Commentary

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.

Almost 30 years ago a young woman made an appointment to see me. I had just started my internal medicine practice and almost all the patients who saw me were new to me. I assumed she was establishing care with me. Her first words to me were “Hello Dr. Paauw, I would like to interview you to see if you will be a good fit as my doctor.” We talked for the 40-minute appointment time. I asked her about her health, her life, and what she wanted out of both. We shared with each other that we both were parents of young children. When the appointment was over, she said she would really like for me to be her doctor. She told me that the main thing she appreciated about me was that I listened, and that her previous physician never sat down at her appointments and often had his hand on the door handle for much of the visit. Physicians and patients both agree that compassionate care is essential for good patient care, yet about half of patients and 60% of doctors believe it is lacking in our medical system.¹

Remember the golden first minutes

When you step in the room and greet the patient, make sure the first few minutes are about connecting with a new patient or reconnecting with a patient who has visited your office in the past. I often start by asking the patient to give me an update on how they are doing. This lets me know what is important to them. I do not touch the computer until after this initial check-in.

Use the computer as a bond to strengthen your patient relationship

Many studies have shown patients find the computer gets between the doctor and patient. It is especially problematic if it breaks eye contact with the patient. People are less likely to share scary, sensitive, or embarrassing information if someone is looking at a computer and typing. As you look up tests, radiology reports, or consultant notes, let the patient in on what you are doing. Explain why you are searching in the record, and if it helps make an important point, show your findings to the patient. Offer to print out results, so they have something to carry with them.

Explain what you are looking for and what you find on the physical exam

Being a patient is scary. We all want reassurance that our fears are not true. When you find normal findings on exam, share those with the patient. Hearing “your heart sounds good, your pulses are strong” really helps patients. Explaining what we are doing when we examine is also helpful. Explain why you are feeling for lymph nodes in the neck, why we percuss the abdomen. Patients are often fascinated by getting a window into how we are thinking. I usually have medical students with me, which offers another avenue to explaining the how and why behind the exam. In asking and explaining to students, the patient is also taught why we do what we do.

Make sure that we cover what they are afraid of, not just what their symptom is

Patients come in not just to get symptom relief but to rest their mind from their fears of what it could be. I find it helpful to ask the patient what they think is the cause of the problem, or if they are worried about any specific diagnosis. With certain symptoms this is particularly important (for example, headaches, fatigue, or abdominal pain).

None of these suggestions are easy to do in busy, time-pressured clinic visits. I have found though that when patients feel cared about, listened to and can have their fears addressed they value our advice more, and less time is needed to negotiate the plan, as it has been developed together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at fpnews@mdedge.com.

Reference

Lown BA et al. Health Aff (Millwood). 2011 Sep;30(9):1772-8.

Having established that there is a documented increase in sexually transmitted infections (STIs) among older Americans, and furthermore recognizing that a contributing factor to this trend may be communication gaps between patients and their health care providers, I now want to address the “What do we do about it?” aspect of our discussion. As clinicians, we know that the core focus around infectious diseases of any kind is prevention.

There are 3 types of prevention, as noted by Fos and Fine in Introduction to Public Health, all of which fit into our current topic: primary (eliminating risk factors), secondary (early detection), and tertiary (eliminating or moderating disability associated with advanced disease).¹ The following recommendations fall into at least one of these categories.

1. All clinicians need to be involved in educating older Americans about the risks for STIs. Providers should routinely ask seniors if they are sexually active and should be prepared to recommend appropriate screening and education resources. Essentially, older adults should be getting the same basic “safe sex” education that younger people receive: learning about STIs, from recognizing the signs to understanding how STIs complicate other chronic medical conditions.^2,3

2. Seniors also need education on the importance—and proper use—of condoms. Furthermore, we should go a step further and ensure that free condoms are distributed in places where seniors live and congregate. People older than 60 report the lowest condom use of any population.^2,3

3. Information on STI detection and treatment options needs to be well publicized. For example, Medicare provides free STI screenings and low-cost treatments. We need to make sure our older patients are aware of this benefit and encourage them to make use of it.

4. Older Americans should be screened for STIs, regardless of age, per CDC guidelines. Seniors should get annual testing if they have new sexual partners—which means they must be asked the difficult questions.

And that’s the crux of the issue: Family members and clinicians may find it uncomfortable to have this conversation with Grandpa or Grandma. But there should be a dialogue to ensure they are aware of their risk for STIs, as well as how to prevent them.³ A well-known NP colleague reminded me of the importance of emphasizing to our older patients that anything discussed within the encounter is confidential and will not be disclosed without their permission. She starts off her conversations with patients by saying, “A lot of people your age experience …” or “Please don’t be insulted if I ask you about …” or “Is it OK if I ask you a few very personal questions?”

Continue to: It is critical...

It is critical to keep an open mind and accepting attitude when discussing sexuality or intimate issues with older patients. Paying attention to patients’ verbal and nonverbal cues is also essential. Clinicians should never assume older adults are sexually inactive, no longer care about sex, or are necessarily heterosexual. There was an excellent article in the Journal of Family Practice a few years ago on “How to discuss sex with elderly patients” that is worth rereading. In it, the authors suggest using the PLISSIT model to facilitate a conversation with your elderly patient. As explained in the article, the acronym “is a reminder to seek Permission to discuss sexuality, share Limited information about sexual issues that affect the older adult, provide Specific Suggestions to improve sexual health, and offer to provide a referral for Intensive Therapy if needed.”⁴ The Table offers some examples of how to address each step of PLISSIT.

So, as we wrap up our examination of this issue, I encourage you to open this dialogue with your older patients. In light of the increasing number of older patients with STIs, it is essential for clinicians to obtain an accurate and complete sexual history for patients of any age. That starts with asking the appropriate questions, preferably in a manner that puts the patient at ease to share important details. If you have additional ideas about what we can do to reverse this STI trend, please share them with me at PAeditor@MDedge.com.

Having established that there is a documented increase in sexually transmitted infections (STIs) among older Americans, and furthermore recognizing that a contributing factor to this trend may be communication gaps between patients and their health care providers, I now want to address the “What do we do about it?” aspect of our discussion. As clinicians, we know that the core focus around infectious diseases of any kind is prevention.

There are 3 types of prevention, as noted by Fos and Fine in Introduction to Public Health, all of which fit into our current topic: primary (eliminating risk factors), secondary (early detection), and tertiary (eliminating or moderating disability associated with advanced disease).¹ The following recommendations fall into at least one of these categories.

1. All clinicians need to be involved in educating older Americans about the risks for STIs. Providers should routinely ask seniors if they are sexually active and should be prepared to recommend appropriate screening and education resources. Essentially, older adults should be getting the same basic “safe sex” education that younger people receive: learning about STIs, from recognizing the signs to understanding how STIs complicate other chronic medical conditions.^2,3

2. Seniors also need education on the importance—and proper use—of condoms. Furthermore, we should go a step further and ensure that free condoms are distributed in places where seniors live and congregate. People older than 60 report the lowest condom use of any population.^2,3

3. Information on STI detection and treatment options needs to be well publicized. For example, Medicare provides free STI screenings and low-cost treatments. We need to make sure our older patients are aware of this benefit and encourage them to make use of it.

4. Older Americans should be screened for STIs, regardless of age, per CDC guidelines. Seniors should get annual testing if they have new sexual partners—which means they must be asked the difficult questions.

And that’s the crux of the issue: Family members and clinicians may find it uncomfortable to have this conversation with Grandpa or Grandma. But there should be a dialogue to ensure they are aware of their risk for STIs, as well as how to prevent them.³ A well-known NP colleague reminded me of the importance of emphasizing to our older patients that anything discussed within the encounter is confidential and will not be disclosed without their permission. She starts off her conversations with patients by saying, “A lot of people your age experience …” or “Please don’t be insulted if I ask you about …” or “Is it OK if I ask you a few very personal questions?”

Continue to: It is critical...

It is critical to keep an open mind and accepting attitude when discussing sexuality or intimate issues with older patients. Paying attention to patients’ verbal and nonverbal cues is also essential. Clinicians should never assume older adults are sexually inactive, no longer care about sex, or are necessarily heterosexual. There was an excellent article in the Journal of Family Practice a few years ago on “How to discuss sex with elderly patients” that is worth rereading. In it, the authors suggest using the PLISSIT model to facilitate a conversation with your elderly patient. As explained in the article, the acronym “is a reminder to seek Permission to discuss sexuality, share Limited information about sexual issues that affect the older adult, provide Specific Suggestions to improve sexual health, and offer to provide a referral for Intensive Therapy if needed.”⁴ The Table offers some examples of how to address each step of PLISSIT.

So, as we wrap up our examination of this issue, I encourage you to open this dialogue with your older patients. In light of the increasing number of older patients with STIs, it is essential for clinicians to obtain an accurate and complete sexual history for patients of any age. That starts with asking the appropriate questions, preferably in a manner that puts the patient at ease to share important details. If you have additional ideas about what we can do to reverse this STI trend, please share them with me at PAeditor@MDedge.com.

Having established that there is a documented increase in sexually transmitted infections (STIs) among older Americans, and furthermore recognizing that a contributing factor to this trend may be communication gaps between patients and their health care providers, I now want to address the “What do we do about it?” aspect of our discussion. As clinicians, we know that the core focus around infectious diseases of any kind is prevention.

There are 3 types of prevention, as noted by Fos and Fine in Introduction to Public Health, all of which fit into our current topic: primary (eliminating risk factors), secondary (early detection), and tertiary (eliminating or moderating disability associated with advanced disease).¹ The following recommendations fall into at least one of these categories.

1. All clinicians need to be involved in educating older Americans about the risks for STIs. Providers should routinely ask seniors if they are sexually active and should be prepared to recommend appropriate screening and education resources. Essentially, older adults should be getting the same basic “safe sex” education that younger people receive: learning about STIs, from recognizing the signs to understanding how STIs complicate other chronic medical conditions.^2,3

2. Seniors also need education on the importance—and proper use—of condoms. Furthermore, we should go a step further and ensure that free condoms are distributed in places where seniors live and congregate. People older than 60 report the lowest condom use of any population.^2,3

3. Information on STI detection and treatment options needs to be well publicized. For example, Medicare provides free STI screenings and low-cost treatments. We need to make sure our older patients are aware of this benefit and encourage them to make use of it.

4. Older Americans should be screened for STIs, regardless of age, per CDC guidelines. Seniors should get annual testing if they have new sexual partners—which means they must be asked the difficult questions.

And that’s the crux of the issue: Family members and clinicians may find it uncomfortable to have this conversation with Grandpa or Grandma. But there should be a dialogue to ensure they are aware of their risk for STIs, as well as how to prevent them.³ A well-known NP colleague reminded me of the importance of emphasizing to our older patients that anything discussed within the encounter is confidential and will not be disclosed without their permission. She starts off her conversations with patients by saying, “A lot of people your age experience …” or “Please don’t be insulted if I ask you about …” or “Is it OK if I ask you a few very personal questions?”

Continue to: It is critical...

It is critical to keep an open mind and accepting attitude when discussing sexuality or intimate issues with older patients. Paying attention to patients’ verbal and nonverbal cues is also essential. Clinicians should never assume older adults are sexually inactive, no longer care about sex, or are necessarily heterosexual. There was an excellent article in the Journal of Family Practice a few years ago on “How to discuss sex with elderly patients” that is worth rereading. In it, the authors suggest using the PLISSIT model to facilitate a conversation with your elderly patient. As explained in the article, the acronym “is a reminder to seek Permission to discuss sexuality, share Limited information about sexual issues that affect the older adult, provide Specific Suggestions to improve sexual health, and offer to provide a referral for Intensive Therapy if needed.”⁴ The Table offers some examples of how to address each step of PLISSIT.

So, as we wrap up our examination of this issue, I encourage you to open this dialogue with your older patients. In light of the increasing number of older patients with STIs, it is essential for clinicians to obtain an accurate and complete sexual history for patients of any age. That starts with asking the appropriate questions, preferably in a manner that puts the patient at ease to share important details. If you have additional ideas about what we can do to reverse this STI trend, please share them with me at PAeditor@MDedge.com.

I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.

AJ_Watt/E+

In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me, before we can start discussing quality, we must clear up the confusion engendered by the term “telemedicine.”

I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.

In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.

The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.

But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.

AJ_Watt/E+

In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me, before we can start discussing quality, we must clear up the confusion engendered by the term “telemedicine.”

I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.

In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.

The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.

But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

I previously shared my concerns about the compromises some physicians are making when they consent to practicing in a telemedicine arrangement in which the system’s technical limitations prevents them from obtaining information critical to making an accurate diagnosis. In the scenarios that I described, a physician would have great difficulty being a good steward of antibiotic usage if he were willing to make a diagnosis of otitis media or strep throat without access to tympanic membrane visualization or the results of a rapid strep test.

AJ_Watt/E+

In response to my observation, I received an email from Dr. Kenneth McConnochie, a name out of my deep past from when we were teammates in college. Now a professor of pediatrics at University of Rochester (N.Y.) Medical Center, Dr. McConnochie has studied telemedicine in primary care extensively. He has thought a lot about telemedicine and more specifically about how it relates to quality. As he pointed out to me, before we can start discussing quality, we must clear up the confusion engendered by the term “telemedicine.”

I suspect that like me, whenever you look at an article or study that has “telemedicine” in its title or headline, you are never sure what you’re going to be reading about. Is it going to be a discussion of telephone triaging in a suburban primary practice or will the article describe how a pediatric cardiologist in Anchorage can follow his little patients in the Aleutians via an audio/video hookup that provides him with the ability to auscultate and review electrocardiograms and radiographic images? Dr. McConnochie suggests that by using the broader term “connected care” for care that is delivered at a distance, and by clearly specifying different types or levels, we will be one big step closer to a more meaningful way to understand the usefulness of that care.

In the conceptual framework he proposes, level 1 is text-only care because it offers the physician the least capacity for the acquisition of (1) diagnostically relevant information and (2) interpersonal connection. Phone care can provide more and videoconferencing still more. Level 4 would be what Dr. McConnochie labels “information rich” care providing the most abundant capacity. Here, think of an arrangement in which someone at the patient’s end of the connection has been trained to use an electronic otoscope that can capture an image of the child’s tympanic membrane, an electronic stethoscope that can record heart and breath sounds, and a high resolution camera to capture images of the patient’s skin, throat, and eyes, then transmit them to the child’s electronic health record (EHR) in real time. Someone in the school or day care center where the child spends his day has been taught how to obtain and process a rapid strep test. The physician who has instant access to the child’s EHR can communicate “face to face” via teleconferencing with the day care providers and with the parent who is at work to discuss the diagnosis, treatment plan, and follow-up. If any of the parties feels the exchange of information is insufficiently robust, a traditional office visit can be arranged.

The challenge of assigning value to each level care still remains. Is the level 4 scenario I just described as valuable as a face to face traditional office visit? In some situations, it is likely to be more valuable than a visit with a physician in an urgent care clinic or emergency department who has never seen the patient and/or lacks access to the EHR because her computer doesn’t interface with the primary care physician’s EHR. It certainly may be more convenient for the family.

But who is going to assign value? A connected visit may be more efficient for the patient and the parent, but will it be more costly? And who is going to pay? Dr. McConnochie’s observations should be taken seriously by those folks who assign value and pay.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?

Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.¹ charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.²

Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)³ and noted a significant drop in her generalized anxiety score. But how to be sure she is not just less anxious, but also experiencing well-being?

After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale⁴ for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”⁵

With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?

Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,⁶ is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.

Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Am Psychol. 2000;55(1):5-14.

2. Am Psychol. 2007 Feb-Mar;62(2):95-108.

3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.

4. Soc Indic Res. 2009; 39:247-66.

5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).

6. “The Resilience Drive” (Switzerland: Favre, 2017).

7. Am Psychol. 2005 Jul-Aug;60(5):410-21.

Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?

Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.¹ charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.²

Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)³ and noted a significant drop in her generalized anxiety score. But how to be sure she is not just less anxious, but also experiencing well-being?

After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale⁴ for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”⁵

With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?

Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,⁶ is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.

Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Am Psychol. 2000;55(1):5-14.

2. Am Psychol. 2007 Feb-Mar;62(2):95-108.

3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.

4. Soc Indic Res. 2009; 39:247-66.

5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).

6. “The Resilience Drive” (Switzerland: Favre, 2017).

7. Am Psychol. 2005 Jul-Aug;60(5):410-21.

Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?

Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.¹ charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.²

Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)³ and noted a significant drop in her generalized anxiety score. But how to be sure she is not just less anxious, but also experiencing well-being?

After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale⁴ for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”⁵

With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?

Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,⁶ is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.

Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Am Psychol. 2000;55(1):5-14.

2. Am Psychol. 2007 Feb-Mar;62(2):95-108.

3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.

4. Soc Indic Res. 2009; 39:247-66.

5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).

6. “The Resilience Drive” (Switzerland: Favre, 2017).

7. Am Psychol. 2005 Jul-Aug;60(5):410-21.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

Grouping the term “transgender” in the abbreviation LGBT (lesbian, gay, bisexual, transgender) has historically been empowering for trans and gender nonconforming (GNC) persons. However, it also has contributed to the misunderstanding that gender identity is interchangeable with sexual identity. This common misconception can be a barrier to trans and GNC patients seeking care from ob.gyns. for their reproductive health needs.

Rawpixel/Thinkstock

By definition, gender identity refers to an internal experience of one’s gender, of one’s self.¹ While gender identity has social implications, it ultimately is something that a person experiences independently of interactions with others. By contrast, sexual orientation has an explicitly relational underpinning because sexual orientation involves attraction to others. The distinction between gender identity and sexual orientation is similar to an internal-versus-external, or a self-versus-other dichotomy. A further nuance to add is that sexual behavior does not always reflect sexual orientation, and sexual behavior can vary along a wide spectrum when gender identity is added to the equation.

Overall, health care providers should be careful not make assumptions about a patient’s sexual orientation based on a patient’s gender identity. When approaching a sexual history with any patient, but especially a transgender or GNC patient, providers should think deeply about what information is medically relevant.² The purpose of a sexual history is to identify behaviors that contribute to health risk, including pregnancy, sexually transmitted infection, and social problems such as sex-trafficking or intimate partner violence. The health care provider’s job is to ask questions that will uncover these risk factors.

With the advent of a more inclusive attitude toward gay and lesbian partnership, many providers already have learned to collect the sexual history without assuming the gender of a person’s sexual contacts. Still, when a provider is taking the sexual history, gender often is inappropriately used as proxy for the type of sex that a patient may be having. For example, a provider asking a cisgender woman about her sexual activity may ask, “how many sexual partners have you had in the last year?” But then, the provider may follow-up her response of “three sexual partners in the last year” by asking “men, women, or both?” By asking a patient if the patient’s sexual partners are “men, women, or both,” providers fail to accurately elucidate the risk factors that they are actually seeking when taking a sexual history. The cisgender woman from the above scenario may reply that she has been sleeping only with women for the last year, but if the sexual partners are transgender women, aka a woman who was assigned male at birth and therefore still may use her penis/testes for sexual purposes, then the patient actually may be at risk for pregnancy and may also have a different risk factor profile for sexually transmitted infections than if the patient were sexually active with cisgender women.

A different approach to using gender in taking the sexual history is to speak plainly about which sex organs come into contact during sexual activity. When patients identify as transgender or GNC, a provider first should start by asking them what language they would like providers to use when discussing sex organs.³ One example is that many trans men, both those who have undergone mastectomy as well as those who have not, may not use the word “breasts” to describe their “chests.” This distinction may make the difference between gaining and losing the trust of a trans/GNC patient in your clinic. After identifying how a patient would like to refer to sex organs, a provider can continue by asking which of the patient’s sex partners’ organs come into contact with the patient’s organs during sexual activity. Alternatively, starting with an even more broad line of questioning may be best for some patients, such as “how do you like to have sex?”

Carefully identifying the type of sex and what sex organs are involved has concrete medical implications. Patients assigned female at birth who are on hormone therapy with testosterone may need supportive care if they continue to use their vaginas in sexual encounters because testosterone can lead to a relatively hypoestrogenic state. Patients assigned male at birth who have undergone vaginoplasty procedures may need counseling about how to use and support their neovaginas as well as adjusted testing for dysplasia. Patients assigned female at birth who want to avoid pregnancy may need a nuanced consultation regarding contraception. These are just a few examples of how obstetrician-gynecologists can better support the sexual health of their trans/GNC patients by having an accurate understanding of how a trans/GNC person has sex.
 

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Bahng and Dr. Joyner reported no relevant financial disclosures

References

1. Sexual orientation and gender identity definitions. Human Rights Campaign.

2. Taking a sexual history from transgender people. Transforming Health at the Centers for Disease Control and Prevention.

3. Sexual health history: Talking sex with gender non-conforming and trans patients. National LGBT Health Education Center at The Fenway Institute.

Members of the baby boom generation (yes, my generation)—the nomenclature given to the 76 million people born between 1946 and 1964—are now in our 50s, 60s, and 70s. Many of us are enjoying our retirement while others are still working. Regardless of our circumstances, we all share one challenge: aging as comfortably as we can. It’s a fact of our lives that as we age, we battle risk factors for a variety of conditions, ranging from diabetes, heart disease, and Alzheimer disease to … sexually transmitted infections (STIs).

Ever since I saw the statistics about increasing rates of STIs among older Americans, I’ve been mulling possible explanations for this trend. In conversation with my CR colleagues, the question arose as to whether the fact that the current population of senior citizens is comprised largely of Baby Boomers has had an impact. It’s certainly worth considering!

We (the Baby Boomers) are more savvy, assertive, health-conscious, and engaged in our health care than the generations that preceded us.^1,2 When I look around at my friends and colleagues, I see a group of people who want to live more active lives and remain socially engaged—even as we manage our chronic conditions! As self-determining patients, we are likely to question established principles of medical care, demanding greater attention to our own definitions of health-related quality of life, including a satisfactory sex life.³

In fact, some of this increase in STIs among older Americans could be explained by the availability of treatments that address the sexual dysfunction that comes with aging. Previous generations of older adults have faced menopause and erectile dysfunction—but Baby Boomers are living and aging at a time when the symptoms can be more effectively managed. For older women, there are bioidentical hormones to replace those lost during menopause, which is often cited as the primary offender affecting their sexual lives (despite research suggesting that social and psychologic factors—emotional well-being, a strong emotional association with one’s partner, and positive body image—may be more foretelling of sexual activity later in life than the hormonal changes related to menopause).⁴

As for erectile dysfunction, yes, some men still feel awkward about bringing it up with their clinician; it can feel enfeebling for men to acknowledge, even though the physiologic changes are explained by the biology of aging (as we alluded to last week). Continuing sales of Viagra and Cialis suggest that boomer men are overcoming the stigmas of revealing their erectile dysfunction, however.

And maybe that is a contributing factor to this trend in STIs: We are being equipped for sexual performance, but perhaps we haven’t been adequately educated on what the consequences of our sexual encounters are. A lot of today’s seniors were already married when sex education gained prominence and perhaps missed the “safe sex” talks.

When I discussed this with a colleague of mine—a retired employee of the State Department—he noted that this topic was talked about even among US Embassy staff! At the risk of making a sweeping generalization and stating the obvious, he observed that “sexual mores have changed over time. Even many generations ago, they thought previous generations had been restrictive about sexual behavior!” Nevertheless, we agreed that the generation now emerging as “older Americans” grew up during the ’60s Free Love movement—and that philosophy seems to have carried into some individuals’ current sexual behavior. My colleague also noted that “as we get older, we lose partners—and sexual monogamy is lost with the loss of a partner.”

Continue to: The Baby Boomers...

The Baby Boomers are by far the most sexually liberal generation of older adults that this country has ever seen. Providing health care to this population requires addressing all health care needs, including sexual health and prevention. Next week, we’ll examine ways clinicians can comfortably broach these topics with older patients.

In the meantime, I’d love to hear your thoughts: Is this the Second Spring of the Summer of Love generation? Whether you’re a Boomer or a Millennial or anyone in between, feel free to write to me at PAeditor@mdedge.com.

Members of the baby boom generation (yes, my generation)—the nomenclature given to the 76 million people born between 1946 and 1964—are now in our 50s, 60s, and 70s. Many of us are enjoying our retirement while others are still working. Regardless of our circumstances, we all share one challenge: aging as comfortably as we can. It’s a fact of our lives that as we age, we battle risk factors for a variety of conditions, ranging from diabetes, heart disease, and Alzheimer disease to … sexually transmitted infections (STIs).

Ever since I saw the statistics about increasing rates of STIs among older Americans, I’ve been mulling possible explanations for this trend. In conversation with my CR colleagues, the question arose as to whether the fact that the current population of senior citizens is comprised largely of Baby Boomers has had an impact. It’s certainly worth considering!

We (the Baby Boomers) are more savvy, assertive, health-conscious, and engaged in our health care than the generations that preceded us.^1,2 When I look around at my friends and colleagues, I see a group of people who want to live more active lives and remain socially engaged—even as we manage our chronic conditions! As self-determining patients, we are likely to question established principles of medical care, demanding greater attention to our own definitions of health-related quality of life, including a satisfactory sex life.³

In fact, some of this increase in STIs among older Americans could be explained by the availability of treatments that address the sexual dysfunction that comes with aging. Previous generations of older adults have faced menopause and erectile dysfunction—but Baby Boomers are living and aging at a time when the symptoms can be more effectively managed. For older women, there are bioidentical hormones to replace those lost during menopause, which is often cited as the primary offender affecting their sexual lives (despite research suggesting that social and psychologic factors—emotional well-being, a strong emotional association with one’s partner, and positive body image—may be more foretelling of sexual activity later in life than the hormonal changes related to menopause).⁴

As for erectile dysfunction, yes, some men still feel awkward about bringing it up with their clinician; it can feel enfeebling for men to acknowledge, even though the physiologic changes are explained by the biology of aging (as we alluded to last week). Continuing sales of Viagra and Cialis suggest that boomer men are overcoming the stigmas of revealing their erectile dysfunction, however.

And maybe that is a contributing factor to this trend in STIs: We are being equipped for sexual performance, but perhaps we haven’t been adequately educated on what the consequences of our sexual encounters are. A lot of today’s seniors were already married when sex education gained prominence and perhaps missed the “safe sex” talks.

When I discussed this with a colleague of mine—a retired employee of the State Department—he noted that this topic was talked about even among US Embassy staff! At the risk of making a sweeping generalization and stating the obvious, he observed that “sexual mores have changed over time. Even many generations ago, they thought previous generations had been restrictive about sexual behavior!” Nevertheless, we agreed that the generation now emerging as “older Americans” grew up during the ’60s Free Love movement—and that philosophy seems to have carried into some individuals’ current sexual behavior. My colleague also noted that “as we get older, we lose partners—and sexual monogamy is lost with the loss of a partner.”

Continue to: The Baby Boomers...

The Baby Boomers are by far the most sexually liberal generation of older adults that this country has ever seen. Providing health care to this population requires addressing all health care needs, including sexual health and prevention. Next week, we’ll examine ways clinicians can comfortably broach these topics with older patients.

In the meantime, I’d love to hear your thoughts: Is this the Second Spring of the Summer of Love generation? Whether you’re a Boomer or a Millennial or anyone in between, feel free to write to me at PAeditor@mdedge.com.

Members of the baby boom generation (yes, my generation)—the nomenclature given to the 76 million people born between 1946 and 1964—are now in our 50s, 60s, and 70s. Many of us are enjoying our retirement while others are still working. Regardless of our circumstances, we all share one challenge: aging as comfortably as we can. It’s a fact of our lives that as we age, we battle risk factors for a variety of conditions, ranging from diabetes, heart disease, and Alzheimer disease to … sexually transmitted infections (STIs).

Ever since I saw the statistics about increasing rates of STIs among older Americans, I’ve been mulling possible explanations for this trend. In conversation with my CR colleagues, the question arose as to whether the fact that the current population of senior citizens is comprised largely of Baby Boomers has had an impact. It’s certainly worth considering!

We (the Baby Boomers) are more savvy, assertive, health-conscious, and engaged in our health care than the generations that preceded us.^1,2 When I look around at my friends and colleagues, I see a group of people who want to live more active lives and remain socially engaged—even as we manage our chronic conditions! As self-determining patients, we are likely to question established principles of medical care, demanding greater attention to our own definitions of health-related quality of life, including a satisfactory sex life.³

In fact, some of this increase in STIs among older Americans could be explained by the availability of treatments that address the sexual dysfunction that comes with aging. Previous generations of older adults have faced menopause and erectile dysfunction—but Baby Boomers are living and aging at a time when the symptoms can be more effectively managed. For older women, there are bioidentical hormones to replace those lost during menopause, which is often cited as the primary offender affecting their sexual lives (despite research suggesting that social and psychologic factors—emotional well-being, a strong emotional association with one’s partner, and positive body image—may be more foretelling of sexual activity later in life than the hormonal changes related to menopause).⁴

As for erectile dysfunction, yes, some men still feel awkward about bringing it up with their clinician; it can feel enfeebling for men to acknowledge, even though the physiologic changes are explained by the biology of aging (as we alluded to last week). Continuing sales of Viagra and Cialis suggest that boomer men are overcoming the stigmas of revealing their erectile dysfunction, however.

And maybe that is a contributing factor to this trend in STIs: We are being equipped for sexual performance, but perhaps we haven’t been adequately educated on what the consequences of our sexual encounters are. A lot of today’s seniors were already married when sex education gained prominence and perhaps missed the “safe sex” talks.

When I discussed this with a colleague of mine—a retired employee of the State Department—he noted that this topic was talked about even among US Embassy staff! At the risk of making a sweeping generalization and stating the obvious, he observed that “sexual mores have changed over time. Even many generations ago, they thought previous generations had been restrictive about sexual behavior!” Nevertheless, we agreed that the generation now emerging as “older Americans” grew up during the ’60s Free Love movement—and that philosophy seems to have carried into some individuals’ current sexual behavior. My colleague also noted that “as we get older, we lose partners—and sexual monogamy is lost with the loss of a partner.”

Continue to: The Baby Boomers...

The Baby Boomers are by far the most sexually liberal generation of older adults that this country has ever seen. Providing health care to this population requires addressing all health care needs, including sexual health and prevention. Next week, we’ll examine ways clinicians can comfortably broach these topics with older patients.

In the meantime, I’d love to hear your thoughts: Is this the Second Spring of the Summer of Love generation? Whether you’re a Boomer or a Millennial or anyone in between, feel free to write to me at PAeditor@mdedge.com.

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at pdnews@mdedge.com.

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at pdnews@mdedge.com.

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

Influenza gets a lot of attention each winter, but respiratory syncytial virus (RSV) and other respiratory viruses have as much or more impact on pediatric populations, particularly certain high-risk groups. But currently there are no vaccines for noninfluenza respiratory viruses. That said, several are under development, for RSV and parainfluenza.

Which groups are likely to get the most benefit from these newer vaccines?

We all are aware of the extra vulnerability to respiratory viruses (RSV being the most frequent) in premature infants, those with chronic lung disease, or those with congenital heart syndromes; such vulnerable patients are not infrequently seen in routine practice. But patients from another less frequent category – those with neuromuscular disease – may be even more vulnerable and may benefit more from new vaccines. A recent report shined a brighter light on such a group.

Real-world data from a nationwide Canadian surveillance system (CARESS) was used to analyze relative risks of categories of young children who are thought to be vulnerable to respiratory viruses, with a particular focus on those with neuromuscular disease. The CARESS investigators analyzed 12 years’ data on respiratory hospitalizations from among palivizumab-prophylaxed patients (including specific data on RSV when patients were tested for RSV per standard of care).¹ Unfortunately, RSV testing was not universal despite hospitalization, so the true incidence of RSV-specific hospitalizations was likely underestimated.

Nevertheless, more than 25,000 children from 2005 through 2017 were grouped into three categories of palivizumab-prophylaxed high-risk children: standard indications (SI), n = 20,335; chronic medical conditions (CMD), n = 4,063; and neuromuscular disease (NMD), n = 605. This study is notable for having a relatively large number of neuromuscular disease subjects. Two-thirds of each group were fully palivizumab adherent.

The SI group included the standard American Academy of Pediatrics–recommended groups, such as premature infants, congenital heart disease, etc.

The CMD group included conditions that lead clinicians to use palivizumab off label, such as cystic fibrosis, congenital airway anomalies, immunodeficiency, and pulmonary disorders.

The NMD participants were subdivided into two groups. Group 1 comprised general hypotonic neuromuscular diseases such as hypoxic-ischemic encephalopathy, Prader-Willi syndrome, chromosomal disorders, and migration/demyelinating diseases. Group 2 included more severe infantile neuromuscular disorders, such as spinal muscular atrophy, myotonic dystrophy, centronuclear and nemaline myopathy, mitochondrial and glycogen storage myopathies, or arthrogryposis.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospital–Kansas City, Mo. Children’s Mercy Hospital receives grant funding to study two candidate RSV vaccines. The hospital also receives CDC funding under the New Vaccine Surveillance Network for multicenter surveillance of acute respiratory infections, including influenza, RSV, and parainfluenza virus. Email Dr. Harrison at pdnews@mdedge.com.

References

1. Pediatr Infect Dis J. 2019 Apr 10. doi: 10.1097/INF.0000000000002297.

2. “Advances in RSV Vaccine Research and Development – A Global Agenda.”

3. J Pediatric Infect Dis Soc. 2015 Dec;4(4): e143-6.

4. J Virol. 2015 Oct;89(20):10319-32.

5. Vaccine. 2017 Dec 18;35(51):7139-46.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.

June is Pride Month in the United States. It is a time in which people take a stand against discrimination and violence against lesbian, gay, bisexual, and transgender (LGBT) people and promote dignity, equality, and visibility of this community. During this time, many cities will be holding events ranging from rallies to parades to not only celebrate sexual diversity and gender variance, but also to serve as a reminder of the work that needs to be done to foster equal treatment for LGBT people. As a medical provider, you have the unique role of advancing this cause – from educating your colleagues on the health needs of this population to advocating for policies that protect their health and well-being. If you’re interested in serving the LGBT community as a medical provider, here are some ways you can show this community your commitment to their health and well-being.

400tmax/iStock Unreleased

Be visible

There will be numerous LGBT Pride events occurring the month of June and even throughout the summer in the United States. They can occur in cities big and small, and they can even be in the city you work in. Visibility matters for LGBT youth. Eight percent of lesbian, gay, and bisexual people report that a health care provider refused to see them because of their sexual orientation and 29% of transgender people report that their health care providers refused to see them because of their gender identity or expression.¹ Therefore, LGBT people will expect discrimination everywhere they go.²

Being present at a Pride event signals to the community that you are willing to serve LGBT people. Many Pride events will allow hospitals and clinics to have a table at the event, but keep in mind that many will prioritize organizations that specifically cater to the LGBT community or that are owned and operated by members of the community. Another way to show the community that you will treat LGBT people with dignity and respect is to list your practice in a database for LGBT-friendly providers. The Gay and Lesbian Medical Association keeps a database of LGBT-friendly medical providers, and many Pride events will advertise businesses and organizations that serve the LGBT community. You may want to consider having your clinic or hospital participate in the Human Rights Campaign (HRC) Health Equality Index (HEI). The HEI is a list of best practices for hospitals and clinics to use that affirm and support LGBT health (such as having gender-neutral bathrooms in facilities). Hospitals and clinics that endorse a high amount or all of these practices are listed as committed to the health and well-being of the LGBT community on the HRC website.
 

Be a part of LGBT Pride

Many LGBT Pride events are supported by local community organizations, most of which are nonprofits. They will need the necessary resources to keep holding these events every year. These resources can include both time and money. Consider donating your time by volunteering at these Pride events. For example, many Pride events hold health screenings, and you can use your skills and knowledge to promote the well-being of the LGBT community. At the same time, make sure that the PRIDE event is created to help serve the community. There is controversy over the commercialization of LGBT Pride events, as some corporate sponsors have been inconsistent in advocating for the LGBT community. Some feel that the commercialization of LGBT Pride ignores the original purpose of the event as a political movement.³ Do some research to make sure that your donation is going to an LGBT Pride event that serves the whole community, not just certain segments of it, and if you feel that it is not, you may consider donating to other LGBT-serving organizations in your community.

Educate yourself

Even when LGBT Pride season is over, the work of promoting the health and well-being of LGBT youth is never done. There are many medical providers who have made it their life’s work doing this. Consider learning more about the role medical providers have played in the health and well-being of the LGBT community, which may serve as an inspiration for your work. The list is long, and includes pioneers such as Ben Barres, MD, PhD, a transgender neurobiologist and physician who transitioned from female to male mid-career and was known for his work on interaction between neurons and glial cells in the nervous system, and Rachel Levine, MD, a physician who became the first transgender woman to serve as Physician General, then Secretary of State, of Pennsylvania.

Other providers have tackled health problems that plagued the LGBT community. Joel D. Weisman, DO, was one of the first physicians to identify the AIDS epidemic and became an advocate for AIDS research, treatment, and prevention, whereas Kevin A. Fenton, MD, PhD, a gay black man, was the director for the National Center for HIV/AIDS at the Centers for Disease Control and Prevention; he helped cultivate strategies to combat the HIV epidemic among gay black men.⁴ Finally, there is Nanette Gartrell, MD, a psychiatrist and researcher who leads the U.S. National Longitudinal Lesbian Family Study. This ongoing, prospective, and influential study was the first to identify that children raised by lesbian mothers had higher levels of social and school/academic competence and significantly lower levels of social problems, rule-breaking behaviors, and aggressive behaviors, compared with children raised by opposite sex parents.⁵

LGBT Pride is a time to recognize the achievements the LGBT community has made in the last couple of decades, and at the same time, it is a reminder that the work to promote health equity for this community remains unfinished. Health care providers have an important responsibility in fostering this work in a responsible and ethical matter. Many medical providers have dedicated their lives to this movement, and even when the LGBT Pride season is over, their mission will continue.
 

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at pdnews@mdedge.com.

References

1. “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, Jan. 18, 2018.

2. Psychol Bull. 2003 Sep;129(5): 674-97.

3. “How LGBTQ Pride Month became a branded holiday,” Vox, Jun 25, 2018.

4. “Dr. Kevin Fenton stepping down after 8 years,” The Georgia Voice, Dec 7, 2012.

5. Pediatrics. 2010;126(1):28-36.