Commentary

The doctor is sick.

Her feet are swollen, as if her heart is failing. But it is strong and beating faster than usual, as she runs her fingers through her hair. Her vision gets blurry sometimes, and she has to hold onto something when she stands up or she will fall down. The doctor is sick because she is taking medicine to make her well. Lithium, Seroquel, Depakote. Mood stabilizer, antipsychotic, mood stabilizer. Two pills, 4 pills, 3 pills. Plus a multivitamin because Depakote can cause her hair to fall out. Skinny and fat bottles, next to her bed so she won’t forget. As if she would forget.

The doctor is sick because 3 weeks ago tomorrow she made a concrete plan to take her life. She wrote 5 letters, the longest to her sweet and supportive husband. She put some pills and some alcohol and the letters in her backpack and made it to the front stoop before she sat down, her heart breaking, and called her best friend.

The doctor is sick. Sicker now that she is home. As a patient in the psychiatric hospital, she was the doctor, and she held “office hours” (24 hours a day) to answer questions about GERD, schizophrenia, and stomachaches. This made her feel a lot less sick. Everyone said she was clever. She is only a medical student and offers a disclaimer with her advice (along with the suggestion to see a “real doctor”). But to most of the patients she is a doctor. And she feels the calling to be a doctor. Deep down inside herself she feels she was born to be a doctor.

In the psychiatric hospital, she felt alive when she gave advice. It made her feel she was helping people. She lives for people. And it distinguished her from the rest of them. They were her friends and she shared illness with them, but somehow she was different. Sometimes, this gave her comfort. Other times she held onto them as anchors in the madness they were swimming through together. Those times she found comfort in being the same as them. Exactly the same.

The doctor is sick. On the discharge sheet, 18 days after admission, her acceptance of this fact (“judgment and insight”) was judged “fair.” This is because the doctor does not believe in her diagnosis. She does not want to be sick. She wants to be the person she was before—minus those highs and lows. She would trade in the agitated anxious state that caused her to drop out of her pediatric rotation. She would trade in the days spent in bed in college, while everyone seemed to be having fun. She would trade in the Google searches of “suicide methods.” She would trade in the panic that caused her to stop her rotation, and therefore caused her to stop playing with the pediatric patients in the playroom at night, after her clinical duties were finished. In the playroom she was not a doctor or a medical student. She was just someone’s playmate. She held the little hand of her little patient and she felt like she was exactly where she was supposed to be. She knew she belonged when she helped her patients forget they were sick.

The doctor is sick. She is drinking hard lemonade, even though it makes the dizziness worse. The doctor has a swollen face and swollen fingers and her wedding ring does not fit anymore. She has gained 10, no, 15 lb because of the medicine, and she knows her husband has noticed. The doctor knows that she has enough pills beside her bed to end her life, but she also knows she is calm now. She is calm in a way she has not felt for as long as she can remember. She thinks back on college, on that 2-month period when she slept until 2 PM, and got out of bed only to smoke marijuana and change the CD on her stereo. She thinks back on the way she pulled the blanket over her head and she remembers that she wanted to be dead.

The doctor remembers writing her treatises later that year on the meaning of life, of the world, of peace and joy and love, on her desktop computer. She wrote and wrote and wrote, as she often did, and sleep did not seem very necessary or desired. She felt she was more connected to the world than anyone else on the planet. She felt more intensely than anyone else on the planet. She ran 5 miles a day, 15 miles on Saturdays. Tears streamed down her face as she bicycled back from her volunteer work with the elderly. She felt so much love and she felt so different from everyone else. Tears came again when she read literature; she felt alive with politics and meaning and urgency. Her heart pounded and she felt words run through her mind that told her to keep working, harder, and that she was capable of more efficient, more emotive, more effective, more productive work than anyone else on the planet. She had more insight than anyone else on the planet. But all of this was directed to help other people, and so she was connected to the whole world.

The doctor feels sick now as she recalls those events. Now she fears her past is part of this illness. Those thoughts and actions that were her proudest moments, the organizations that offered her awards and accolades, the papers that got high marks—those were just the consequence of neurotransmitters being sucked in and spat out in the wrong ratios. It is that simple. Something we can fix with around 10 pills a day, pills that will make the doctor better but will make the doctor sick. What about the doctor’s sense of humor? What about her energy? What about her wild dancing and her disinhibition? What about her ability to be the life of a party even when she is stone cold sober and everyone else has had 4 or 5 drinks? What about her accomplishments and her intensity? What about her ever-present belief that the world’s people are all connected, and she is to play a small but important, even vital, role in bringing them together? Sick, sick, all sick.

As a patient in the psychiatric hospital, the doctor would dance sometimes. She would be dancing, twirling, laughing, making others laugh. Then, on the same day, she would burst into tears and sit in her room, blanket over head, turning over the possibilities for a painless but sure death. She didn’t have much time to think on it because soon it would be time to line up for medicine.

Next … it’s time for her office hours, to reassure other patients, to pretend she is a doctor. But soon enough … the shrink beckons her for the daily session, and she is reminded of his infinite wisdom and her relative ignorance. She nods and agrees with some of what he says, believes it even when she is talking to him in his little room, but not later, when she is back in bed, nighttime, waiting for nightmares. The psychiatrist says that her frantic sleepless days before Christmas, the ones where her friends couldn’t understand why she couldn’t even sit down for lunch (“You’re going to have a stroke!” a less tactful one declared), the ones where she feigned listening to someone talking while in her head she entertained a disorganized, discordant symphony of thoughts trying to hammer out a requiem, a death march … those days were a “mixed state.” Mumbo jumbo. Nonsense. She tells herself she is just moody. At least now there are moments of heady delicious delight, no matter if they are brief.

So the doctor is improving! And she has reason to doubt their boxes and their labels, as she reads on this illness in rare moments when her mind is still, and she finds there is controversy surrounding every diagnosis and delineation. And so that is fuel for her disapproving, disbelieving fire. All of this is just an expression of eccentricity, she tells herself, and these lousy doctors don’t appreciate someone “as brilliant and beautiful as me.” But later, watching the nurses as they fill out their assessments of the day, she wonders how sick they think she really is, and she hates herself and this lunatic frenzy and she is embarrassed and ashamed.

If she does not believe she is sick, then she has to blame herself, and that hurts. But she can handle that pain and that bleeding, for she alone can suffer pain and bleeding like no others, and that is part of what makes her beautiful. But she is not sick …. According to them, the doctor is sick every day and so she stays in the hospital. She retorts, “Of course that is what they say. Isn’t that their job, to call me crazy?” And then, “If I was not crazy, wouldn’t that put them out of business?”

Nightmares have tormented the doctor since she was a child. But lately they are more twisted. They pull her out of the safety of the day such that she plunges, screaming, down, head-first, into black night, afraid. Some of her medicines exacerbate nightmares. In one awful dream, she is a patient, then a doctor, then a patient again, and she keeps waking up inside the dream to be transformed into doctor or patient, one then the other; it never stops. So first she is giving medicines, then she is being intubated, then she is finishing rounds, then she is enduring electroconvulsive therapy. Finally she drops out of the dream as if from the sky, and she is shivering and afraid.

Now, as she dozes, she awakens to every noise, and the shadows look like people, and she knows the nightmares wait for her again, so she fights sleep. Paxil made her hear voices (the psychiatrists proclaimed this “classic” for her illness; she shrugged her shoulders in response) and so now she listens carefully, holding her breath, in bed, trying to hear voices. She thought she heard something. Of course, now she is hypersensitive. Now it is hard not to describe everything as “classic” for the illness. If she thinks about it, from junior high school onwards she was “classic.” What nonsense! Her vision is 20/20 in hindsight. Who wouldn’t find madness in their past if they looked hard enough?

The doctor is sick. The night lasts forever. Somebody opens the door because, at this hospital, they check every 15 minutes, 24 hours per day, to make sure the doctor has not slit her wrists or hanged herself or found another way to end her sick life. For this reason, they have confiscated her shoelaces, and she has to floss at the nurses’ station. She startles as they open the door, and screams out loud. They reassure her they are just checking on her, and now they are gone, and the doctor is left to imagine them walking down the corridor to the nurses’ station, shaking their heads, saying, “That doctor sure is sick!”.

Yes, the doctor is sick. Who is she anyway? She is not even a doctor! She is just a third-year medical student who is fighting, fists up, her descent into madness. Has she won? She is trying to find a way to accept what she is. Does that mean she is a winner or a loser? It is chronic, but manageable, bipolar madness. There are lots of other people like her. But it is still overwhelming, and she is not even sure she wants to join anybody else. She never defined herself as part of any group before. Now she tries to get back to normal—but what can that mean now, after all this time, after release from a mental hospital, after taking a leave from school, after swallowing 10 pills a day (every day, for the rest of her life?), after finding out she is so sick? It is time for her meds. She hasn’t told most of her classmates or her parents because she doesn’t want them to find out that the doctor is sick. She doesn’t want to know if the doctor is sick. She doesn’t want to ponder if the doctor can ever get well.

The doctor misses seeing her patients. Tears are in her eyes and she swallows her sadness as best as she can. She aims to keep a brave face, but she is sad for what she has lost. She tries to shake that off, but it keeps returning. Like a virus, it sneaks up on her and she is shivering, feverish with grief. She hears stories from her friends as they continue to round, heal, cut and sew, take histories, stay up all night, get yelled at by senior physicians, and she wants so much to be there. She is in nowhere land. To some, a few, those who know the twisted tale of the last few months, she is sick. To those who know nothing of it, she is her usual slightly eccentric self, but well. But really she knows she is a liar and a fraud. Because somewhere in the middle she exists alone.

Well, no, she is not alone. Her husband stands by her and he is wonderful. He holds her and laughs with her and tells her she is beautiful and amazing. But she misses seeing lots of people; she thrives on people. Doesn’t anyone understand that she needs people to be alive? Is that so wrong? Is that so sick? She feels sorry for herself, sorry for what she must give up, sorry that she must graduate a year later, sorry that she cannot be with people, sorry that she feels so sorry so much of the time. And then she gets angry with herself for feeling so sorry and being so sick.

Every now and then, the doctor sees another side of things. She surfs the Internet and reads books and she finds out about lots of smart and creative and beautiful people who were sick like she is. These people have twisted, wonderful abilities but so many of them plunged to their death or swallowed pills or died so young. They wrote books or composed symphonies or made people laugh or created works of art but then they died. And so she is left feeling strong and beautiful sometimes, but also lonely and sad that all those souls have deserted her. She is sad that they have left her in this madness, and she must fight to stay alive all by herself. Then, every now and then, there are flickers of wisdom and insight and she knows she will stay alive and she will create beautiful things too, one day.

The doctor is sick. Getting sick stinks. She admits, “Nobody, especially not me, counted on the doctor getting sick. Please! Enough!”

She concedes: “I won’t forget this. I promise. OK, I have learned my lesson now. Please, enough of this!”

She pleads: “I need the doctor to get well. I am afraid of being the doctor that is sick, so afraid.”

She ponders: “Does this mean I will never be free? Does this mean I will never be well? Does this mean I will never be a mother? Oh, God, does this mean I will never be a doctor?”

Then there is silence because she asks these questions of herself, and she has no answers, and no office hours today.

Somebody better call a doctor.

Acknowledgment
The author is grateful for the support of her medical school and residency program during training.

The doctor is sick.

Her feet are swollen, as if her heart is failing. But it is strong and beating faster than usual, as she runs her fingers through her hair. Her vision gets blurry sometimes, and she has to hold onto something when she stands up or she will fall down. The doctor is sick because she is taking medicine to make her well. Lithium, Seroquel, Depakote. Mood stabilizer, antipsychotic, mood stabilizer. Two pills, 4 pills, 3 pills. Plus a multivitamin because Depakote can cause her hair to fall out. Skinny and fat bottles, next to her bed so she won’t forget. As if she would forget.

The doctor is sick because 3 weeks ago tomorrow she made a concrete plan to take her life. She wrote 5 letters, the longest to her sweet and supportive husband. She put some pills and some alcohol and the letters in her backpack and made it to the front stoop before she sat down, her heart breaking, and called her best friend.

The doctor is sick. Sicker now that she is home. As a patient in the psychiatric hospital, she was the doctor, and she held “office hours” (24 hours a day) to answer questions about GERD, schizophrenia, and stomachaches. This made her feel a lot less sick. Everyone said she was clever. She is only a medical student and offers a disclaimer with her advice (along with the suggestion to see a “real doctor”). But to most of the patients she is a doctor. And she feels the calling to be a doctor. Deep down inside herself she feels she was born to be a doctor.

In the psychiatric hospital, she felt alive when she gave advice. It made her feel she was helping people. She lives for people. And it distinguished her from the rest of them. They were her friends and she shared illness with them, but somehow she was different. Sometimes, this gave her comfort. Other times she held onto them as anchors in the madness they were swimming through together. Those times she found comfort in being the same as them. Exactly the same.

The doctor is sick. On the discharge sheet, 18 days after admission, her acceptance of this fact (“judgment and insight”) was judged “fair.” This is because the doctor does not believe in her diagnosis. She does not want to be sick. She wants to be the person she was before—minus those highs and lows. She would trade in the agitated anxious state that caused her to drop out of her pediatric rotation. She would trade in the days spent in bed in college, while everyone seemed to be having fun. She would trade in the Google searches of “suicide methods.” She would trade in the panic that caused her to stop her rotation, and therefore caused her to stop playing with the pediatric patients in the playroom at night, after her clinical duties were finished. In the playroom she was not a doctor or a medical student. She was just someone’s playmate. She held the little hand of her little patient and she felt like she was exactly where she was supposed to be. She knew she belonged when she helped her patients forget they were sick.

The doctor is sick. She is drinking hard lemonade, even though it makes the dizziness worse. The doctor has a swollen face and swollen fingers and her wedding ring does not fit anymore. She has gained 10, no, 15 lb because of the medicine, and she knows her husband has noticed. The doctor knows that she has enough pills beside her bed to end her life, but she also knows she is calm now. She is calm in a way she has not felt for as long as she can remember. She thinks back on college, on that 2-month period when she slept until 2 PM, and got out of bed only to smoke marijuana and change the CD on her stereo. She thinks back on the way she pulled the blanket over her head and she remembers that she wanted to be dead.

The doctor remembers writing her treatises later that year on the meaning of life, of the world, of peace and joy and love, on her desktop computer. She wrote and wrote and wrote, as she often did, and sleep did not seem very necessary or desired. She felt she was more connected to the world than anyone else on the planet. She felt more intensely than anyone else on the planet. She ran 5 miles a day, 15 miles on Saturdays. Tears streamed down her face as she bicycled back from her volunteer work with the elderly. She felt so much love and she felt so different from everyone else. Tears came again when she read literature; she felt alive with politics and meaning and urgency. Her heart pounded and she felt words run through her mind that told her to keep working, harder, and that she was capable of more efficient, more emotive, more effective, more productive work than anyone else on the planet. She had more insight than anyone else on the planet. But all of this was directed to help other people, and so she was connected to the whole world.

The doctor feels sick now as she recalls those events. Now she fears her past is part of this illness. Those thoughts and actions that were her proudest moments, the organizations that offered her awards and accolades, the papers that got high marks—those were just the consequence of neurotransmitters being sucked in and spat out in the wrong ratios. It is that simple. Something we can fix with around 10 pills a day, pills that will make the doctor better but will make the doctor sick. What about the doctor’s sense of humor? What about her energy? What about her wild dancing and her disinhibition? What about her ability to be the life of a party even when she is stone cold sober and everyone else has had 4 or 5 drinks? What about her accomplishments and her intensity? What about her ever-present belief that the world’s people are all connected, and she is to play a small but important, even vital, role in bringing them together? Sick, sick, all sick.

As a patient in the psychiatric hospital, the doctor would dance sometimes. She would be dancing, twirling, laughing, making others laugh. Then, on the same day, she would burst into tears and sit in her room, blanket over head, turning over the possibilities for a painless but sure death. She didn’t have much time to think on it because soon it would be time to line up for medicine.

Next … it’s time for her office hours, to reassure other patients, to pretend she is a doctor. But soon enough … the shrink beckons her for the daily session, and she is reminded of his infinite wisdom and her relative ignorance. She nods and agrees with some of what he says, believes it even when she is talking to him in his little room, but not later, when she is back in bed, nighttime, waiting for nightmares. The psychiatrist says that her frantic sleepless days before Christmas, the ones where her friends couldn’t understand why she couldn’t even sit down for lunch (“You’re going to have a stroke!” a less tactful one declared), the ones where she feigned listening to someone talking while in her head she entertained a disorganized, discordant symphony of thoughts trying to hammer out a requiem, a death march … those days were a “mixed state.” Mumbo jumbo. Nonsense. She tells herself she is just moody. At least now there are moments of heady delicious delight, no matter if they are brief.

So the doctor is improving! And she has reason to doubt their boxes and their labels, as she reads on this illness in rare moments when her mind is still, and she finds there is controversy surrounding every diagnosis and delineation. And so that is fuel for her disapproving, disbelieving fire. All of this is just an expression of eccentricity, she tells herself, and these lousy doctors don’t appreciate someone “as brilliant and beautiful as me.” But later, watching the nurses as they fill out their assessments of the day, she wonders how sick they think she really is, and she hates herself and this lunatic frenzy and she is embarrassed and ashamed.

If she does not believe she is sick, then she has to blame herself, and that hurts. But she can handle that pain and that bleeding, for she alone can suffer pain and bleeding like no others, and that is part of what makes her beautiful. But she is not sick …. According to them, the doctor is sick every day and so she stays in the hospital. She retorts, “Of course that is what they say. Isn’t that their job, to call me crazy?” And then, “If I was not crazy, wouldn’t that put them out of business?”

Nightmares have tormented the doctor since she was a child. But lately they are more twisted. They pull her out of the safety of the day such that she plunges, screaming, down, head-first, into black night, afraid. Some of her medicines exacerbate nightmares. In one awful dream, she is a patient, then a doctor, then a patient again, and she keeps waking up inside the dream to be transformed into doctor or patient, one then the other; it never stops. So first she is giving medicines, then she is being intubated, then she is finishing rounds, then she is enduring electroconvulsive therapy. Finally she drops out of the dream as if from the sky, and she is shivering and afraid.

Now, as she dozes, she awakens to every noise, and the shadows look like people, and she knows the nightmares wait for her again, so she fights sleep. Paxil made her hear voices (the psychiatrists proclaimed this “classic” for her illness; she shrugged her shoulders in response) and so now she listens carefully, holding her breath, in bed, trying to hear voices. She thought she heard something. Of course, now she is hypersensitive. Now it is hard not to describe everything as “classic” for the illness. If she thinks about it, from junior high school onwards she was “classic.” What nonsense! Her vision is 20/20 in hindsight. Who wouldn’t find madness in their past if they looked hard enough?

The doctor is sick. The night lasts forever. Somebody opens the door because, at this hospital, they check every 15 minutes, 24 hours per day, to make sure the doctor has not slit her wrists or hanged herself or found another way to end her sick life. For this reason, they have confiscated her shoelaces, and she has to floss at the nurses’ station. She startles as they open the door, and screams out loud. They reassure her they are just checking on her, and now they are gone, and the doctor is left to imagine them walking down the corridor to the nurses’ station, shaking their heads, saying, “That doctor sure is sick!”.

Yes, the doctor is sick. Who is she anyway? She is not even a doctor! She is just a third-year medical student who is fighting, fists up, her descent into madness. Has she won? She is trying to find a way to accept what she is. Does that mean she is a winner or a loser? It is chronic, but manageable, bipolar madness. There are lots of other people like her. But it is still overwhelming, and she is not even sure she wants to join anybody else. She never defined herself as part of any group before. Now she tries to get back to normal—but what can that mean now, after all this time, after release from a mental hospital, after taking a leave from school, after swallowing 10 pills a day (every day, for the rest of her life?), after finding out she is so sick? It is time for her meds. She hasn’t told most of her classmates or her parents because she doesn’t want them to find out that the doctor is sick. She doesn’t want to know if the doctor is sick. She doesn’t want to ponder if the doctor can ever get well.

The doctor misses seeing her patients. Tears are in her eyes and she swallows her sadness as best as she can. She aims to keep a brave face, but she is sad for what she has lost. She tries to shake that off, but it keeps returning. Like a virus, it sneaks up on her and she is shivering, feverish with grief. She hears stories from her friends as they continue to round, heal, cut and sew, take histories, stay up all night, get yelled at by senior physicians, and she wants so much to be there. She is in nowhere land. To some, a few, those who know the twisted tale of the last few months, she is sick. To those who know nothing of it, she is her usual slightly eccentric self, but well. But really she knows she is a liar and a fraud. Because somewhere in the middle she exists alone.

Well, no, she is not alone. Her husband stands by her and he is wonderful. He holds her and laughs with her and tells her she is beautiful and amazing. But she misses seeing lots of people; she thrives on people. Doesn’t anyone understand that she needs people to be alive? Is that so wrong? Is that so sick? She feels sorry for herself, sorry for what she must give up, sorry that she must graduate a year later, sorry that she cannot be with people, sorry that she feels so sorry so much of the time. And then she gets angry with herself for feeling so sorry and being so sick.

Every now and then, the doctor sees another side of things. She surfs the Internet and reads books and she finds out about lots of smart and creative and beautiful people who were sick like she is. These people have twisted, wonderful abilities but so many of them plunged to their death or swallowed pills or died so young. They wrote books or composed symphonies or made people laugh or created works of art but then they died. And so she is left feeling strong and beautiful sometimes, but also lonely and sad that all those souls have deserted her. She is sad that they have left her in this madness, and she must fight to stay alive all by herself. Then, every now and then, there are flickers of wisdom and insight and she knows she will stay alive and she will create beautiful things too, one day.

The doctor is sick. Getting sick stinks. She admits, “Nobody, especially not me, counted on the doctor getting sick. Please! Enough!”

She concedes: “I won’t forget this. I promise. OK, I have learned my lesson now. Please, enough of this!”

She pleads: “I need the doctor to get well. I am afraid of being the doctor that is sick, so afraid.”

She ponders: “Does this mean I will never be free? Does this mean I will never be well? Does this mean I will never be a mother? Oh, God, does this mean I will never be a doctor?”

Then there is silence because she asks these questions of herself, and she has no answers, and no office hours today.

Somebody better call a doctor.

Acknowledgment
The author is grateful for the support of her medical school and residency program during training.

The doctor is sick.

Her feet are swollen, as if her heart is failing. But it is strong and beating faster than usual, as she runs her fingers through her hair. Her vision gets blurry sometimes, and she has to hold onto something when she stands up or she will fall down. The doctor is sick because she is taking medicine to make her well. Lithium, Seroquel, Depakote. Mood stabilizer, antipsychotic, mood stabilizer. Two pills, 4 pills, 3 pills. Plus a multivitamin because Depakote can cause her hair to fall out. Skinny and fat bottles, next to her bed so she won’t forget. As if she would forget.

The doctor is sick because 3 weeks ago tomorrow she made a concrete plan to take her life. She wrote 5 letters, the longest to her sweet and supportive husband. She put some pills and some alcohol and the letters in her backpack and made it to the front stoop before she sat down, her heart breaking, and called her best friend.

The doctor is sick. Sicker now that she is home. As a patient in the psychiatric hospital, she was the doctor, and she held “office hours” (24 hours a day) to answer questions about GERD, schizophrenia, and stomachaches. This made her feel a lot less sick. Everyone said she was clever. She is only a medical student and offers a disclaimer with her advice (along with the suggestion to see a “real doctor”). But to most of the patients she is a doctor. And she feels the calling to be a doctor. Deep down inside herself she feels she was born to be a doctor.

In the psychiatric hospital, she felt alive when she gave advice. It made her feel she was helping people. She lives for people. And it distinguished her from the rest of them. They were her friends and she shared illness with them, but somehow she was different. Sometimes, this gave her comfort. Other times she held onto them as anchors in the madness they were swimming through together. Those times she found comfort in being the same as them. Exactly the same.

The doctor is sick. On the discharge sheet, 18 days after admission, her acceptance of this fact (“judgment and insight”) was judged “fair.” This is because the doctor does not believe in her diagnosis. She does not want to be sick. She wants to be the person she was before—minus those highs and lows. She would trade in the agitated anxious state that caused her to drop out of her pediatric rotation. She would trade in the days spent in bed in college, while everyone seemed to be having fun. She would trade in the Google searches of “suicide methods.” She would trade in the panic that caused her to stop her rotation, and therefore caused her to stop playing with the pediatric patients in the playroom at night, after her clinical duties were finished. In the playroom she was not a doctor or a medical student. She was just someone’s playmate. She held the little hand of her little patient and she felt like she was exactly where she was supposed to be. She knew she belonged when she helped her patients forget they were sick.

The doctor is sick. She is drinking hard lemonade, even though it makes the dizziness worse. The doctor has a swollen face and swollen fingers and her wedding ring does not fit anymore. She has gained 10, no, 15 lb because of the medicine, and she knows her husband has noticed. The doctor knows that she has enough pills beside her bed to end her life, but she also knows she is calm now. She is calm in a way she has not felt for as long as she can remember. She thinks back on college, on that 2-month period when she slept until 2 PM, and got out of bed only to smoke marijuana and change the CD on her stereo. She thinks back on the way she pulled the blanket over her head and she remembers that she wanted to be dead.

The doctor remembers writing her treatises later that year on the meaning of life, of the world, of peace and joy and love, on her desktop computer. She wrote and wrote and wrote, as she often did, and sleep did not seem very necessary or desired. She felt she was more connected to the world than anyone else on the planet. She felt more intensely than anyone else on the planet. She ran 5 miles a day, 15 miles on Saturdays. Tears streamed down her face as she bicycled back from her volunteer work with the elderly. She felt so much love and she felt so different from everyone else. Tears came again when she read literature; she felt alive with politics and meaning and urgency. Her heart pounded and she felt words run through her mind that told her to keep working, harder, and that she was capable of more efficient, more emotive, more effective, more productive work than anyone else on the planet. She had more insight than anyone else on the planet. But all of this was directed to help other people, and so she was connected to the whole world.

The doctor feels sick now as she recalls those events. Now she fears her past is part of this illness. Those thoughts and actions that were her proudest moments, the organizations that offered her awards and accolades, the papers that got high marks—those were just the consequence of neurotransmitters being sucked in and spat out in the wrong ratios. It is that simple. Something we can fix with around 10 pills a day, pills that will make the doctor better but will make the doctor sick. What about the doctor’s sense of humor? What about her energy? What about her wild dancing and her disinhibition? What about her ability to be the life of a party even when she is stone cold sober and everyone else has had 4 or 5 drinks? What about her accomplishments and her intensity? What about her ever-present belief that the world’s people are all connected, and she is to play a small but important, even vital, role in bringing them together? Sick, sick, all sick.

As a patient in the psychiatric hospital, the doctor would dance sometimes. She would be dancing, twirling, laughing, making others laugh. Then, on the same day, she would burst into tears and sit in her room, blanket over head, turning over the possibilities for a painless but sure death. She didn’t have much time to think on it because soon it would be time to line up for medicine.

Next … it’s time for her office hours, to reassure other patients, to pretend she is a doctor. But soon enough … the shrink beckons her for the daily session, and she is reminded of his infinite wisdom and her relative ignorance. She nods and agrees with some of what he says, believes it even when she is talking to him in his little room, but not later, when she is back in bed, nighttime, waiting for nightmares. The psychiatrist says that her frantic sleepless days before Christmas, the ones where her friends couldn’t understand why she couldn’t even sit down for lunch (“You’re going to have a stroke!” a less tactful one declared), the ones where she feigned listening to someone talking while in her head she entertained a disorganized, discordant symphony of thoughts trying to hammer out a requiem, a death march … those days were a “mixed state.” Mumbo jumbo. Nonsense. She tells herself she is just moody. At least now there are moments of heady delicious delight, no matter if they are brief.

So the doctor is improving! And she has reason to doubt their boxes and their labels, as she reads on this illness in rare moments when her mind is still, and she finds there is controversy surrounding every diagnosis and delineation. And so that is fuel for her disapproving, disbelieving fire. All of this is just an expression of eccentricity, she tells herself, and these lousy doctors don’t appreciate someone “as brilliant and beautiful as me.” But later, watching the nurses as they fill out their assessments of the day, she wonders how sick they think she really is, and she hates herself and this lunatic frenzy and she is embarrassed and ashamed.

If she does not believe she is sick, then she has to blame herself, and that hurts. But she can handle that pain and that bleeding, for she alone can suffer pain and bleeding like no others, and that is part of what makes her beautiful. But she is not sick …. According to them, the doctor is sick every day and so she stays in the hospital. She retorts, “Of course that is what they say. Isn’t that their job, to call me crazy?” And then, “If I was not crazy, wouldn’t that put them out of business?”

Nightmares have tormented the doctor since she was a child. But lately they are more twisted. They pull her out of the safety of the day such that she plunges, screaming, down, head-first, into black night, afraid. Some of her medicines exacerbate nightmares. In one awful dream, she is a patient, then a doctor, then a patient again, and she keeps waking up inside the dream to be transformed into doctor or patient, one then the other; it never stops. So first she is giving medicines, then she is being intubated, then she is finishing rounds, then she is enduring electroconvulsive therapy. Finally she drops out of the dream as if from the sky, and she is shivering and afraid.

Now, as she dozes, she awakens to every noise, and the shadows look like people, and she knows the nightmares wait for her again, so she fights sleep. Paxil made her hear voices (the psychiatrists proclaimed this “classic” for her illness; she shrugged her shoulders in response) and so now she listens carefully, holding her breath, in bed, trying to hear voices. She thought she heard something. Of course, now she is hypersensitive. Now it is hard not to describe everything as “classic” for the illness. If she thinks about it, from junior high school onwards she was “classic.” What nonsense! Her vision is 20/20 in hindsight. Who wouldn’t find madness in their past if they looked hard enough?

The doctor is sick. The night lasts forever. Somebody opens the door because, at this hospital, they check every 15 minutes, 24 hours per day, to make sure the doctor has not slit her wrists or hanged herself or found another way to end her sick life. For this reason, they have confiscated her shoelaces, and she has to floss at the nurses’ station. She startles as they open the door, and screams out loud. They reassure her they are just checking on her, and now they are gone, and the doctor is left to imagine them walking down the corridor to the nurses’ station, shaking their heads, saying, “That doctor sure is sick!”.

Yes, the doctor is sick. Who is she anyway? She is not even a doctor! She is just a third-year medical student who is fighting, fists up, her descent into madness. Has she won? She is trying to find a way to accept what she is. Does that mean she is a winner or a loser? It is chronic, but manageable, bipolar madness. There are lots of other people like her. But it is still overwhelming, and she is not even sure she wants to join anybody else. She never defined herself as part of any group before. Now she tries to get back to normal—but what can that mean now, after all this time, after release from a mental hospital, after taking a leave from school, after swallowing 10 pills a day (every day, for the rest of her life?), after finding out she is so sick? It is time for her meds. She hasn’t told most of her classmates or her parents because she doesn’t want them to find out that the doctor is sick. She doesn’t want to know if the doctor is sick. She doesn’t want to ponder if the doctor can ever get well.

The doctor misses seeing her patients. Tears are in her eyes and she swallows her sadness as best as she can. She aims to keep a brave face, but she is sad for what she has lost. She tries to shake that off, but it keeps returning. Like a virus, it sneaks up on her and she is shivering, feverish with grief. She hears stories from her friends as they continue to round, heal, cut and sew, take histories, stay up all night, get yelled at by senior physicians, and she wants so much to be there. She is in nowhere land. To some, a few, those who know the twisted tale of the last few months, she is sick. To those who know nothing of it, she is her usual slightly eccentric self, but well. But really she knows she is a liar and a fraud. Because somewhere in the middle she exists alone.

Well, no, she is not alone. Her husband stands by her and he is wonderful. He holds her and laughs with her and tells her she is beautiful and amazing. But she misses seeing lots of people; she thrives on people. Doesn’t anyone understand that she needs people to be alive? Is that so wrong? Is that so sick? She feels sorry for herself, sorry for what she must give up, sorry that she must graduate a year later, sorry that she cannot be with people, sorry that she feels so sorry so much of the time. And then she gets angry with herself for feeling so sorry and being so sick.

Every now and then, the doctor sees another side of things. She surfs the Internet and reads books and she finds out about lots of smart and creative and beautiful people who were sick like she is. These people have twisted, wonderful abilities but so many of them plunged to their death or swallowed pills or died so young. They wrote books or composed symphonies or made people laugh or created works of art but then they died. And so she is left feeling strong and beautiful sometimes, but also lonely and sad that all those souls have deserted her. She is sad that they have left her in this madness, and she must fight to stay alive all by herself. Then, every now and then, there are flickers of wisdom and insight and she knows she will stay alive and she will create beautiful things too, one day.

The doctor is sick. Getting sick stinks. She admits, “Nobody, especially not me, counted on the doctor getting sick. Please! Enough!”

She concedes: “I won’t forget this. I promise. OK, I have learned my lesson now. Please, enough of this!”

She pleads: “I need the doctor to get well. I am afraid of being the doctor that is sick, so afraid.”

She ponders: “Does this mean I will never be free? Does this mean I will never be well? Does this mean I will never be a mother? Oh, God, does this mean I will never be a doctor?”

Then there is silence because she asks these questions of herself, and she has no answers, and no office hours today.

Somebody better call a doctor.

Acknowledgment
The author is grateful for the support of her medical school and residency program during training.

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.

Since JFP’s launch of the PURL department in November of 2007, 122 PURLs—Priority Updates from the Research Literature—have been published. The Journal of Family Practice is the exclusive publication venue for these items. Because they have stood the test of time and are one of the more popular columns in JFP, I thought it would be worthwhile to describe the rigorous evaluation they undergo before they are published.

Many studies, but few PURLs. Each year, approximately 200,000 new human medical research studies are indexed on PubMed. Very few of these studies are pertinent to family medicine, however, and even fewer provide new patient-oriented evidence for primary care clinicians.

In 2005, the leaders of the Family Physician Inquiries Network (FPIN), which produces another popular JFP column, Clinical Inquiries, set about identifying high-priority research findings relevant to family medicine. A group of family physicians and librarians began combing the research literature monthly to find those rare randomized trials or high-quality observational studies that pertained to our specialty. To qualify as a PURL, a study had to meet 6 criteria. It had to be scientifically valid, relevant to family medicine, applicable in a medical care setting, immediately implementable, clinically meaningful, and practice changing. These criteria still stand today.

Making the cut. When a study is identified as a potential PURL, it is submitted to one of FPIN’s PURL review groups for a critical appraisal and rigorous peer review. If the group cannot convince the PURLs editors that the original research meets all 6 criteria, the study falls by the wayside. Most potential PURLs do not make the cut. I was one of the early PURL “divers,” and I was amazed at how few PURLs existed. Given the emphasis of research on subspecialties and the dearth of primary care research funding in the United States, I probably shouldn’t have been surprised.

Interested in research that is clinically meaningful and practice changing for family physicians? Then check out our PURLs column.

Holding their value. I reviewed all 122 PURLs this week and am proud to say that nearly all still provide highly pertinent, practice-changing information for family physicians and other primary care clinicians. For a quick review of our string of PURLs, go to www.jfponline.com, select “Articles” in the banner, and then “PURLs,” and read the short practice changer box for each one. I guarantee it will be time well spent!

If you would like to become part of the PURLs process, either by nominating or reviewing a PURL, please contact the PURLs Project Manager at purls@fpin.org.

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

A few weeks ago, Marilyn and I were left in charge of two of our grandchildren, 8 and 10 years old. The morning was overcast and drizzly, eliminating their first choice of going to the college athletic fields to practice their lacrosse skills. A game of Monopoly seemed like a good idea until it became obvious that someone was going to win and that another someone who doesn’t handle defeat very well was going to lose. So off we went to the bowling alley. As we pulled into the sparsely occupied parking lot, the ever-observant 8-year-old noted that almost all of the vehicles were vans.

As we checked in to rent our shoes, the explanation for the vans became clear. It turns out that on Thursday mornings, the bowling alley is the place to be if you are an adult with a mental disability in Brunswick, Maine.

Our grandchildren had a wonderful hour of bowling surrounded by the cacophony created by the several dozen adults with whom we were sharing the lanes. As my wife and I revisited our morning adventure that evening, we recalled how comfortable our grandchildren had been in the midst of a scenario that had the chaotic feel of a Hieronymus Bosch painting.

The explanation for their lack of discomfort lies in the fact that they have grown up in a time and in a town in which the individuals with chromosomal anomalies and birth injury are accepted and cared for in the community and not hidden away in an institution. Our grandchildren’s parents were born as this sea change was just beginning. In fact, when my son was born, I was moonlighting as the night emergency physician at an institution that housed a few hundred of these individuals, many of whom had disabilities similar to those of the folks with whom we had shared the bowling alley. It closed a few years later. And, by the time my son and his sisters entered middle school, they had become accustomed to having classmates with mental disabilities.

The next step in the evolution came when the children who had been “mainstreamed” grew too old for high school and began transitioning to the handful of small group homes that sprang up around the community. It was not always a smooth process and would not have happened without tireless pressure from their parents. Even today, funding and staffing problems continue. Despite initial concerns that some neighborhoods might resist the introduction of a group home, acceptance has not been a problem.

It has almost been a win-win situation. Our citizens with mental disabilities have a far richer life than they would have had in even the most progressive institution. And the rest of us have benefited by learning tolerance from having our challenged family members close by.

However, the transition from institutionalization to community-based support has not been without its downside, particularly for a small town like Brunswick, Maine. Federal and state mandates now place on the shoulders of the school a significant financial burden for the special services required by children with mental disabilities. Small communities with only a few students with disabilities can’t benefit from the economies of scale that allow larger school systems to staff their programs more efficiently and provide more specialized services. Smaller school districts can sometimes pool their resources. But if this solution necessitates transporting the students with mental disabilities out of their own school district to a central location, it runs the risk of robbing the other students, like my grandchildren, of an enriching experience that I wouldn’t want to see them lose.

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.”

Wait, I know what you’re thinking, boring, dry, and don’t scold me. I am not going to do any of that today, and instead am going to tell you how to easily improve patient care, save money, and improve staff morale.

The easiest things to do to improve safety in the office include better communications, infection control, correct patient/site identification, dealing with emergencies, and staff safety.

Staff communication is often surprisingly poor, and physicians often assume staff can read our minds (and if they have worked for you for many years, maybe they can!). Always make sure staff – and patients – repeat back complicated instructions (better to start by making them less complicated). Never assume your patients are literate, 14% of adults cannot read, so make sure your staff goes over printed materials with the patients.

Something easy you can do is eliminate abbreviations from your prescription pad and your medical record.

Failure to follow up on path reports and lost biopsies is a frequent cause for lawsuits. You need to make sure you have a redundant system for tracking and reporting pathology results. In addition to the old reliable pathology log book, you need a sequential system ensuring that the specimen made it to the lab, that the result was generated and received, that the patient was notified, and that further action was taken if needed. If this is integrated into your electronic medical record, so much the better, but you still need a paper backup log book, “just in case.”

We all take basic infection precautions when performing procedures, including alcohol hand gel, eye protection, gloves, mask, and cleaning of surgical sites prior to excision. When there are wound infections, which should be rare, you should always culture, and if there is a cluster of infections, particularly with methicillin-resistant staphylococcus aureus (MRSA), you should consider culturing the anterior nares of the staff. Alternatively, you can preemptively treat the staff with intranasal topical mupirocin daily for 2 weeks.

Measuring the use of alcohol gel before and after staff education is an easy and beneficial quality improvement project. You and your staff are, of course, vaccinated for hepatitis B, and yearly for influenza, and you should consider PPD testing every 2 years for everyone. My asymptomatic receptionist converted, and needed prophylactic tuberculosis treatment and contact tracing.

Wrong-site surgery is a frequent problem for dermatologists. Many of our biopsies are tangential, heal almost invisibly, without marking sutures, and patients have battle-scarred skin, and are elderly. The patients may have trouble remembering or seeing where the biopsy was, so good charts and family members are helpful. Photographs of the biopsy sites can be priceless. If the site still cannot be identified, then rebiopsy, or close follow-up is indicated.

Emergencies are rare, but it is prudent to have an automatic external defibrillator in the office. These are automated, so Advanced Cardiovascular Life Support (ACLS), or even basic CPR is not required to operate them, and the survival rate after cardiac arrest increases from 2% to 50%. When it has to be replaced after 5 years, take the old one home and teach your spouse how to use it, and maybe they will.

If you do a lot of surgery you may want to get the ACLS training and buy the crash cart drug kit, but many of the drugs have become ferociously expensive, despite being generic.

Staff safety is a crucial consideration and showing concern boosts staff morale. You should dispose of sharps directly into a sharps container and remove the sharps from the tray at the end of the case. You should have a written protocol for needle sticks. I keep the red top tubes, and the first 2 days of HIV medication on site. Sometimes a patient is HIV positive, the sharp exposure is unknown (a cryostat tissue tease for example), or the patient refuses to have their blood drawn. Less obvious, but important to staff, are locks on doors, alarm systems, good parking lot lighting, and security cameras.

Office safety may seem mundane but a few simple measures can save you a fortune, boost employee morale, and most important of all, improve patient care.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Wait, I know what you’re thinking, boring, dry, and don’t scold me. I am not going to do any of that today, and instead am going to tell you how to easily improve patient care, save money, and improve staff morale.

The easiest things to do to improve safety in the office include better communications, infection control, correct patient/site identification, dealing with emergencies, and staff safety.

Staff communication is often surprisingly poor, and physicians often assume staff can read our minds (and if they have worked for you for many years, maybe they can!). Always make sure staff – and patients – repeat back complicated instructions (better to start by making them less complicated). Never assume your patients are literate, 14% of adults cannot read, so make sure your staff goes over printed materials with the patients.

Something easy you can do is eliminate abbreviations from your prescription pad and your medical record.

Failure to follow up on path reports and lost biopsies is a frequent cause for lawsuits. You need to make sure you have a redundant system for tracking and reporting pathology results. In addition to the old reliable pathology log book, you need a sequential system ensuring that the specimen made it to the lab, that the result was generated and received, that the patient was notified, and that further action was taken if needed. If this is integrated into your electronic medical record, so much the better, but you still need a paper backup log book, “just in case.”

We all take basic infection precautions when performing procedures, including alcohol hand gel, eye protection, gloves, mask, and cleaning of surgical sites prior to excision. When there are wound infections, which should be rare, you should always culture, and if there is a cluster of infections, particularly with methicillin-resistant staphylococcus aureus (MRSA), you should consider culturing the anterior nares of the staff. Alternatively, you can preemptively treat the staff with intranasal topical mupirocin daily for 2 weeks.

Measuring the use of alcohol gel before and after staff education is an easy and beneficial quality improvement project. You and your staff are, of course, vaccinated for hepatitis B, and yearly for influenza, and you should consider PPD testing every 2 years for everyone. My asymptomatic receptionist converted, and needed prophylactic tuberculosis treatment and contact tracing.

Wrong-site surgery is a frequent problem for dermatologists. Many of our biopsies are tangential, heal almost invisibly, without marking sutures, and patients have battle-scarred skin, and are elderly. The patients may have trouble remembering or seeing where the biopsy was, so good charts and family members are helpful. Photographs of the biopsy sites can be priceless. If the site still cannot be identified, then rebiopsy, or close follow-up is indicated.

Emergencies are rare, but it is prudent to have an automatic external defibrillator in the office. These are automated, so Advanced Cardiovascular Life Support (ACLS), or even basic CPR is not required to operate them, and the survival rate after cardiac arrest increases from 2% to 50%. When it has to be replaced after 5 years, take the old one home and teach your spouse how to use it, and maybe they will.

If you do a lot of surgery you may want to get the ACLS training and buy the crash cart drug kit, but many of the drugs have become ferociously expensive, despite being generic.

Staff safety is a crucial consideration and showing concern boosts staff morale. You should dispose of sharps directly into a sharps container and remove the sharps from the tray at the end of the case. You should have a written protocol for needle sticks. I keep the red top tubes, and the first 2 days of HIV medication on site. Sometimes a patient is HIV positive, the sharp exposure is unknown (a cryostat tissue tease for example), or the patient refuses to have their blood drawn. Less obvious, but important to staff, are locks on doors, alarm systems, good parking lot lighting, and security cameras.

Office safety may seem mundane but a few simple measures can save you a fortune, boost employee morale, and most important of all, improve patient care.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Wait, I know what you’re thinking, boring, dry, and don’t scold me. I am not going to do any of that today, and instead am going to tell you how to easily improve patient care, save money, and improve staff morale.

The easiest things to do to improve safety in the office include better communications, infection control, correct patient/site identification, dealing with emergencies, and staff safety.

Staff communication is often surprisingly poor, and physicians often assume staff can read our minds (and if they have worked for you for many years, maybe they can!). Always make sure staff – and patients – repeat back complicated instructions (better to start by making them less complicated). Never assume your patients are literate, 14% of adults cannot read, so make sure your staff goes over printed materials with the patients.

Something easy you can do is eliminate abbreviations from your prescription pad and your medical record.

Failure to follow up on path reports and lost biopsies is a frequent cause for lawsuits. You need to make sure you have a redundant system for tracking and reporting pathology results. In addition to the old reliable pathology log book, you need a sequential system ensuring that the specimen made it to the lab, that the result was generated and received, that the patient was notified, and that further action was taken if needed. If this is integrated into your electronic medical record, so much the better, but you still need a paper backup log book, “just in case.”

We all take basic infection precautions when performing procedures, including alcohol hand gel, eye protection, gloves, mask, and cleaning of surgical sites prior to excision. When there are wound infections, which should be rare, you should always culture, and if there is a cluster of infections, particularly with methicillin-resistant staphylococcus aureus (MRSA), you should consider culturing the anterior nares of the staff. Alternatively, you can preemptively treat the staff with intranasal topical mupirocin daily for 2 weeks.

Measuring the use of alcohol gel before and after staff education is an easy and beneficial quality improvement project. You and your staff are, of course, vaccinated for hepatitis B, and yearly for influenza, and you should consider PPD testing every 2 years for everyone. My asymptomatic receptionist converted, and needed prophylactic tuberculosis treatment and contact tracing.

Wrong-site surgery is a frequent problem for dermatologists. Many of our biopsies are tangential, heal almost invisibly, without marking sutures, and patients have battle-scarred skin, and are elderly. The patients may have trouble remembering or seeing where the biopsy was, so good charts and family members are helpful. Photographs of the biopsy sites can be priceless. If the site still cannot be identified, then rebiopsy, or close follow-up is indicated.

Emergencies are rare, but it is prudent to have an automatic external defibrillator in the office. These are automated, so Advanced Cardiovascular Life Support (ACLS), or even basic CPR is not required to operate them, and the survival rate after cardiac arrest increases from 2% to 50%. When it has to be replaced after 5 years, take the old one home and teach your spouse how to use it, and maybe they will.

If you do a lot of surgery you may want to get the ACLS training and buy the crash cart drug kit, but many of the drugs have become ferociously expensive, despite being generic.

Staff safety is a crucial consideration and showing concern boosts staff morale. You should dispose of sharps directly into a sharps container and remove the sharps from the tray at the end of the case. You should have a written protocol for needle sticks. I keep the red top tubes, and the first 2 days of HIV medication on site. Sometimes a patient is HIV positive, the sharp exposure is unknown (a cryostat tissue tease for example), or the patient refuses to have their blood drawn. Less obvious, but important to staff, are locks on doors, alarm systems, good parking lot lighting, and security cameras.

Office safety may seem mundane but a few simple measures can save you a fortune, boost employee morale, and most important of all, improve patient care.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.