besnier, MD; Jean Baptiste Emile Vidal, MD; Ferdinand-Jean Darier, MD; Louis Brocq, MD; Bernard Felix Duperrat, MD; Gaston Auguste Milian, MD; Albert Sézary, MD; Achille Civatte, MD; Raymond Sabouraud, MD; Henri Gougerot, MD; Albert Touraine, MD; Arnault Tzanck, MD; and Robert Degos, MD, among others.

Saint-Louis Hospital, Paris

Anonymous, free screening services are available at the Sexually Transmitted Diseases Center through “CeGIDD,” a free center for HIV/AIDS screening and specialized consultations in venereology and mucosal pathologies.

The surgical activity of the department is provided in the Center of Dermo-Surgery. Dedicated medical and paramedical consultations ensure the management of ulcers and therapeutic baths for patients and families with refractory scabies.

The technical platform includes an allergology consultation, a phototherapy center, a Fotofinder diagnosis, a photodynamic therapy unit, and a confocal microscopy unit. The department, completed in September 2019 with a laser center with four devices, also works in close collaboration with the Sabouraud Center, created by Dr. Sabouraud and dedicated to the investigation and treatment of scalp diseases.

We are absolutely aware that working in a hospital so rich in past personalities and discoveries and part of the history of dermatology is not only a huge honor requiring a special commitment to continue the tradition of research and excellence in dermatology initiated hundreds of years ago, but also an important responsibility to focus all our efforts on teaching dermatology to next generations in France and around the world. It is also our responsibility to pursue this historic tradition of excellence by developing dynamic translational research activities that lead to innovations in the field of dermatology.

Professor Bagot is head of the dermatology department of University Hospital Saint-Louis, Paris. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris and is a member of the Dermatology News editorial board. Write to them at dermnews@mdedge.com.

The Hospital “Saint Louis” was founded in 1607 by King Henry IV of France to relieve overcrowding of Parisian hospitals during the plague epidemic of 1605-1606. He named it Saint-Louis in memory of his grandfather, King Louis IX.

Today, the Hospital Saint-Louis, a registered historic monument, is used for administrative activities.

Saint-Louis Hospital, Paris

Saint-Louis Hospital, Paris

Saint-Louis Hospital is known for its long tradition in hematology; it is the site of the first successful allogeneic bone marrow transplant in 1958, performed by Georges Mathé, MD, Professor Jean Bernard, and one of the recipients of the 1980 Nobel Prize in Medicine, Professor Jean Dausset. The hospital is known for not only its activity in dermatology care and research (such as oncodermatology and inflammatory diseases) but also its long tradition of teaching in dermatology and venereology.

Over the last four centuries, great physicians have practiced their art here and many professors, and clinicians at Saint-Louis Hospital have authored publications and developed manuals of dermatology that have been translated across five continents. Many diseases and semiology signs in dermatology were first described by physicians from this hospital, their names familiar to dermatologists worldwide: Jean-Louis-Marc Alibert, MD; Jean Guillaume Auguste Lugol, MD; Laurent-Théodore Biett, MD; Pierre-Antoine-Ernest Bazin, MD; Pierre Louis Alphée Cazenave, MD; François Henri Hallopeau, MD; Léon Lortat-Jacob, MD; Henri-Alexandre Danlos, MD; Ernest Besnier, MD; Jean Baptiste Emile Vidal, MD; Ferdinand-Jean Darier, MD; Louis Brocq, MD; Bernard Felix Duperrat, MD; Gaston Auguste Milian, MD; Albert Sézary, MD; Achille Civatte, MD; Raymond Sabouraud, MD; Henri Gougerot, MD; Albert Touraine, MD; Arnault Tzanck, MD; and Robert Degos, MD, among others.

Saint-Louis Hospital, Paris

Anonymous, free screening services are available at the Sexually Transmitted Diseases Center through “CeGIDD,” a free center for HIV/AIDS screening and specialized consultations in venereology and mucosal pathologies.

The surgical activity of the department is provided in the Center of Dermo-Surgery. Dedicated medical and paramedical consultations ensure the management of ulcers and therapeutic baths for patients and families with refractory scabies.

The technical platform includes an allergology consultation, a phototherapy center, a Fotofinder diagnosis, a photodynamic therapy unit, and a confocal microscopy unit. The department, completed in September 2019 with a laser center with four devices, also works in close collaboration with the Sabouraud Center, created by Dr. Sabouraud and dedicated to the investigation and treatment of scalp diseases.

We are absolutely aware that working in a hospital so rich in past personalities and discoveries and part of the history of dermatology is not only a huge honor requiring a special commitment to continue the tradition of research and excellence in dermatology initiated hundreds of years ago, but also an important responsibility to focus all our efforts on teaching dermatology to next generations in France and around the world. It is also our responsibility to pursue this historic tradition of excellence by developing dynamic translational research activities that lead to innovations in the field of dermatology.

Professor Bagot is head of the dermatology department of University Hospital Saint-Louis, Paris. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris and is a member of the Dermatology News editorial board. Write to them at dermnews@mdedge.com.