Commentary

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

 

 

Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

 

 

Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

 

 

Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

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

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

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

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

We were delighted to read Dr. Nasrallah’s coruscating editorial about the deceptive, unethical, and clinically harmful practice of insurance companies requiring pre-authorization before granting coverage of psychotropic medications that are not on their short list of inexpensive alternatives (“Pre-authorization is illegal, unethical, and adversely disrupts patient care.” From the Editor, Current Psychiatry. April 2020, p. 5,10-11). Obtaining pre-authorization is time-consuming for busy doctors, often prohibitively so—and sometimes simply impossible, regardless of the time and effort invested. In this way, insurers can cleverly withhold optimal treatment while still being able to assert that they will cover all “medically necessary” treatments, as initially determined by a nonphysician reviewer working from a checklist. In a recently published survey of 1,000 psychiatrists we conducted (Barnett BS, Bodkin JA. A survey of American psychiatrists concerning medication prior authorization requirements. J Nerv Ment Dis. 2020;208(7):566-573), respondents predominantly believed the obligation to obtain prior authorization negatively impacts patient care and reduces psychiatrists’ job satisfaction.

Brian S. Barnett, MD
Staff Psychiatrist
Cleveland Clinic
Lutheran Hospital
Cleveland, Ohio

J. Alexander Bodkin, MD
Chief
Clinical Psychopharmacology
Research Program
McLean Hospital
Harvard Medical School
Belmont, Massachusetts

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

I thank Dr. Nasrallah for bringing up the issue of pre-authorization in his editorial and could not agree with him more. As a practicing geriatric psychiatrist—for several decades—I experienced all of what he so nicely summarized, and more. The amount and degree of humiliation, frustration, and (mainly) waste of time have been painful and unacceptable. As he said: It must be stopped! The question is “How?” Hopefully this editorial triggers some activity against pre-authorization. It was time somebody addressed this problem.

Istvan Boksay, MD, PhD
Private psychiatric practice
New York, New York

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I thank Dr. Nasrallah...

I thank Dr. Nasrallah for his editorial about pre-authorization, which was well organized and had a perfect headline. In succinct paragraphs, it says what we practitioners have wanted to say for years. If only the American Psychiatric Association and American Medical Association would take up the cause, perhaps some limitations might be put on this corporate intrusion into our practice. Pre-authorization may save insurance companies money, but its cost in time, frustration, and clinical outcomes adds a considerable burden to the financial problems of health care in the United States.

John Buckley, MD
Private psychiatric practice
Glen Arm, Maryland

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

I thank Dr. Nasrallah so much for his editorial. These types of clinically useless administrative tasks are invisible barriers to mental health care access, because the time utilized to complete these tasks can easily be used to see one more patient who needs to be treated. However, I also wonder how we as psychiatrists can move forward so that our psychiatric organizations and legislative bodies can take further action to the real barriers to health care and effective interventions. 

Ranvinder Kaur Rai, MD
Private psychiatric practice
Fremont, California

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

Continue to: I read with interest...

I read with interest Dr. Nasrallah’s editorials “We are physicians, not providers, and we treat patients, not clients!” (From the Editor, Current Psychiatry. February 2020, p. 5,10-11) and “Pre-authorization is illegal, unethical, and adversely disrupts patient care.” I can’t help but link the 2 editorials together.

Dr. Nasrallah’s strong advocacy against the use of the term “provider” is long overdue. I distinctly remember the insidious onset of the use of the terms provider and “consumer” during my years as a medical director of a mental health center. The inception of the provider/consumer terminology can be construed as striving for cultural correctness when psychiatry was going through its own identity crisis in response to deinstitutionalization and the destruction of the so-called myth of psychiatrists as paternalistic and all-powerful. Managed care as the business model of medicine further destroyed the perception of the psychiatric physician as noble and caring, and demythologized the physician–patient relationship. It is amazing how the term provider has persisted and become part of the language of medicine. During the last 20 years or so, psychiatric and medical professional organizations have done little to squash the usage of the term.

Furthermore, the concept of pre-authorization is not new to medicine, but has insidiously become part of the tasks of the psychiatric physician. It has morphed into more than having to obtain approval for using a branded medication over a cheaper generic alternative to having to obtain approval for the use of any medication that does not fall under the approved tier. Even antipsychotics (generally a protected class) have not been immune.

Both the use of the term provider and the concept of pre-authorization require more than the frustration and indignation of a clinical psychiatrist. It requires the determination of professional psychiatric organizations and those with power to fight the gradual but ever-deteriorating authority of medical practice and the role of the psychiatric physician.

Elizabeth A. Varas, MD
Private psychiatric practice
Westwood, New Jersey

Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.

As the life-altering coronavirus disease 2019 (COVID-19) pandemic gradually ebbs, we are all its survivors. Now, we are experiencing COVID-19 fatigue, trying to emerge from its dense fog that pervaded every facet of our lives. We are fully cognizant that there will not be a return to the previous “normal.” The pernicious virus had a transformative effect that did not spare any component of our society. Full recovery will not be easy.

As the uncertainty lingers about another devastating return of the pandemic later this year, we can see the reverberation of this invisible assault on human existence. Although a relatively small fraction of the population lost their lives, the rest of us are valiantly trying to readjust to the multiple ways our world has changed. Consider the following abrupt and sweeping burdens inflicted by the pandemic within a few short weeks:

Mental health. The acute stress of thanatophobia generated a triad of anxiety, depression, and nosophobia on a large scale. The demand for psychiatric care rapidly escalated. Suicide rate increased not only because of the stress of being locked down at home (alien to most people’s lifestyle) but because of the coincidental timing of the pandemic during April and May, the peak time of year for suicide. Animal researchers use immobilization as a paradigm to stress a rat or mouse. Many humans immobilized during the pandemic have developed exquisite empathy towards those rodents! The impact on children may also have long-term effects because playing and socializing with friends is a vital part of their lives. Parents have noticed dysphoria and acting out among their children, and an intense compensatory preoccupation with video games and electronic communications with friends.

Physical health. Medical care focused heavily on COVID-19 victims, to the detriment of all other medical conditions. Non-COVID-19 hospital admissions plummeted, and all elective surgeries and procedures were put on hold, depriving many people of medical care they badly needed. Emergency department (ED) visits also declined dramatically, including the usual flow of heart attacks, stroke, pulmonary embolus, asthma attacks, etc. The minimization of driving greatly reduced the admission of accident victims to EDs. Colonoscopies, cardiac stents, hip replacements, MRIs, mammography, and other procedures that are vital to maintain health and quality of life were halted. Dentists shuttered their practices due to the high risk of infection from exposure to oral secretions and breathing. One can only imagine the suffering of having a toothache with no dental help available, and how that might lead to narcotic abuse.

Social health. The imperative of social distancing disrupted most ordinary human activities, such as dining out, sitting in an auditorium for Grand Rounds or a lecture, visiting friends at their homes, the cherished interactions between grandparents and grandchildren (the lack of which I painfully experienced), and even seeing each other’s smiles behind the ubiquitous masks. And forget about hugging or kissing. The aversion to being near anyone who is coughing or sneezing led to an adaptive social paranoia and the social shunning of anyone who appeared to have an upper respiratory infection, even if it was unrelated to COVID-19.

Redemption for the pharmaceutical industry. The deadly pandemic intensified the public’s awareness of the importance of developing treatments and vaccines for COVID-19. The often-demonized pharmaceutical companies, with their extensive R&D infrastructure, emerged as a major source of hope for discovering an effective treatment for the coronavirus infection, or—better still—one or more vaccines that will enable society to return to its normal functions. It was quite impressive how many pharmaceutical companies “came to the rescue” with clinical trials to repurpose existing medications or to develop new ones. It was very encouraging to see multiple vaccine candidates being developed and expedited for testing around the world. A process that usually takes years was reduced to a few months, thanks to the existing technical infrastructure and thousands of scientists who enable rapid drug development. It is possible that the public may gradually modify its perception of the pharmaceutical industry from a “corporate villain” to an “indispensable health industry” for urgent medical crises such as a pandemic, and also for hundreds of medical diseases that are still in need of safe, effective therapies.

Economic burden. The unimaginable nightmare scenario of a total shutdown of all businesses led to the unprecedented loss of millions of jobs and livelihoods, reflected in miles-long lines of families at food banks. Overnight, the government switched from worrying about its $20-trillion deficit to printing several more trillion dollars to rescue the economy from collapse. The huge magnitude of a trillion can be appreciated if one is aware that it takes roughly 32 years to count to 1 billion, and 32,000 years to count to 1 trillion. Stimulating the economy while the gross domestic product threatens to sink by terrifying percentages (20% to 30%) was urgently needed, even though it meant mortgaging the future, especially when interest rates, and servicing the debt, will inevitably rise from the current zero to much higher levels in the future. The collapse of the once-thriving airline industry (bookings were down an estimated 98%) is an example of why desperate measures were needed to salvage an economy paralyzed by a viral pandemic.

Continue to: Political repercussions

Political repercussions. In our already hyperpartisan country, the COVID-19 crisis created more fissures across party lines. The blame game escalated as each side tried to exploit the crisis for political gain during a presidential election year. None of the leaders, from mayors to governors to the president, had any notion of how to wisely manage an unforeseen catastrophic pandemic. Thus, a political cacophony has developed, further exacerbating the public’s anxiety and uncertainty, especially about how and when the pandemic will end.

Education disruption. Never before have all schools and colleges around the country abruptly closed and sent students of all ages to shelter at home. Massive havoc ensued, with a wholesale switch to solitary online learning, the loss of the unique school and college social experience in the classroom and on campus, and the loss of experiencing commencement to receive a diploma (an important milestone for every graduate). Even medical students were not allowed to complete their clinical rotations and were sent home to attend online classes. A complete paradigm shift emerged about entrance exams: the SAT and ACT were eliminated for college applicants, and the MCAT for medical school applicants. This was unthinkable before the pandemic descended upon us, but benchmarks suddenly evaporated to adjust to the new reality. Then there followed disastrous financial losses by institutions of higher learning as well as academic medical centers and teaching hospitals, all slashing their budgets, furloughing employees, cutting salaries, and eliminating programs. Even the “sacred” tenure of senior faculty became a casualty of the financial “exigency.” Children’s nutrition suffered, especially among those in lower socioeconomic groups for whom the main meal of the day was the school lunch, and was made worse by their parents’ loss of income. For millions of people, the emotional toll was inevitable following the draconian measure of closing all educational institutions to contain the spread of the pandemic.

Family burden. Sheltering at home might have been fun for a few days, but after many weeks, it festered into a major stress, especially for those living in a small house, condominium, or apartment. The resilience of many families was tested as the exercise of freedoms collided with the fear of getting infected. Families were deprived of celebrating birthdays, weddings, funerals, graduation parties, retirement parties, Mother’s Day, Father’s Day, and various religious holidays, including Easter, Passover, and Eid al-Fitr.

Sexual burden. Intimacy and sexual contact between consenting adults living apart were sacrificed on the altar of the pernicious viral pandemic. Mandatory social distancing of 6 feet or more to avoid each other’s droplets emanating from simple speech, not just sneezing or coughing, makes intimacy practically impossible. Thus, physical closeness became taboo, and avoiding another person’s saliva or body secretions became a must to avoid contracting the virus. Being single was quite a lonely experience during this pandemic!

Entertainment deprivation. Americans are known to thrive on an extensive diet of spectator sports. Going to football, basketball, baseball, or hockey games to root for one’s team is intrinsically American. The pursuit of happiness extends to attending concerts, movies, Broadway shows, theme parks, and cruises with thousands of others. The pandemic ripped all those pleasurable leisure activities from our daily lives, leaving a big hole in people’s lives at the precise time fun activities were needed as a useful diversion from the dismal stress of a pandemic. To make things worse, it is uncertain when (if ever) such group activities will be restored, especially if the pandemic returns with another wave. But optimists would hurry to remind us that the “Roaring 20s” blossomed in the decade following the 1918 Spanish Flu pandemic.

Continue to: Legal system

Legal system. Astounding changes were instigated by the pandemic, such as the release of thousands of inmates, including felons, to avoid the spread of the virus in crowded prisons. For us psychiatrists, the silver lining in that unexpected action is that many of those released were patients with mental illness who were incarcerated because of the lack of hospitals that would take them. The police started issuing citations instead of arresting and jailing violators. Enforcement of the law was welcome when it targeted those who gouged the public for personal profit during the scarcity of masks, sanitizers, or even toilet paper and soap.

Medical practice. In addition to delaying medical care for patients, the freeze on so-called elective surgeries or procedures (many of which were actually necessary) was financially ruinous for physicians. Another regrettable consequence of the pandemic is a drop in pediatric vaccinations because parents were reluctant to take their children to the pediatrician. On a more positive note, the massive switch to telehealth was advantageous for both patients and psychiatrists because this technology is well-suited for psychiatric care. Fortunately, regulations that hampered telepsychiatry practice were substantially loosened or eliminated, and even the usually sacrosanct HIPAA regulations were temporarily sidelined.

Medical research. Both human and animal research came to a screeching halt, and many research assistants were furloughed. Data collection was disrupted, and a generation of scientific and medical discoveries became a casualty of the pandemic.

Medical literature. It was stunning to see how quickly COVID-19 occupied most of the pages of prominent journals. The scholarly articles were frankly quite useful, covering topics ranging from risk factors to early symptoms to treatment and pathophysiology across multiple organs. As with other paradigm shifts, there was an accelerated publication push, sometimes with expedited peer reviews to inform health care workers and the public while the pandemic was still raging. However, a couple of very prominent journals had to retract flawed articles that were hastily published without the usual due diligence and rigorous peer review. The pandemic clearly disrupted the science publishing process.

Travel effects. The steep reduction of flights (by 98%) was financially catastrophic, not only for airline companies but to business travel across the country. However, fewer cars on the road resulted in fewer accidents and deaths, and also reduced pollution. Paradoxically, to prevent crowding in subways, trains, and buses, officials reversed their traditional instructions and advised the public to drive their own cars instead of using public transportation!

Continue to: Heroism of front-line medical personnel

Heroism of front-line medical personnel. Everyone saluted and prayed for the health care professionals working at the bedside of highly infectious patients who needed 24/7 intensive care. Many have died while carrying out the noble but hazardous medical duties. Those heroes deserve our lasting respect and admiration.

The COVID-19 pandemic insidiously permeated and altered every aspect of our complex society and revealed how fragile our “normal lifestyle” really is. It is possible that nothing will ever be the same again, and an uneasy sense of vulnerability will engulf us as we cautiously return to a “new normal.” Even our language has expanded with the lexicon of pandemic terminology (Table). We all pray and hope that this plague never returns. And let’s hope one or more vaccines are developed soon so we can manage future recurrences like the annual flu season. In the meantime, keep your masks and sanitizers close by…

Postscript: Shortly after I completed this editorial, the ongoing COVID-19 plague was overshadowed by the scourge of racism, with massive protests, at times laced by violence, triggered by the death of a black man in custody of the police, under condemnable circumstances. The COVID-19 pandemic and the necessary social distancing it requires were temporarily ignored during the ensuing protests. The combined effect of those overlapping scourges are jarring to the country’s psyche, complicating and perhaps sabotaging the social recovery from the pandemic.

As psychiatrists, we are increasingly using digital technology, such as e-mail, video conferencing, social media, and text messaging, to communicate with and even treat our patients.¹ The benefits of using digital technology for treating patients include, but are not limited to, enhancing access to psychiatric services that are unavailable due to a patient’s geographical location and/or physical disability; providing more cost‐effective delivery of services; and creating more ways for patients to communicate with their physicians.¹ While there are benefits to using digital technology, there are also possible repercussions, such as breaches of confidentiality or boundary violations.² Although there is no evidence-based guidance about how to best use digital technology in patient care,³ the following approaches can help you protect your patients and minimize your liability.

Assess competence. Determine how familiar and comfortable both you and your patient are with the specific software and/or devices you intend to use. Confirm that your patient can access the technology, and inform them of the benefits and risks of using digital technology in their care.¹

Create a written policy about your use of digital technology, and review it with all patients to explain how it will be used in their treatment.¹ This policy should include a back-up plan in the event of technology failures.¹ It should clearly explain that the information gathered with this technology can become part of the patient’s medical record. It should also prohibit patients from using their devices to record other patients in the waiting room or other areas. Such a policy could enhance the protection of private information and help maintain clear boundaries.¹ Review and update your policy as often as needed.

Obtain your patients’ written consent to use digital technology. If you want to post information about your patients on social media, obtain their written consent to do so, and mutually agree as to what information would be posted. This should not include their identity or confidential information.¹

Do not accept friend requests or contact requests from current or former patients on any social networking platform. Do not follow your patients’ blogs, Twitter accounts, or any other accounts. Be aware that if you and your patients share the same “friend” network on social media, this may create boundary confusion, inappropriate dual relationships, and potential conflicts of interest.¹ Keep personal and professional accounts separate to maintain appropriate boundaries and minimize compromising patient confidentiality. Do not post private information on professional practice accounts, and do not link/sync your personal accounts with professional accounts.

Do not store patient information on your personal electronic devices because these devices could be lost or hacked. Avoid contacting your patients via non-secured platforms because doing so could compromise patient confidentiality. Use encrypted software and firewalls for communicating with your patients and storing their information.¹ Also, periodically assess your confidentiality policies and procedures to ensure compliance with appropriate statutes and laws.¹

As psychiatrists, we are increasingly using digital technology, such as e-mail, video conferencing, social media, and text messaging, to communicate with and even treat our patients.¹ The benefits of using digital technology for treating patients include, but are not limited to, enhancing access to psychiatric services that are unavailable due to a patient’s geographical location and/or physical disability; providing more cost‐effective delivery of services; and creating more ways for patients to communicate with their physicians.¹ While there are benefits to using digital technology, there are also possible repercussions, such as breaches of confidentiality or boundary violations.² Although there is no evidence-based guidance about how to best use digital technology in patient care,³ the following approaches can help you protect your patients and minimize your liability.

Assess competence. Determine how familiar and comfortable both you and your patient are with the specific software and/or devices you intend to use. Confirm that your patient can access the technology, and inform them of the benefits and risks of using digital technology in their care.¹

Create a written policy about your use of digital technology, and review it with all patients to explain how it will be used in their treatment.¹ This policy should include a back-up plan in the event of technology failures.¹ It should clearly explain that the information gathered with this technology can become part of the patient’s medical record. It should also prohibit patients from using their devices to record other patients in the waiting room or other areas. Such a policy could enhance the protection of private information and help maintain clear boundaries.¹ Review and update your policy as often as needed.

Obtain your patients’ written consent to use digital technology. If you want to post information about your patients on social media, obtain their written consent to do so, and mutually agree as to what information would be posted. This should not include their identity or confidential information.¹

Do not accept friend requests or contact requests from current or former patients on any social networking platform. Do not follow your patients’ blogs, Twitter accounts, or any other accounts. Be aware that if you and your patients share the same “friend” network on social media, this may create boundary confusion, inappropriate dual relationships, and potential conflicts of interest.¹ Keep personal and professional accounts separate to maintain appropriate boundaries and minimize compromising patient confidentiality. Do not post private information on professional practice accounts, and do not link/sync your personal accounts with professional accounts.

Do not store patient information on your personal electronic devices because these devices could be lost or hacked. Avoid contacting your patients via non-secured platforms because doing so could compromise patient confidentiality. Use encrypted software and firewalls for communicating with your patients and storing their information.¹ Also, periodically assess your confidentiality policies and procedures to ensure compliance with appropriate statutes and laws.¹

As psychiatrists, we are increasingly using digital technology, such as e-mail, video conferencing, social media, and text messaging, to communicate with and even treat our patients.¹ The benefits of using digital technology for treating patients include, but are not limited to, enhancing access to psychiatric services that are unavailable due to a patient’s geographical location and/or physical disability; providing more cost‐effective delivery of services; and creating more ways for patients to communicate with their physicians.¹ While there are benefits to using digital technology, there are also possible repercussions, such as breaches of confidentiality or boundary violations.² Although there is no evidence-based guidance about how to best use digital technology in patient care,³ the following approaches can help you protect your patients and minimize your liability.

Assess competence. Determine how familiar and comfortable both you and your patient are with the specific software and/or devices you intend to use. Confirm that your patient can access the technology, and inform them of the benefits and risks of using digital technology in their care.¹

Create a written policy about your use of digital technology, and review it with all patients to explain how it will be used in their treatment.¹ This policy should include a back-up plan in the event of technology failures.¹ It should clearly explain that the information gathered with this technology can become part of the patient’s medical record. It should also prohibit patients from using their devices to record other patients in the waiting room or other areas. Such a policy could enhance the protection of private information and help maintain clear boundaries.¹ Review and update your policy as often as needed.

Obtain your patients’ written consent to use digital technology. If you want to post information about your patients on social media, obtain their written consent to do so, and mutually agree as to what information would be posted. This should not include their identity or confidential information.¹

Do not accept friend requests or contact requests from current or former patients on any social networking platform. Do not follow your patients’ blogs, Twitter accounts, or any other accounts. Be aware that if you and your patients share the same “friend” network on social media, this may create boundary confusion, inappropriate dual relationships, and potential conflicts of interest.¹ Keep personal and professional accounts separate to maintain appropriate boundaries and minimize compromising patient confidentiality. Do not post private information on professional practice accounts, and do not link/sync your personal accounts with professional accounts.

Do not store patient information on your personal electronic devices because these devices could be lost or hacked. Avoid contacting your patients via non-secured platforms because doing so could compromise patient confidentiality. Use encrypted software and firewalls for communicating with your patients and storing their information.¹ Also, periodically assess your confidentiality policies and procedures to ensure compliance with appropriate statutes and laws.¹

This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
 

I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.

So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.

But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.

I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.

As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!

As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.

All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.

As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.

So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.

As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.

Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.

As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)

Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.

As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.

So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.

The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.

So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.

How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
 

1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).

2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.

3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.

These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”

It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.


Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.

This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
 

I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.

So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.

But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.

I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.

As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!

As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.

All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.

As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.

So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.

As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.

Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.

As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)

Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.

As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.

So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.

The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.

So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.

How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
 

1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).

2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.

3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.

These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”

It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.


Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.

This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
 

I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.

So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.

But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.

I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.

As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!

As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.

All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.

As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.

So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.

As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.

Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.

As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)

Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.

As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.

So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.

The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.

So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.

How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
 

1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).

2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.

3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.

These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”

It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.


Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

A striking clinical feature of illness from SARS-CoV-2 is a marked increase in thrombotic and microvascular complications, or COVID-19–associated coagulopathy (CAC).

A new study suggests endothelial cell injury plays a major role in the pathogenesis of CAC, and blood levels of soluble thrombomodulin correlate with mortality.

George Goshua, MD, of Yale University, New Haven, Conn., presented this study as a late-breaking abstract at the virtual annual congress of the European Hematology Association.

Dr. Goshua cited past research showing CAC to be highly prevalent among hospitalized patients. Venous thromboembolism was found in 17% to 69% of patients, despite thromboprophylaxis.^1-4 Arterial thrombosis has been seen in 3.6% to 4.0% of patients,^1-3 and autopsy findings have shown microvascular thrombosis in as many as 87% of patients.^5-7

For their study, Dr. Goshua and colleagues assessed endothelial cell damage, platelet activation, and hemostatic and fibrinolytic cascade effects of CAC.

The investigators measured markers of endothelial cell injury and platelet activation, plasminogen activation inhibitor 1 (PAI-1), and coagulation factors in stable and critically ill patients hospitalized with COVID-19. In addition, the team sought to identify biomarkers of mortality in hospitalized patients.

Dr. Goshua and colleagues studied 68 adults hospitalized for suspected COVID-19 – 48 in the ICU and 20 outside the ICU. Patients in the ICU received mechanical ventilation, while the non-ICU patients required supplemental oxygen (≤3 L/min per nasal cannula).

There were more men than women (69% vs. 31%) in the ICU population but not in the non-ICU population (40% vs. 60%). There were no statistically significant differences in age or comorbid conditions between the ICU and non-ICU patients.
 

Results and interpretation

Consistent with augmentation of the coagulation cascade – and as expected – D-dimer and thrombin-antithrombin levels were high in both the ICU and non-ICU populations, but levels were significantly higher (P < .001) among the ICU patients.

Endogenous anticoagulants (antithrombin and proteins C and S) and fibrinolytic enzymes (alpha 2-antiplasmin) were preserved, verifying that CAC is distinct from disseminated intravascular coagulation. Classic fibrinolysis did not occur, as PAI-1 was high in ICU and non-ICU patients, and lysis-30 was normal in nearly all ICU patients (96%).

Von Willebrand factor antigen and activity levels and factor VIII levels were markedly elevated in non-ICU and ICU patients, but they were significantly higher (P < .001) in the ICU cohort. This supports the hypothesis that endothelial cell damage and platelet activation play major roles in CAC.

Similarly, soluble P-selectin, which is shed from endothelial cells and platelets, was dramatically elevated in ICU patients in comparison with controls and non-ICU patients (P < .001 for both comparisons).

Levels of soluble thrombomodulin, which is released from endothelial cells, were not significantly different in ICU patients and controls. However, given thrombomodulin’s significant role in the coagulation cascade, Dr. Goshua and colleagues plotted receiver operating curves to see if soluble thrombomodulin levels were predictive of mortality.

The results showed that soluble thrombomodulin correlated with the probability of survival, both overall and in ICU patients. Soluble thrombomodulin levels greater than 3.26 ng/mL were associated with significantly worse survival in all patients (P = .0087) and ICU patients (P = .0309).
 

Influence on therapy

Laboratory perturbations were detected in both ICU and non-ICU patients, and otherwise healthy outpatients have exhibited potentially life-threatening CAC, according to Dr. Goshua.

These findings suggest the prothrombotic state occurs early in the pathogenesis of SARS-CoV-2 infection, is driven by platelet activation and endotheliopathy, and becomes more pronounced with worsening severity of infection.

The results of this study prompted a change in how Yale–New Haven Hospital manages COVID-19 patients. Patients without a clinical contraindication now receive aspirin at 81 mg daily in addition to the anticoagulation regimen typically used for all hospitalized COVID-19 patients.

Investigations regarding other medications that can influence platelet-endothelial cell interactions and modulate endothelial cell damage in CAC – such as dipyridamole, defibrotide, and eculizumab – are planned.
 

Challenges and unanswered questions

Virchow’s triad was described by the eminent German physician, Rudolf Virchow, MD, in the 19th century. It refers to the three broad categories of factors that can predispose patients to thrombosis — circulatory stasis, hypercoagulability, and endothelial injury.

Although all of these elements could be operative in CAC, the current study suggests platelet activation and endothelial cell injury in CAC may be of primary importance.

Because of the limited ability to test critically ill patients and concerns regarding exposure of additional hospital personnel to COVID-19 patients, the current report lacked clarity about the relationship of the detected laboratory abnormalities to confirmed thrombotic events.

It is unknown whether endothelial cells in different organs are damaged uniformly. It is also unclear if the laboratory abnormalities identified in this analysis can be used to monitor response to therapy, to guide follow-up management of discharged patients with CAC, or to identify infected outpatients who should receive prophylactic anticoagulation.

The mechanism by which SARS-CoV-2 injures endothelial cells is not explained by these data. Neutrophil defensins and other prothrombotic peptides or markers of inflammation could play key roles in pathogenesis, assessment of disease severity, or monitoring for therapeutic efficacy.

Today, we have more sophisticated diagnostic tools than Dr. Virchow had. We also have the ability to record and rapidly disseminate information globally. Still, with regard to the COVID-19 pandemic, clinicians face many of the same challenges that confronted Dr. Virchow in his era.

The analysis conducted by Dr. Goshua and colleagues goes a long way toward elucidating some of the mechanisms and therapeutic targets to meet these challenges.

Dr. Goshua disclosed no conflicts of interest.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Goshua G et al. EHA Congress. Abstract LB2605.

References

1. Klok FA et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res. 2020;191:148-50. doi: 10.1016/j.thromres.2020.04.041.

2. Thomas W et al. Thrombotic complications of patients admitted to intensive care with COVID-19 at a teaching hospital in the United Kingdom. Thromb Res. 2020;191:76-7. doi: 10.1016/j.thromres.2020.04.028

3. Lodigiani C et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024

4. Llitjos JF et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [published online ahead of print, 2020 Apr 22]. J Thromb Haemost. 2020;10.1111/jth.14869. doi: 10.1111/jth.14869

5. Carsana L et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv 2020.04.19.20054262; doi: 10.1101/2020.04.19.20054262v1.

6. Menter T et al. Post-mortem examination of COVID19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction [published online ahead of print, 2020 May 4]. Histopathology. 2020;10.1111/his.14134. doi: 10.1111/his.14134

7. Lax SF, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: Results from a prospective, single-center, clinicopathologic case series [published online ahead of print, 2020 May 14]. Ann Intern Med. 2020;M20-2566. doi: 10.7326/M20-2566.

A striking clinical feature of illness from SARS-CoV-2 is a marked increase in thrombotic and microvascular complications, or COVID-19–associated coagulopathy (CAC).

A new study suggests endothelial cell injury plays a major role in the pathogenesis of CAC, and blood levels of soluble thrombomodulin correlate with mortality.

George Goshua, MD, of Yale University, New Haven, Conn., presented this study as a late-breaking abstract at the virtual annual congress of the European Hematology Association.

Dr. Goshua cited past research showing CAC to be highly prevalent among hospitalized patients. Venous thromboembolism was found in 17% to 69% of patients, despite thromboprophylaxis.^1-4 Arterial thrombosis has been seen in 3.6% to 4.0% of patients,^1-3 and autopsy findings have shown microvascular thrombosis in as many as 87% of patients.^5-7

For their study, Dr. Goshua and colleagues assessed endothelial cell damage, platelet activation, and hemostatic and fibrinolytic cascade effects of CAC.

The investigators measured markers of endothelial cell injury and platelet activation, plasminogen activation inhibitor 1 (PAI-1), and coagulation factors in stable and critically ill patients hospitalized with COVID-19. In addition, the team sought to identify biomarkers of mortality in hospitalized patients.

Dr. Goshua and colleagues studied 68 adults hospitalized for suspected COVID-19 – 48 in the ICU and 20 outside the ICU. Patients in the ICU received mechanical ventilation, while the non-ICU patients required supplemental oxygen (≤3 L/min per nasal cannula).

There were more men than women (69% vs. 31%) in the ICU population but not in the non-ICU population (40% vs. 60%). There were no statistically significant differences in age or comorbid conditions between the ICU and non-ICU patients.
 

Results and interpretation

Consistent with augmentation of the coagulation cascade – and as expected – D-dimer and thrombin-antithrombin levels were high in both the ICU and non-ICU populations, but levels were significantly higher (P < .001) among the ICU patients.

Endogenous anticoagulants (antithrombin and proteins C and S) and fibrinolytic enzymes (alpha 2-antiplasmin) were preserved, verifying that CAC is distinct from disseminated intravascular coagulation. Classic fibrinolysis did not occur, as PAI-1 was high in ICU and non-ICU patients, and lysis-30 was normal in nearly all ICU patients (96%).

Von Willebrand factor antigen and activity levels and factor VIII levels were markedly elevated in non-ICU and ICU patients, but they were significantly higher (P < .001) in the ICU cohort. This supports the hypothesis that endothelial cell damage and platelet activation play major roles in CAC.

Similarly, soluble P-selectin, which is shed from endothelial cells and platelets, was dramatically elevated in ICU patients in comparison with controls and non-ICU patients (P < .001 for both comparisons).

Levels of soluble thrombomodulin, which is released from endothelial cells, were not significantly different in ICU patients and controls. However, given thrombomodulin’s significant role in the coagulation cascade, Dr. Goshua and colleagues plotted receiver operating curves to see if soluble thrombomodulin levels were predictive of mortality.

The results showed that soluble thrombomodulin correlated with the probability of survival, both overall and in ICU patients. Soluble thrombomodulin levels greater than 3.26 ng/mL were associated with significantly worse survival in all patients (P = .0087) and ICU patients (P = .0309).
 

Influence on therapy

Laboratory perturbations were detected in both ICU and non-ICU patients, and otherwise healthy outpatients have exhibited potentially life-threatening CAC, according to Dr. Goshua.

These findings suggest the prothrombotic state occurs early in the pathogenesis of SARS-CoV-2 infection, is driven by platelet activation and endotheliopathy, and becomes more pronounced with worsening severity of infection.

The results of this study prompted a change in how Yale–New Haven Hospital manages COVID-19 patients. Patients without a clinical contraindication now receive aspirin at 81 mg daily in addition to the anticoagulation regimen typically used for all hospitalized COVID-19 patients.

Investigations regarding other medications that can influence platelet-endothelial cell interactions and modulate endothelial cell damage in CAC – such as dipyridamole, defibrotide, and eculizumab – are planned.
 

Challenges and unanswered questions

Virchow’s triad was described by the eminent German physician, Rudolf Virchow, MD, in the 19th century. It refers to the three broad categories of factors that can predispose patients to thrombosis — circulatory stasis, hypercoagulability, and endothelial injury.

Although all of these elements could be operative in CAC, the current study suggests platelet activation and endothelial cell injury in CAC may be of primary importance.

Because of the limited ability to test critically ill patients and concerns regarding exposure of additional hospital personnel to COVID-19 patients, the current report lacked clarity about the relationship of the detected laboratory abnormalities to confirmed thrombotic events.

It is unknown whether endothelial cells in different organs are damaged uniformly. It is also unclear if the laboratory abnormalities identified in this analysis can be used to monitor response to therapy, to guide follow-up management of discharged patients with CAC, or to identify infected outpatients who should receive prophylactic anticoagulation.

The mechanism by which SARS-CoV-2 injures endothelial cells is not explained by these data. Neutrophil defensins and other prothrombotic peptides or markers of inflammation could play key roles in pathogenesis, assessment of disease severity, or monitoring for therapeutic efficacy.

Today, we have more sophisticated diagnostic tools than Dr. Virchow had. We also have the ability to record and rapidly disseminate information globally. Still, with regard to the COVID-19 pandemic, clinicians face many of the same challenges that confronted Dr. Virchow in his era.

The analysis conducted by Dr. Goshua and colleagues goes a long way toward elucidating some of the mechanisms and therapeutic targets to meet these challenges.

Dr. Goshua disclosed no conflicts of interest.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Goshua G et al. EHA Congress. Abstract LB2605.

References

1. Klok FA et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res. 2020;191:148-50. doi: 10.1016/j.thromres.2020.04.041.

2. Thomas W et al. Thrombotic complications of patients admitted to intensive care with COVID-19 at a teaching hospital in the United Kingdom. Thromb Res. 2020;191:76-7. doi: 10.1016/j.thromres.2020.04.028

3. Lodigiani C et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024

4. Llitjos JF et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [published online ahead of print, 2020 Apr 22]. J Thromb Haemost. 2020;10.1111/jth.14869. doi: 10.1111/jth.14869

5. Carsana L et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv 2020.04.19.20054262; doi: 10.1101/2020.04.19.20054262v1.

6. Menter T et al. Post-mortem examination of COVID19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction [published online ahead of print, 2020 May 4]. Histopathology. 2020;10.1111/his.14134. doi: 10.1111/his.14134

7. Lax SF, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: Results from a prospective, single-center, clinicopathologic case series [published online ahead of print, 2020 May 14]. Ann Intern Med. 2020;M20-2566. doi: 10.7326/M20-2566.

A striking clinical feature of illness from SARS-CoV-2 is a marked increase in thrombotic and microvascular complications, or COVID-19–associated coagulopathy (CAC).

A new study suggests endothelial cell injury plays a major role in the pathogenesis of CAC, and blood levels of soluble thrombomodulin correlate with mortality.

George Goshua, MD, of Yale University, New Haven, Conn., presented this study as a late-breaking abstract at the virtual annual congress of the European Hematology Association.

Dr. Goshua cited past research showing CAC to be highly prevalent among hospitalized patients. Venous thromboembolism was found in 17% to 69% of patients, despite thromboprophylaxis.^1-4 Arterial thrombosis has been seen in 3.6% to 4.0% of patients,^1-3 and autopsy findings have shown microvascular thrombosis in as many as 87% of patients.^5-7

For their study, Dr. Goshua and colleagues assessed endothelial cell damage, platelet activation, and hemostatic and fibrinolytic cascade effects of CAC.

The investigators measured markers of endothelial cell injury and platelet activation, plasminogen activation inhibitor 1 (PAI-1), and coagulation factors in stable and critically ill patients hospitalized with COVID-19. In addition, the team sought to identify biomarkers of mortality in hospitalized patients.

Dr. Goshua and colleagues studied 68 adults hospitalized for suspected COVID-19 – 48 in the ICU and 20 outside the ICU. Patients in the ICU received mechanical ventilation, while the non-ICU patients required supplemental oxygen (≤3 L/min per nasal cannula).

There were more men than women (69% vs. 31%) in the ICU population but not in the non-ICU population (40% vs. 60%). There were no statistically significant differences in age or comorbid conditions between the ICU and non-ICU patients.
 

Results and interpretation

Consistent with augmentation of the coagulation cascade – and as expected – D-dimer and thrombin-antithrombin levels were high in both the ICU and non-ICU populations, but levels were significantly higher (P < .001) among the ICU patients.

Endogenous anticoagulants (antithrombin and proteins C and S) and fibrinolytic enzymes (alpha 2-antiplasmin) were preserved, verifying that CAC is distinct from disseminated intravascular coagulation. Classic fibrinolysis did not occur, as PAI-1 was high in ICU and non-ICU patients, and lysis-30 was normal in nearly all ICU patients (96%).

Von Willebrand factor antigen and activity levels and factor VIII levels were markedly elevated in non-ICU and ICU patients, but they were significantly higher (P < .001) in the ICU cohort. This supports the hypothesis that endothelial cell damage and platelet activation play major roles in CAC.

Similarly, soluble P-selectin, which is shed from endothelial cells and platelets, was dramatically elevated in ICU patients in comparison with controls and non-ICU patients (P < .001 for both comparisons).

Levels of soluble thrombomodulin, which is released from endothelial cells, were not significantly different in ICU patients and controls. However, given thrombomodulin’s significant role in the coagulation cascade, Dr. Goshua and colleagues plotted receiver operating curves to see if soluble thrombomodulin levels were predictive of mortality.

The results showed that soluble thrombomodulin correlated with the probability of survival, both overall and in ICU patients. Soluble thrombomodulin levels greater than 3.26 ng/mL were associated with significantly worse survival in all patients (P = .0087) and ICU patients (P = .0309).
 

Influence on therapy

Laboratory perturbations were detected in both ICU and non-ICU patients, and otherwise healthy outpatients have exhibited potentially life-threatening CAC, according to Dr. Goshua.

These findings suggest the prothrombotic state occurs early in the pathogenesis of SARS-CoV-2 infection, is driven by platelet activation and endotheliopathy, and becomes more pronounced with worsening severity of infection.

The results of this study prompted a change in how Yale–New Haven Hospital manages COVID-19 patients. Patients without a clinical contraindication now receive aspirin at 81 mg daily in addition to the anticoagulation regimen typically used for all hospitalized COVID-19 patients.

Investigations regarding other medications that can influence platelet-endothelial cell interactions and modulate endothelial cell damage in CAC – such as dipyridamole, defibrotide, and eculizumab – are planned.
 

Challenges and unanswered questions

Virchow’s triad was described by the eminent German physician, Rudolf Virchow, MD, in the 19th century. It refers to the three broad categories of factors that can predispose patients to thrombosis — circulatory stasis, hypercoagulability, and endothelial injury.

Although all of these elements could be operative in CAC, the current study suggests platelet activation and endothelial cell injury in CAC may be of primary importance.

Because of the limited ability to test critically ill patients and concerns regarding exposure of additional hospital personnel to COVID-19 patients, the current report lacked clarity about the relationship of the detected laboratory abnormalities to confirmed thrombotic events.

It is unknown whether endothelial cells in different organs are damaged uniformly. It is also unclear if the laboratory abnormalities identified in this analysis can be used to monitor response to therapy, to guide follow-up management of discharged patients with CAC, or to identify infected outpatients who should receive prophylactic anticoagulation.

The mechanism by which SARS-CoV-2 injures endothelial cells is not explained by these data. Neutrophil defensins and other prothrombotic peptides or markers of inflammation could play key roles in pathogenesis, assessment of disease severity, or monitoring for therapeutic efficacy.

Today, we have more sophisticated diagnostic tools than Dr. Virchow had. We also have the ability to record and rapidly disseminate information globally. Still, with regard to the COVID-19 pandemic, clinicians face many of the same challenges that confronted Dr. Virchow in his era.

The analysis conducted by Dr. Goshua and colleagues goes a long way toward elucidating some of the mechanisms and therapeutic targets to meet these challenges.

Dr. Goshua disclosed no conflicts of interest.

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

SOURCE: Goshua G et al. EHA Congress. Abstract LB2605.

References

1. Klok FA et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res. 2020;191:148-50. doi: 10.1016/j.thromres.2020.04.041.

2. Thomas W et al. Thrombotic complications of patients admitted to intensive care with COVID-19 at a teaching hospital in the United Kingdom. Thromb Res. 2020;191:76-7. doi: 10.1016/j.thromres.2020.04.028

3. Lodigiani C et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024

4. Llitjos JF et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients [published online ahead of print, 2020 Apr 22]. J Thromb Haemost. 2020;10.1111/jth.14869. doi: 10.1111/jth.14869

5. Carsana L et al. Pulmonary post-mortem findings in a large series of COVID-19 cases from Northern Italy. medRxiv 2020.04.19.20054262; doi: 10.1101/2020.04.19.20054262v1.

6. Menter T et al. Post-mortem examination of COVID19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction [published online ahead of print, 2020 May 4]. Histopathology. 2020;10.1111/his.14134. doi: 10.1111/his.14134

7. Lax SF, et al. Pulmonary arterial thrombosis in COVID-19 with fatal outcome: Results from a prospective, single-center, clinicopathologic case series [published online ahead of print, 2020 May 14]. Ann Intern Med. 2020;M20-2566. doi: 10.7326/M20-2566.

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.

Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?

Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?

When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
 

Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?

Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.

Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.

One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.

I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.

I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.

To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.

I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.

It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.

Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.

My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
 

Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from?
Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.

I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
 

Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.

It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.

Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
 

Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.

In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.

Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.

One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
 

Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.

Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.

Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.

Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.

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

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.

Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?

Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?

When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
 

Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?

Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.

Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.

One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.

I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.

I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.

To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.

I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.

It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.

Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.

My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
 

Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from?
Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.

I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
 

Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.

It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.

Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
 

Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.

In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.

Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.

One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
 

Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.

Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.

Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.

Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.

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

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.

Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?

Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?

When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
 

Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?

Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.

Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.

One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.

I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.

I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.

To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.

I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.

It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.

Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.

My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
 

Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from?
Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.

I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
 

Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.

It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.

Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
 

Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.

In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.

Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.

One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
 

Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.

Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.

Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.

Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.

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

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.

I’m a black man, husband, father, son, brother, and a board-certified psychiatrist, child and adolescent psychiatry fellow, and addiction medicine fellow. I write this article as the latter, a colleague, from the former’s perspective, which you would not need to verify via Google, social media, or a badge upon meeting me.

Motortion/Getty Images

July is Minority Mental Health Awareness Month, established to bring awareness to the unique struggles that marginalized groups face concerning mental illness in the United States.

Given the events of the last few months, including a global pandemic and videotaped killings of Ahmaud Arbery and George Floyd, two unarmed black men, America’s structural racism and inequality are being challenged in historic ways. Black people are suffering. In fact, I was not surprised to learn¹ that some black families with sons have expanded the “talk” – which traditionally has focused on dealing with police officers – to include vigilantes.

Because of my extensive work with and treatment of men of color, I would like to answer a key question: “How do psychiatrists and other mental health clinicians better engage men of color? Before the “how,” let’s review the state of black men’s mental health.

According to Healthy People 2020, mental disorders are the leading cause of disability in the United States.² Among those with diagnosable mental disorders, black people are more likely than are their white counterparts to experience severe symptoms and protracted diseases. Roughly 7% of black men meet the criteria for a lifetime prevalence of major depressive disorder.³ Applying that figure to recent national population estimates means that there are 1.4 million black men currently suffering from major depression. Suicide has been on a continued uptrend among black male youth for more than 2 decades. Moreover, given the high rates of stigma and unmet need in this population, it is likely that these figures are even more dire.

Compared with other groups, black men in the United States face a disproportionate burden of preventable morbidity and mortality rates. Of all the health concerns faced by black men, mental health challenges may be among the most stigmatized.⁴ Evidence suggests that black men have more adverse life experiences than do men of other racial/ethnic groups, and consequently, experience poorer mental health.⁵ Black men experience high rates of poverty, unemployment, and underemployment, and are incarcerated at much higher rates than those of men of other racial/ethnic groups.⁶ It is notable that black male youth are often perceived as older by law enforcement, beginning as early as 10 years old, often resulting in negative interactions.⁷

Despite those challenges, black men are often expected to project strength, they are expected to minimize displays of emotion when off the field or court (i.e., “Just shut up and dribble”), and they are expected to be true versions of folk hero John Henry. This caricature of black males is used at times to validate shootings of unarmed black males (adults and youth).

Black men’s mental health should be a priority for those in the mental health field. This is particularly the case light of our field’s historical involvement in and promotion of stereotyped clinical descriptions of black men and contributing to health disparities that persist. Black men are nearly six times as likely to be diagnosed with schizophrenia as are white men. To read about holdovers from the days of targeted advertising against black protesters of the 1960s and 1970s, check out “The Protest Psychosis” (Beacon Press, 2010) by psychiatrist and anthropologist Jonathan Metzl, MD, PhD. If you go further back in psychiatric history, the late 1800s, you can learn about the devious diagnosis of drapetomania attributed to enslaved people who were seeking freedom.

Those on the front lines providing mental health services should understand black men’s mental health from an ecological perspective. Beyond the emotional burden that mental illness imposes on the individual, there are more considerable interpersonal and societal implications for the state of black men’s mental health. As such, in our full capacity like other men, black men play an essential role within families, churches, neighborhoods, and organizations.

Given our brief review, we can reconsider our question, “How do psychiatrists and mental health clinicians better engage men of color?”

I will suggest a few fundamental principles that honestly can be applied to any patient but should be strongly considered with your black male patients – given they are likely not accustomed to engaging with the health care system, let alone with a mental health clinician:

1. Create a comfortable environment. Because of stigma, persistent myths, and lack of normalcy with talking to a mental health professional, many patients, including black men, do not have a framework for a psychiatric/psychological evaluation or treatment. It would be essential to set the frame of your encounter. Evidence suggests this can improve engagement and follow-up care among black men.⁸ In addition, keep in mind that “fictive kin^”9 tend to play a major role in the transmission of culture, health promotion, and decision-making in the black community. This helps explain why barbershop initiatives¹⁰ are effective. If clinicians are able to allow black male patients to feel comfortable, the clinician, too, might become part of that fictive community and enhance the patient-provider relationship.

2. Allow for storytelling. In the age of the checklist, it can be relatively easy to lose sight that our patients, including black men, have their own narratives. Evidence suggests that physicians interrupt patients early and often. Challenge yourself to allow the patient to tell his story. In consideration of an initial evaluation, it may help to begin by first gathering sociodemographic information (i.e. housing, education, employment, family, etc.); doing so will allow the patient time to get comfortable before you assess possible psychiatric symptoms.

3. Confidentiality assurance. Many black men have a distrust for the health care profession; as such, it is vital that clinicians emphasize that their patients’ information and history will be used only to help the patient. It will be important to inform black male patients of their rights, because often in the greater society, their rights seem to be negated.

4. Be aware of nonverbal language. Given black men’s stereotyped roles in society and recognition that they are regularly perceived as threats, many black men have become adept at reading nonverbal cues (i.e., purse clutched, side comment, etc.). In doing so, clinicians must be attuned to their own nonverbal language. For example, a glance at one’s watch might be interpreted as you’re not listening. It would be better to be upfront and candid by saying something like, “I need to check the time,” rather than attempting to be stealth. Being transparent in that way will let the patient know that you will be upfront with him.

5. Be respectful. During an encounter, and in particular when discussing treatment plans, clinicians must allow the patient space to process and be involved in his care. Allowing the patient time to think through how he would want to proceed provides him a sense of personal agency and lets him know that he is capable of improving his mental wellness.

Black male patients need to feel comfortable, safe, able to trust the clinician. They must feel listened to, understood, and respected. This information might help some clinicians better understand what needs to happen between a black male patient and a nonblack clinician so the patient can feel good about his mental health engagement. To some, these recommendations might seem obvious or too simple, yet if we consider the countless reports of poor patient treatment engagement, adherence, and retention, we cannot deny the need for change. Having black male patients disclose important information during encounters could prevent poor clinical interactions that leave them feeling uncomfortable, uncertain, skeptical, disrespected, and further cynical about mental health care.

 

Dr. Simon practices at Boston Children’s Hospital. He has no disclosures.

References

1. Bunn C. After Arbery shooting, black parents are rethinking “the talk” to explain white vigilantes. NBC News. 2020 May 19.

2. U.S. Department of Health and Human Services. Office of Disease Prevention and Promotion. Healthy People 2020.

3. Ward E and Mangesha M. Am J Orthopsychiatry. 2013 Apr-Jul;83(2 0 3):386-97.

4. Holden KB et al. J Mens health. 2012 Jun 1;9(2):63-9.

5. Brown TH et al. Fam Community Health. 2015 Oct-Dec;38(4):307-18.

6. Jäggi et al. Soc Ment Health. 2016 Nov;6(3):187-296.

7. Goff PA et al. J Pers Soc Psychol. 2014;106(4):526-45.

8. Alsan M et al. National Bureau of Economic Research. NBER Working Paper No. 24787. 2018 Jun. Revised 2019 Aug.

9. Spruill IJ. J Nat Black Nurses Assoc. 2014 Dec;25(2):23-30.

10. Graham LF et al. Am J Mens Health. 2018 Sep;12(5):1307-16.