Commentary

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at obnews@frontlinemedcom.com.

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at obnews@frontlinemedcom.com.

The current epidemic of obesity presents gynecologic surgeons with the challenge of safely and successfully performing minimally invasive surgery in women who are morbidly or superobese.

In 2004, the prevalence of a body mass index greater than 40 kg/m² was almost 7.0% in females in the United States (JAMA. 2006 Apr 5;295[13]:1549-55.). Most recently, 8.3% of women were reported to have a BMI greater than 40 (JAMA. 2014 Feb 26;311[8]:806-14.). This is a value that the World Health Organization defines as Class III obesity and that, according to further stratification reported in the surgical literature, includes the categories of morbid obesity (40-44.9), superobesity (greater than 45), and super-superobesity (greater than 60).

As a gynecologic oncologist, I see firsthand the impact of obesity on the risk of multiple gynecologic conditions and female cancers, including endometrial cancer, as well as the benefits of a minimally invasive approach. I frequently perform hysterectomies via the minimally invasive approach to treat precancer and cancer of the uterus in morbidly and superobese women who have significant central adiposity.

MIGS benefits in the obese

In the past 15 years, and particularly in the past decade, evidence that obese patients benefit from laparoscopic surgery compared with traditional laparotomy has increased. I consider minimally invasive surgery the standard of care for women with endometrial cancer, regardless of the BMI.

As Dr. Stacey A. Scheib and her colleagues wrote in a recent review on laparoscopy in the morbidly obese, most of the gynecologic literature comparing laparoscopic surgery with laparotomy in this population is focused on gynecologic oncology because obesity is so strongly associated with endometrial and other cancers in women (J Minim Invasive Gynecol. 2014 Mar-Apr;21[2]:182-95.). In one prospective study of women with clinical stage I endometrial cancer and BMIs between 28 and 60, those who underwent laparoscopic surgery – 40 of 42 women over 2 years – had significantly longer operative times but less operative morbidity, shorter hospital stays, faster recovery and better postsurgical quality of life, compared with women who had undergone laparotomy in the previous 2 years. The control patients also had clinical stage I endometrial cancer and similar BMIs (Gynecol Oncol. 2000 Sep;78[3 Pt 1]:329-35.).

Research comparing robotics and conventional laparoscopy in obese gynecologic surgery patients is limited, and findings are inconsistent. It will remain difficult to compare the two approaches because few surgeons are equally skilled in both approaches and because the learning curve for conventional laparoscopy is so much steeper than for robotics.

I favor the robotic approach for morbidly and superobese patients for its superior visualization and ergonomics.

Patient positioning

It is important to use an operative bed that will accommodate the weight and width of obese patients and enable Trendelenburg positioning of up to 45 degrees. We use a bariatric bed with a 1,000-pound weight limit.

Obese patients are at greater risk for neuromuscular injuries and pressure sores, so careful patient positioning and padding of pressure points is critically important. We have found a surgical bean bag to be much more effective in preventing slippage for the morbidly or superobese patient than is egg-crate foam. The bean bag conforms nicely to the shape of the patient’s back, neck, and arms when it is appropriately desufflated. After desufflation, the bean bag must be well taped onto the operative bed.

I sometimes use shoulder blocks for extra assurance. When used, these braces must be attached to the bean bag and not to the patient.

We typically pad the arms completely with gel pads or foam before the bean bag is desufflated. We also often pad the knees and calves before the legs are placed and secured in stirrups made for the morbidly obese, with the buttocks slightly off the table.

In a review of literature on obesity and laparoscopy outcomes, Dr. Georgine Lamvu and her associates recommended that the arms be tucked in the “military” position, along the length of the body (Am J Obstet Gynecol. 2004 Aug;191[2]:669-74.). To ensure that both arms are properly tucked against the length of the body, we use bed extenders or sleds to widen the bed as necessary.

Abdominal access

I use the open Hasson technique in my obese patients and enter the peritoneum under direct visualization. In patients with high levels of morbid obesity, I have found it helpful to retract the adipose tissue using thin Breisky vaginal retractors. These retractors can hold the adipose tissue away from the fascia to facilitate entry into the abdominal cavity via the open technique.

Utilizing the umbilicus as the initial entry point – often desirable in minimally invasive surgery – is frequently not possible in morbidly obese patients because as BMI increases, the umbilicus migrates toward the pubic bone and away from the aortic bifurcation. In patients who were overweight (BMI greater than 25), Dr. W.W. Hurd and his associates noted a repositioning of the umbilicus below the aortic bifurcation of 2 cm or greater (Obstet Gynecol. 1992 Jul;80[1]:48-51.).

Instead, a supraumbilical or left upper quadrant site for initial entry enables optimal triangulation of trocars and visualization of disease. The trocars must then be placed more lateral and cephalad than in thinner women. In doing so, risk to the inferior epigastric is mitigated. Moreover, longer trocar lengths (150 mm) may be required.

To utilize an umbilical entry, it is imperative that the panniculus be placed cephalad to a position between the two anterior iliac spines (Obstet Gynecol. 1998 Nov;92[5]:869-72.). By doing this, the umbilicus is now repositioned relative to the bifurcation of the aorta similar to the thinner patient. This can either be accomplished using assistants to move the panniculus cephalad or taping the panniculus.

Alternatively, if the Hasson technique is not utilized, a Veress needle (50 mm in length) may be used. Based on MRI and CT visualization, Dr. Hurd has long recommended using a 90-degree angle in the obese population, compared with a 45-degree angle in nonobese women (J Reprod Med. 1991;36[7]:473-6.).

I usually place the patient into a moderate Trendelenburg position before docking the robot and observe the patient’s cardiac and respiratory responses to the induction of anesthesia. Adjustments in the degree of Trendelenburg positioning, the insufflation pressure level, and the ventilation settings can then be made if necessary. Occasionally I will decrease the insufflation pressure from 15 to 12 mm Hg, for instance, to accommodate ventilation needs.

A note from Dr. Charles E. Miller, Master Class Medical Editor

It must be recognized that not all physicians agree with the use of shoulder braces. In a review of literature on brachial plexus injuries in gynecologic surgery during 1980-2012, Dr. Nigel Pereira and his associates identified eight case reports, all of which involved Trendelenburg positioning and seven of which utilized shoulder braces. In their evaluation of the literature, the authors concluded that “the force of the shoulder braces on the clavicle and scapula opposes the force of gravity on the humerus, thereby stretching the brachial plexus and leading to nerve injury. This is particularly exaggerated when the arm is hyperabducted (less than 90 degrees), the head is laterally flexed to the opposite side, or the abducted arm is sagging.”

The authors also point out that longer times spent under general anesthesia (commensurate with increased operating times) increase the risk of brachial plexus injury “by increasing joint mobility (particularly when muscle relaxants are used) because the neighboring bony structure is more likely to compress or impinge on the brachial plexus” (CRSLS e2014.00077. [doi:10.4293/CRSLS.2014.00077]).

More pearls from Dr. Miller

Preoperative care. Prior to surgery it is important to examine a patient’s panniculus closely for evidence of infection. As the area underneath the panniculus receives little oxygen, it is at greater risk for both bacterial and fungal infections. If infection is noted, treatment prior to surgery is strongly recommended. Moreover, as the skin under the panniculus is often times “broken down,” which can compromise healing, lateral incisions should not be made in this area.

Since obese women have more severe comorbidities (such as metabolic syndrome, obstructed sleep apnea, coronary artery disease, poorly controlled hypertension, and a difficult airway) and a greater risk of perioperative complications than women who are not obese, they generally require a more-extensive preoperative work-up and additional perioperative considerations. If the minimally invasive gynecologic surgeon is uncomfortable with evaluation of cardiac and pulmonary status, medical clearance and perioperative consultation with an anesthesiologist prior to surgery is strongly recommended.

Perioperative care. There are no studies in the literature supporting the use of antibiotic prophylaxis prior to surgery despite the increased risk of postoperative wound infection in morbidly obese patients. Increased risk of surgical site infection post abdominal hysterectomy has been noted in women with a BMI greater than 35. Therefore, consideration should be given to the use of prophylactic antibiotics. For patients weighing more than 80 kg, I advise using 2 gm prophylactic cefazolin; increase this to 3 gm in patients that weigh more than 120 kg.

The morbidly obese patient is also at greater risk of deep venous thrombosis, especially when the procedure is lengthy. Sequential compression devices are essential. Moreover, use of such antithrombotic agents as Lovenox [enoxaparin] and heparin should be considered until the patient is ambulating.

Postoperative care. It is imperative to stress the need for extensive pulmonary toilet or hygiene (i.e., coughing and breathing deeply to clear mucus and secretions from the airways) as well as early ambulation. The patient should also be counseled to use pain medication judiciously. And until the patient is mobile, the use of antithrombotic agents, such as Lovenox and heparin, should be continued.

Dr. Ahmed reports that she has no disclosures related to this Master Class. Dr. Miller disclosed that he is a consultant and is on the speakers bureau for Ethicon and Intuitive Surgical, and is a consultant for Covidien. Email Dr. Ahmed and Dr. Miller at obnews@frontlinemedcom.com.

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

With few exceptions, I have found that patients who have chronic moder­ate or severe mental illness tend to be relatively more vulnerable in terms of (1) receiving suboptimal primary medical care and (2) suffering a result­ing increase in morbidity, mortality, and disability.

Across the board, I’ve found, psychiatrists are more likely to treat patients who are chronically vulnerable.

Why are they so vulnerable?
The unique vulnerability of patients with severe mental illness stems from several causative factors:
   • the stigma attached to mental illness
   • poor implementation of parity in reimbursement for mental health services
   • a suboptimal-sized mental health workforce
   • related poor patient-centered support
   • most important, these patients’ lack of primary and preventive medical care.

Here are a few examples that dem­onstrate how dire the situation is:

Smoking cigarettes is one of the most dangerous modifiable risk factors for vascular disease and early death. People with mental illness smoke almost half (44%) of the cigarettes sold in the United States and are twice as likely to smoke than those who do not have a mental illness.^1,2

HIV infection is at least 2 or 3 times more prevalent among people with severe mental illness as it is in the gen­eral population.³

Hepatitis C infection is at least twice as prevalent in people with a diagno­sis of schizophrenia as it is in the gen­eral population.⁴

Schizophrenia. As many as 60% of premature deaths among people with schizophrenia are attributable to a medical illness.⁵ For example, those with schizophrenia have an increased 10-year cardiac mortality; compara­tively higher rates of hypertension, diabetes, and smoking; and, on aver­age, a lower level of high-density lipoprotein cholesterol. Nasrallah et al reported that the rate of untreated hypertension among patients with schizophrenia is 62.4%.⁶

Premature death. People who have a diagnosis of severe mental illness are at risk of dying prematurely by as much as 25 years.^5,7-10

Who should take the lead?
How can psychiatrists address this ongoing vulnerability within the men­tally ill patient population, and advo­cate for their patients? A comprehensive answer to this question is beyond the scope of this article, but I can offer this prescription for your consideration.

Be an advocate. You, as a psychiatrist, are well positioned to counter the men­tal health-related stigma and advocate for implementation of mental health parity nationwide. In addition to par­ticipating in community education and outreach, become a member of, and get involved in, established organiza­tions, such as the American Psychiatric Association, that advocates for psychi­atric patients at all levels.

Keep patients connected. Make sure your patients are connected with a pri­mary care provider, and use your psy­chotherapeutic skills to help patients understand the importance of receiv­ing primary and secondary preventive medical care.

Monitor health and disease. As a phy­sician first and a psychiatrist second, closely monitor your patients for general medical conditions that are related to the presence and treatment of psychiatric disorders. Consider routinely reviewing pertinent lab work with patients—even results of tests ordered by a primary care provider (eg, the metabolic panel and a thyroid-stimulating hormone level in patients taking lithium).

Collaborate with your primary care col­leagues; they need your help as much as you can use their help! Make sure your patients witness this collaboration, because it mirrors how you would like them to interact with their primary care provider.

Educate yourself. Education in the essentials of psychiatry-based preven­tive medical care is key, as we work to more effectively address the increased disability, morbidity, mortality, and overall vulnerability in our patients. Stay “current” on general medical top­ics by reading the “Med/Psych Update” section of Current Psychiatry and relevant articles in other clinical guides to both integrated and preventive medicine.¹¹

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.

Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.

Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.

Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).

Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.

This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.

Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com. Dr. Powell said he had no relevant financial disclosures.

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.

Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.

The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.

This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.

It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”

The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.

Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.

Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.

Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.

Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”

Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.

But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.

Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.

Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.

Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?

Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.

But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.

In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.

While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at pdnews@frontlinemedcom.com.

I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.

But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.

Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.

Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.

Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?

Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.

But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.

In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.

While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at pdnews@frontlinemedcom.com.

I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.

But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.

Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.

Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.

Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?

Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.

But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.

In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.

While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at pdnews@frontlinemedcom.com.

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

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 Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

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 Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

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 Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

Vulvar cancer is a rare gynecologic cancer comprising only 5% of gynecologic malignancies. Given the low incidence of disease, many primary providers and even obstetricians and gynecologists many never encounter a case. Increased awareness of vulvar cancer and vulvar dysplasia among patients and physicians may decrease diagnostic delays and expedite patient therapy.

Diagnosis

There is a well documented delay in diagnosis of vulvar cancer that is attributed to both the patient and the physician. Patients may feel uncomfortable or embarrassed telling their physicians about vulvar symptoms and providers may not recognize the risk for malignancy and provide alternative therapies prior to biopsy (J Reprod Med. 1999;44[9]:766-8.).

Risk factors for vulvar cancer include human papillomavirus (HPV) infection, a history of smoking, immunosuppression, and a history of an abnormal pap smear. Vulvar dystrophy, lichen sclerosis, and squamous intraepithelial lesions have also been suggested as precursor lesions of invasive cancers. The key to early diagnosis and treatment is immediate in-office biopsy.

When evaluating a patient with a vulvar lesion, the initial evaluation should include a thorough exam with a measurement of the lesion and evaluation of inguinal lymph nodes. Also, a detailed description of a lesion’s relationship to the midline (how many centimeters away) and other vital structures (clitoris, urethra, anus) is important.

An in-office biopsy can be done on initial presentation and should include the lesion in question and underlying stroma in an effort to delineate depth of invasion. While shave biopsies may be appropriate for some skin lesions, if there is any concern for malignancy, a punch biopsy is preferred.

Pathology

Squamous cell carcinoma is the most common histologic subtype (greater than 90%) followed by malignant melanoma. Malignant melanoma poses a diagnostic challenge as 25% may present with nonpigmented lesions. These lesions may arise from a junctional nevus and are more common in postmenopausal white women.

The measurement of tumor thickness is essential in evaluation of melanoma. A diagnosis of vulvar melanoma should be referred to a gynecologic oncologist for further evaluation and treatment. Frequently these patients require a multidisciplinary approach with other medical and surgical subspecialties consulting.

Adenocarcinoma of the vulva frequently arises within the Bartholin glands. Bartholin gland disease is typically a disease of young women. Any abscess or lesion in the bartholin gland in women older than 50 years should raise awareness of the possibility of malignancy. Providers should have a low threshold for biopsy of any Bartholin lesion in older women and for any Bartholin gland lesion or cyst that returns or persists after initial drainage.

Staging pearls

Vulvar cancer spreads by direct extension, lymphatic embolization and hematogenous spread. Lymphatic spread can occur early in the disease and portends a much worse prognosis. In 2009, the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system. The most significant change was in stage III disease, which now includes any patient with lymph node involvement. This change emphasizes lymph node status as the single most important prognostic factor. The 5-year overall survival of patients with locally advanced tumors but negative regional lymph nodes (62%) has been found to be significantly better than those with positive nodal status (39%, P value less than.0001) (Gynecol Oncol. 2008;110[1]:83-6.).

In patients with stage IA disease, which includes lesions less than 2 cm in size with stromal invasion of less than 1 mm, the risk of lymph node metastasis is low. These patients do not require inguinal lymph node dissection. If lesions are greater than 2 cm and/or have greater than 1 mm depth of invasion, a lymph node dissection is indicated. Lymph node dissection is performed on the ipsilateral side of the lesion as long as the lesion is more than 2 cm from a midline structure. If the lesion is in the midline or within 2 cm of the midline, a bilateral inguinal lymph node dissection is recommended.

There has been a recent uptake of the sentinel inguinal lymph node biopsy technique after two large prospective studies (the GROINSS V trial and GOG 173) validated this methodology (Lancet Oncol. 2010 Jul;11[7]:646-52 and Gynecol Oncol. 2013 Feb;128[2]:155-9).

Treatment

Surgical management of stage I and II disease involves a wide radical excision of the tumor with a 1-cm circumferential margin. Tumors with a depth of invasion of less than 1 mm do not require lymphadenectomy (Gynecol Oncol. 1992 Mar;44[3]:240-4). Stage I/II disease with deeper than 1-mm invasion requires a 2-cm margin and either sentinel node evaluation or lymphadenectomy. Survival for women with adequate resection of primary squamous carcinoma with negative lymph node involvement is greater than 90%.

Patients with metastasis to the groin frequently receive bilateral groin and pelvic radiation; however, recommendations are individualized based on size and number of metastasis. Patients should expect to receive recommendations for therapy after pathologic review and multidisciplinary consultation; therapy should be individualized for each clinical situation.

This disease is one of the elderly, but it is important to remember that treatment recommendations should not be made according to age alone. A British study found that when women over the age of 80 received standard treatment, their recurrence rate was 25% compared with a 53% recurrence rate in those whose treatment was modified (Int J Gynecol Cancer. 2009;19[4]:752-5.). In patients with advanced disease, preoperative radiation, with or without chemotherapy, is frequently regarded as the treatment of choice and may eliminate the need for radical surgery.

While vulvar cancer is a rare gynecologic malignancy, it can be devastating for patients and families, especially at late stages. Early diagnosis and treatment is imperative for improved patient outcomes. An increased awareness among patients and physicians alike may allow for earlier diagnosis and treatment.

Dr. Sullivan is a fellow in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Sullivan and Dr. Gehrig reported having no relevant financial disclosures.

Vulvar cancer is a rare gynecologic cancer comprising only 5% of gynecologic malignancies. Given the low incidence of disease, many primary providers and even obstetricians and gynecologists many never encounter a case. Increased awareness of vulvar cancer and vulvar dysplasia among patients and physicians may decrease diagnostic delays and expedite patient therapy.

Diagnosis

There is a well documented delay in diagnosis of vulvar cancer that is attributed to both the patient and the physician. Patients may feel uncomfortable or embarrassed telling their physicians about vulvar symptoms and providers may not recognize the risk for malignancy and provide alternative therapies prior to biopsy (J Reprod Med. 1999;44[9]:766-8.).

Risk factors for vulvar cancer include human papillomavirus (HPV) infection, a history of smoking, immunosuppression, and a history of an abnormal pap smear. Vulvar dystrophy, lichen sclerosis, and squamous intraepithelial lesions have also been suggested as precursor lesions of invasive cancers. The key to early diagnosis and treatment is immediate in-office biopsy.

When evaluating a patient with a vulvar lesion, the initial evaluation should include a thorough exam with a measurement of the lesion and evaluation of inguinal lymph nodes. Also, a detailed description of a lesion’s relationship to the midline (how many centimeters away) and other vital structures (clitoris, urethra, anus) is important.

An in-office biopsy can be done on initial presentation and should include the lesion in question and underlying stroma in an effort to delineate depth of invasion. While shave biopsies may be appropriate for some skin lesions, if there is any concern for malignancy, a punch biopsy is preferred.

Pathology

Squamous cell carcinoma is the most common histologic subtype (greater than 90%) followed by malignant melanoma. Malignant melanoma poses a diagnostic challenge as 25% may present with nonpigmented lesions. These lesions may arise from a junctional nevus and are more common in postmenopausal white women.

The measurement of tumor thickness is essential in evaluation of melanoma. A diagnosis of vulvar melanoma should be referred to a gynecologic oncologist for further evaluation and treatment. Frequently these patients require a multidisciplinary approach with other medical and surgical subspecialties consulting.

Adenocarcinoma of the vulva frequently arises within the Bartholin glands. Bartholin gland disease is typically a disease of young women. Any abscess or lesion in the bartholin gland in women older than 50 years should raise awareness of the possibility of malignancy. Providers should have a low threshold for biopsy of any Bartholin lesion in older women and for any Bartholin gland lesion or cyst that returns or persists after initial drainage.

Staging pearls

Vulvar cancer spreads by direct extension, lymphatic embolization and hematogenous spread. Lymphatic spread can occur early in the disease and portends a much worse prognosis. In 2009, the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system. The most significant change was in stage III disease, which now includes any patient with lymph node involvement. This change emphasizes lymph node status as the single most important prognostic factor. The 5-year overall survival of patients with locally advanced tumors but negative regional lymph nodes (62%) has been found to be significantly better than those with positive nodal status (39%, P value less than.0001) (Gynecol Oncol. 2008;110[1]:83-6.).

In patients with stage IA disease, which includes lesions less than 2 cm in size with stromal invasion of less than 1 mm, the risk of lymph node metastasis is low. These patients do not require inguinal lymph node dissection. If lesions are greater than 2 cm and/or have greater than 1 mm depth of invasion, a lymph node dissection is indicated. Lymph node dissection is performed on the ipsilateral side of the lesion as long as the lesion is more than 2 cm from a midline structure. If the lesion is in the midline or within 2 cm of the midline, a bilateral inguinal lymph node dissection is recommended.

There has been a recent uptake of the sentinel inguinal lymph node biopsy technique after two large prospective studies (the GROINSS V trial and GOG 173) validated this methodology (Lancet Oncol. 2010 Jul;11[7]:646-52 and Gynecol Oncol. 2013 Feb;128[2]:155-9).

Treatment

Surgical management of stage I and II disease involves a wide radical excision of the tumor with a 1-cm circumferential margin. Tumors with a depth of invasion of less than 1 mm do not require lymphadenectomy (Gynecol Oncol. 1992 Mar;44[3]:240-4). Stage I/II disease with deeper than 1-mm invasion requires a 2-cm margin and either sentinel node evaluation or lymphadenectomy. Survival for women with adequate resection of primary squamous carcinoma with negative lymph node involvement is greater than 90%.

Patients with metastasis to the groin frequently receive bilateral groin and pelvic radiation; however, recommendations are individualized based on size and number of metastasis. Patients should expect to receive recommendations for therapy after pathologic review and multidisciplinary consultation; therapy should be individualized for each clinical situation.

This disease is one of the elderly, but it is important to remember that treatment recommendations should not be made according to age alone. A British study found that when women over the age of 80 received standard treatment, their recurrence rate was 25% compared with a 53% recurrence rate in those whose treatment was modified (Int J Gynecol Cancer. 2009;19[4]:752-5.). In patients with advanced disease, preoperative radiation, with or without chemotherapy, is frequently regarded as the treatment of choice and may eliminate the need for radical surgery.

While vulvar cancer is a rare gynecologic malignancy, it can be devastating for patients and families, especially at late stages. Early diagnosis and treatment is imperative for improved patient outcomes. An increased awareness among patients and physicians alike may allow for earlier diagnosis and treatment.

Dr. Sullivan is a fellow in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Sullivan and Dr. Gehrig reported having no relevant financial disclosures.

Vulvar cancer is a rare gynecologic cancer comprising only 5% of gynecologic malignancies. Given the low incidence of disease, many primary providers and even obstetricians and gynecologists many never encounter a case. Increased awareness of vulvar cancer and vulvar dysplasia among patients and physicians may decrease diagnostic delays and expedite patient therapy.

Diagnosis

There is a well documented delay in diagnosis of vulvar cancer that is attributed to both the patient and the physician. Patients may feel uncomfortable or embarrassed telling their physicians about vulvar symptoms and providers may not recognize the risk for malignancy and provide alternative therapies prior to biopsy (J Reprod Med. 1999;44[9]:766-8.).

Risk factors for vulvar cancer include human papillomavirus (HPV) infection, a history of smoking, immunosuppression, and a history of an abnormal pap smear. Vulvar dystrophy, lichen sclerosis, and squamous intraepithelial lesions have also been suggested as precursor lesions of invasive cancers. The key to early diagnosis and treatment is immediate in-office biopsy.

When evaluating a patient with a vulvar lesion, the initial evaluation should include a thorough exam with a measurement of the lesion and evaluation of inguinal lymph nodes. Also, a detailed description of a lesion’s relationship to the midline (how many centimeters away) and other vital structures (clitoris, urethra, anus) is important.

An in-office biopsy can be done on initial presentation and should include the lesion in question and underlying stroma in an effort to delineate depth of invasion. While shave biopsies may be appropriate for some skin lesions, if there is any concern for malignancy, a punch biopsy is preferred.

Pathology

Squamous cell carcinoma is the most common histologic subtype (greater than 90%) followed by malignant melanoma. Malignant melanoma poses a diagnostic challenge as 25% may present with nonpigmented lesions. These lesions may arise from a junctional nevus and are more common in postmenopausal white women.

The measurement of tumor thickness is essential in evaluation of melanoma. A diagnosis of vulvar melanoma should be referred to a gynecologic oncologist for further evaluation and treatment. Frequently these patients require a multidisciplinary approach with other medical and surgical subspecialties consulting.

Adenocarcinoma of the vulva frequently arises within the Bartholin glands. Bartholin gland disease is typically a disease of young women. Any abscess or lesion in the bartholin gland in women older than 50 years should raise awareness of the possibility of malignancy. Providers should have a low threshold for biopsy of any Bartholin lesion in older women and for any Bartholin gland lesion or cyst that returns or persists after initial drainage.

Staging pearls

Vulvar cancer spreads by direct extension, lymphatic embolization and hematogenous spread. Lymphatic spread can occur early in the disease and portends a much worse prognosis. In 2009, the International Federation of Gynecology and Obstetrics (FIGO) revised the staging system. The most significant change was in stage III disease, which now includes any patient with lymph node involvement. This change emphasizes lymph node status as the single most important prognostic factor. The 5-year overall survival of patients with locally advanced tumors but negative regional lymph nodes (62%) has been found to be significantly better than those with positive nodal status (39%, P value less than.0001) (Gynecol Oncol. 2008;110[1]:83-6.).

In patients with stage IA disease, which includes lesions less than 2 cm in size with stromal invasion of less than 1 mm, the risk of lymph node metastasis is low. These patients do not require inguinal lymph node dissection. If lesions are greater than 2 cm and/or have greater than 1 mm depth of invasion, a lymph node dissection is indicated. Lymph node dissection is performed on the ipsilateral side of the lesion as long as the lesion is more than 2 cm from a midline structure. If the lesion is in the midline or within 2 cm of the midline, a bilateral inguinal lymph node dissection is recommended.

There has been a recent uptake of the sentinel inguinal lymph node biopsy technique after two large prospective studies (the GROINSS V trial and GOG 173) validated this methodology (Lancet Oncol. 2010 Jul;11[7]:646-52 and Gynecol Oncol. 2013 Feb;128[2]:155-9).

Treatment

Surgical management of stage I and II disease involves a wide radical excision of the tumor with a 1-cm circumferential margin. Tumors with a depth of invasion of less than 1 mm do not require lymphadenectomy (Gynecol Oncol. 1992 Mar;44[3]:240-4). Stage I/II disease with deeper than 1-mm invasion requires a 2-cm margin and either sentinel node evaluation or lymphadenectomy. Survival for women with adequate resection of primary squamous carcinoma with negative lymph node involvement is greater than 90%.

Patients with metastasis to the groin frequently receive bilateral groin and pelvic radiation; however, recommendations are individualized based on size and number of metastasis. Patients should expect to receive recommendations for therapy after pathologic review and multidisciplinary consultation; therapy should be individualized for each clinical situation.

This disease is one of the elderly, but it is important to remember that treatment recommendations should not be made according to age alone. A British study found that when women over the age of 80 received standard treatment, their recurrence rate was 25% compared with a 53% recurrence rate in those whose treatment was modified (Int J Gynecol Cancer. 2009;19[4]:752-5.). In patients with advanced disease, preoperative radiation, with or without chemotherapy, is frequently regarded as the treatment of choice and may eliminate the need for radical surgery.

While vulvar cancer is a rare gynecologic malignancy, it can be devastating for patients and families, especially at late stages. Early diagnosis and treatment is imperative for improved patient outcomes. An increased awareness among patients and physicians alike may allow for earlier diagnosis and treatment.

Dr. Sullivan is a fellow in the division of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Sullivan and Dr. Gehrig reported having no relevant financial disclosures.

I prescribe medications. You do, too. It’s part of what we do.

What I don’t do is prescribe meds for other docs, or expect them to prescribe mine.

Seems reasonable, right? Yet, I’ve seen several recent posts on physician gripe boards talking about doctors dodging out on this in a few ways. Some examples follow:

• Specialists who diagnose a patient with epilepsy, and send a note back to the internists suggesting they start Tegretol.

• Internists who want the patient to take a drug for neuropathy, and give them a note to take to the specialist asking them to start Lyrica.

• Specialists who want the internist to manage another field entirely, such as a dermatologist telling the internist what to prescribe for a patient’s diabetes.

Personally, I wouldn’t expect any internist to continue a medication that I started prescribing. If they referred the patient to me, I assume they want me to handle it. If they’d prefer the patient return to them for continuing care of the condition, that’s fine, but I generally figure it’s now my issue.

On the flip side, it always bugs me when someone who’s not in my field tells a patient what they think I should prescribe. Sometimes I agree with the choice, but to me it undermines my relationship with the patient. If you want me to handle the case, then don’t give the patient expectations of what should be used. Otherwise, if I decide to try something else, Mr. Smith feels like he’s been short-changed and may call the internist to complain.

I wouldn’t dream of handing a patient a card that says, “Needs to be started on (Actos/Coreg/amiodarone/whatever),” so am always surprised when they bring a note saying, “Please start Dilantin, I think he has seizures.”

This isn’t, I admit, a common occurrence. In my little world, I can count on one hand the number of times it happens per year, almost always from a physician whom I haven’t previously worked with. My referral sources (hopefully) trust me to handle neurology, and I feel the same way about them to handle other issues.

But it must be happening to others, or it wouldn’t be showing up on Sermo and other sites. I have to wonder about the background mindset. Is it just laziness on the part of other doctors? A reluctance to prescribe, knowing that then you’ll be the one stuck with the prior authorization and refill requests? A paternalistic approach to medicine, where you feel you’re right, and therefore another doc should unquestioningly follow your instructions (if you know what’s best, why refer at all?).

More disturbingly, are a few docs seeing patients as someone else’s problem? I really hope not. I’d like to think that the affront, when present, is simply from a lack of practice experience and/or social skills, and will fade with time. Things that irritate other physicians only end up hurting the patient, which isn’t what we’re here for.

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

I prescribe medications. You do, too. It’s part of what we do.

What I don’t do is prescribe meds for other docs, or expect them to prescribe mine.

Seems reasonable, right? Yet, I’ve seen several recent posts on physician gripe boards talking about doctors dodging out on this in a few ways. Some examples follow:

• Specialists who diagnose a patient with epilepsy, and send a note back to the internists suggesting they start Tegretol.

• Internists who want the patient to take a drug for neuropathy, and give them a note to take to the specialist asking them to start Lyrica.

• Specialists who want the internist to manage another field entirely, such as a dermatologist telling the internist what to prescribe for a patient’s diabetes.

Personally, I wouldn’t expect any internist to continue a medication that I started prescribing. If they referred the patient to me, I assume they want me to handle it. If they’d prefer the patient return to them for continuing care of the condition, that’s fine, but I generally figure it’s now my issue.

On the flip side, it always bugs me when someone who’s not in my field tells a patient what they think I should prescribe. Sometimes I agree with the choice, but to me it undermines my relationship with the patient. If you want me to handle the case, then don’t give the patient expectations of what should be used. Otherwise, if I decide to try something else, Mr. Smith feels like he’s been short-changed and may call the internist to complain.

I wouldn’t dream of handing a patient a card that says, “Needs to be started on (Actos/Coreg/amiodarone/whatever),” so am always surprised when they bring a note saying, “Please start Dilantin, I think he has seizures.”

This isn’t, I admit, a common occurrence. In my little world, I can count on one hand the number of times it happens per year, almost always from a physician whom I haven’t previously worked with. My referral sources (hopefully) trust me to handle neurology, and I feel the same way about them to handle other issues.

But it must be happening to others, or it wouldn’t be showing up on Sermo and other sites. I have to wonder about the background mindset. Is it just laziness on the part of other doctors? A reluctance to prescribe, knowing that then you’ll be the one stuck with the prior authorization and refill requests? A paternalistic approach to medicine, where you feel you’re right, and therefore another doc should unquestioningly follow your instructions (if you know what’s best, why refer at all?).

More disturbingly, are a few docs seeing patients as someone else’s problem? I really hope not. I’d like to think that the affront, when present, is simply from a lack of practice experience and/or social skills, and will fade with time. Things that irritate other physicians only end up hurting the patient, which isn’t what we’re here for.

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

I prescribe medications. You do, too. It’s part of what we do.

What I don’t do is prescribe meds for other docs, or expect them to prescribe mine.

Seems reasonable, right? Yet, I’ve seen several recent posts on physician gripe boards talking about doctors dodging out on this in a few ways. Some examples follow:

• Specialists who diagnose a patient with epilepsy, and send a note back to the internists suggesting they start Tegretol.

• Internists who want the patient to take a drug for neuropathy, and give them a note to take to the specialist asking them to start Lyrica.

• Specialists who want the internist to manage another field entirely, such as a dermatologist telling the internist what to prescribe for a patient’s diabetes.

Personally, I wouldn’t expect any internist to continue a medication that I started prescribing. If they referred the patient to me, I assume they want me to handle it. If they’d prefer the patient return to them for continuing care of the condition, that’s fine, but I generally figure it’s now my issue.

On the flip side, it always bugs me when someone who’s not in my field tells a patient what they think I should prescribe. Sometimes I agree with the choice, but to me it undermines my relationship with the patient. If you want me to handle the case, then don’t give the patient expectations of what should be used. Otherwise, if I decide to try something else, Mr. Smith feels like he’s been short-changed and may call the internist to complain.

I wouldn’t dream of handing a patient a card that says, “Needs to be started on (Actos/Coreg/amiodarone/whatever),” so am always surprised when they bring a note saying, “Please start Dilantin, I think he has seizures.”

This isn’t, I admit, a common occurrence. In my little world, I can count on one hand the number of times it happens per year, almost always from a physician whom I haven’t previously worked with. My referral sources (hopefully) trust me to handle neurology, and I feel the same way about them to handle other issues.

But it must be happening to others, or it wouldn’t be showing up on Sermo and other sites. I have to wonder about the background mindset. Is it just laziness on the part of other doctors? A reluctance to prescribe, knowing that then you’ll be the one stuck with the prior authorization and refill requests? A paternalistic approach to medicine, where you feel you’re right, and therefore another doc should unquestioningly follow your instructions (if you know what’s best, why refer at all?).

More disturbingly, are a few docs seeing patients as someone else’s problem? I really hope not. I’d like to think that the affront, when present, is simply from a lack of practice experience and/or social skills, and will fade with time. Things that irritate other physicians only end up hurting the patient, which isn’t what we’re here for.

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

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.

Muslim Bangladeshi female presents

The patient is a 31-year-old married Muslim Bangladeshi female homemaker admitted to an inpatient unit in a private hospital in a large urban area in the northeastern United States because of postpartum psychosis. She recently had immigrated to the United States and spoke no English. She lived with her husband, his parents, and his siblings in a city neighborhood predominantly comprised of South Asian immigrants. Her sole source of financial support was her husband, who worked as a cab driver. Both patient and her husband were uninsured. They identified strongly with their religion and culture of origin.

Key questions

Communication was a challenge and was accomplished using an interpreter, who was not always available. The patient did not seem to respond to treatment, and there was a question about the possibility that she was “cheeking” her medications. Her husband requested her discharge against medical advice, despite her still showing signs of psychosis. He appeared ambivalent about outpatient follow-up.

What is the duty of care in this situation, given the complexities inherent in a cross-cultural situation, the presence of communication barriers, the question of patient and infant safety, the husband’s role (given the understanding that his actions were probably culturally sanctioned and consistent with his role), issues regarding financing their current and follow-up care, and their ambivalence toward follow-up care?

Family perspective

Working with a qualified medical interpreter is imperative, and hospitals and health care providers who accept federal funds are obliged to provide language assistance services under Title VI of the Civil Rights Act of 1964.

First, it is important to accurately assess the woman’s psychosis, including risk of self-harm, risk of harming the infant or others, and capacity to care adequately and safely for the infant.

Second, the team should assess the patient’s and husband’s beliefs about the illness, hospitalization, and treatment. For some Muslim patients, the daily practice of Islam may necessitate the separation of sexes, meaning that female nurses and physicians might be optimal. Accessing professional spiritual or pastoral care in meeting the patient’s and family’s religious needs should be considered. Additional cultural practices that might help increase the acceptability of inpatient psychiatric care for the family include practices regarding diet, dress, hygiene, and prayer. The husband also might want to stay and sleep in the patient’s room during her hospitalization.

It also might be challenging for some North American therapists to understand and focus on the entire family as a functioning unit, rather than seeing the issues as only between husband and wife. Learning about how “normal family functioning” is defined, especially in terms of roles, hierarchy, and intimacy, is critical to supporting this mother and baby. Cultivating “cultural humility” in working with patients and families from diverse backgrounds is extremely important.

During the hospitalization as the patient improves, a plan for care needs to be developed with the patient and her family. This plan should include adequate support of the mother and her baby. The husband should bring his parents and siblings to an initial meeting early during the hospitalization, being mindful of addressing any HIPAA-related issues. This will allow for a uniform understanding of the patient’s illness and treatment. At this meeting, all family members should express their concerns, worries, beliefs, and perceived barriers to optimal care. If the family members feel listened to, they are more likely to feel understood and adhere to recommendations.

At the initial meeting and subsequent ones, the following questions might be helpful to ask to gather information in negotiating a mutually acceptable treatment plan:

1. What is the family’s understanding of her illness? What do they think may have caused it? How do they understand postpartum psychosis? Do they think there is a role for medication? Are any other alternative healing modalities being considered or used?

2. Who is caring for the baby now? Is the baby healthy? Does the family understand how the mother’s illness affects the baby? Can the family provide adequate care for the baby?

3. How are decisions made in the family? Are there any other issues in the family, such as ill health in a parent?

4. Was this an arranged marriage? How long have they known the patient? Do they care for her? What is the family’s attitude toward her?

5. Besides the mother-in-law, are there other adult females (for example, her husband’s sisters and his brothers’ wives) living in the household? How old is the mother-in-law? Who runs the household? Who does all the work? If possible, it will be important to interview anyone else in the household. How long have the couple and the family been in the United States? Did they all come at the same time?

6. Does the family have a supportive community? What are their beliefs about mental illness? Whom do they trust in their community? A religious leader? A local doctor? Who treats the women in the community?

7. If there is time, other issues can be explored. For example, what were the circumstances of their immigration? What has the transition from Bangladesh to life in the United States been like for the family?

8. Who will care for her at home? Who will ensure she takes her medications? Who will take her to follow-up visits?

There are many unknowns in this case that require further exploration. Time taken to arrange for a medically qualified interpreter and an extended family meeting will help the physician and psychiatric team understand the current situation and set up an appropriate plan of care.

Cultural perspective

The case material raises many questions. In the first place, there is no need to assume that the husband was behaving in a “culturally sanctioned and consistent way.” In a large population like that of Bangladeshi Muslims, significant heterogeneity exists, and there are more ways than one to respond. Although access to care is increasing for some population segments, Bangladesh still has limited mental health services and resources.

What were the reasons for the patient to be admitted to a psychiatric unit? How many days after the delivery? Were there any hostile actions or reactions to the baby? What is the patient’s pregnancy history? What meaning was ascribed to the symptoms and behavior that the patient manifested prior to hospitalization? Was this the first episode of psychiatric illness for the patient? Has she shown any dangerous behaviors before?

The reason why the husband is taking the wife home against medical advice is unclear. What reason did the husband give for this decision? Could stigma toward mental illness or hospitalization play a role? Was an interpreter used to help understand his reasoning? Was the husband dissatisfied about something? This is important, because it is likely that the husband brought the wife for hospitalization in the first place. Were the inpatient physician and nurses male or female, and could gender-related issues have been a barrier to accepting care? Might there have been a Muslim chaplain in the hospital or in the community or someone else who could have served as a cultural broker earlier in the hospitalization to have prevented this impasse?

The Cultural Formulation Interview (CFI) in the DSM-5 and the CFI-Informant Version for family members provide a framework to explore these questions and the questions recommended in the Family Perspective throughout the course of treatment.

Additional relevant questions include the following: What are cultural norms for their expectations for support of a new mother during the postpartum period? What are the norms for who, besides the mother, provides infant care? Are normative postpartum practices possible, or have they been disrupted in the hospital setting and/or in their home? If the mother and baby are both on the unit, is the request motivated by a desire to bring the baby home? If the baby is not on the unit, is this driving the family’s concern?

How isolated will the woman feel when she is home with the baby and her husband is out working as a taxi driver? Are there community-based organizations that the clinicians could collaborate with to provide resources and support for this woman (for example, women’s groups, immigrant groups, religious groups)? This would require learning more about what appeals to her, which groups she might identify with, and what is available in her neighborhood/community that aligns with what appeals to her.

It also would be important to determine if the patient was having any side effects from her psychotropic medications. Many South Asians have a low tolerance for side effects. Did the patient or family have any religious or cultural concerns about how the medications were manufactured or their composition (for example, worries about alcohol content)? Could any of these factors be related to the patient’s possible “cheeking” of her medications?

The major ethical/legal question to address is the patient’s attitude toward and relationship with the baby, and whether she was and is currently a danger to herself or others. Was the baby with the patient in the hospital? Did she feed the baby? What were the signs of psychosis that the patient exhibited, and what were the bases of her diagnosis? Was there an opportunity to discuss these issues with the husband? If so, what was his response?

Unless the patient is found to be dangerous to herself or others, including the baby, there is no option but to discharge. If a Bengali-speaking psychiatrist/therapist could be located within a reasonable driving distance, every effort should be made to connect the two. Husband and wife certainly should be instructed at the first sign of trouble to seek medical/psychiatric assistance, with or without insurance. Is there a possibility of home visits with an interpreter given the potential risks of patient and infant safety? Close follow-up and coordination of care with the patient’s and baby’s primary care physician is needed. Seeking support from the patient’s religious community also is worth considering.

Contributors

Alison M. Heru, M.D. – University of Colorado Denver, Aurora

Ellen Berman, M.D. – University of Pennsylvania, Philadelphia

Annelle B. Primm, M.D., M.P.H. – Johns Hopkins University, Baltimore (adjunct faculty)

Anne E. Becker, M.D., Ph.D. – Harvard Medical School, Boston

Robert C. Like, M.D., M.S. – Rutgers University, Robert Wood Johnson Medical School, New Brunswick

Resources

Farooq S., Fear C. Working Through Interpreters. (Adv Psychiatr Treat. 2003 Mar;9[2]:104-9. doi: 10.1192/apt.01.12 http://apt.rcpsych.org/content/9/2/104.full.)

Chandra P.S. Postpartum Psychiatric Care in India: The need for Integration and Innovation. (World Psychiatry. 2004;3[2]:99-100.)

Ahmad F., Shik A., Vanza R., Cheung A.M., George U, Stewart D.E. Voices of South Asian Women: Immigration and Mental Health. (Women Health 2004; 40[4]:113-130.)

Mantle F. Developing a Culture-Specific Tool to Assess Postnatal Depression in the Indian Community. (Br J Community Nurs. 2003;8[4]:176-180.)

To read about the goals of Curbside Consult, the guiding principles for assessment, and the guidelines for case submission, see “Considering patients’ family, culture,” Clinical Psychiatry News, January 2015, p. 12. The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or affiliated with or the Group for the Advancement of Psychiatry (GAP).

This column is in memory of Dr. Prakash N. Desai, who contributed to this piece before his death earlier this year.