Residents/Training

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

[polldaddy:9796432]

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

The term psychiatry is derived from the Greek words “pskhe” and “iatreia” which mean “healing of the soul.”¹ The desire to heal souls from different ethnicities, religions, and languages can be overwhelming for a trainee resident who is new to U.S. culture. The fear of having difficulty in building rapport with patients because of cultural bias and the dread of not understanding accents, slang, jokes, and nonverbal communication can be so frustrating that it overrides the intense desire of becoming an empathetic and successful physician.² During this critical period of training, residents need a training director who nudges them forward through the darkness and peels away the superficial and suffocating layers of incompetency that may keep them from reaching their full potential.

I started my residency training in 2014 without any substantial scholarly work in my background or clinical experience in the United States. However, I had a great learning experience at my training program and would like to express my gratitude by recognizing my program director’s (Panagiota Korenis, MD) role in helping me accomplish my career goals. She believed in me when I was not able to believe in myself, and helped me overcome a helpless feeling of isolation and desperation during my intern year. Because of her mentorship and supervision, I presented 20 posters and oral presentations; published 5 works; drafted guidelines for training residents, including course material on the health care disparities faced by the Lesbian, Gay Bisexual, Transgender, Queer community; created a tool to predict readmissions in an inpatient psychiatric setting; received many prestigious awards, including Resident of the Year, a Certificate of Academic Excellence, a Young Scholar Award, and an American Psychiatric Association Diversity Leadership Fellowship for 2017-2019; and was accepted for a child and adolescent psychiatry fellowship in one of my dream programs, Boston Children’s Hospital.

I strongly believe that the impact of an inspiring, motivating, and encouraging program director on a resident’s life is monumental. Here are some of the qualities I believe make a great program director who can significantly transform a trainee’s life:

A positive attitude.

• Encourage trainees to believe in their abilities, even if they stumble.
• Unleash and nurture their talents, and help them recognize their strengths and confidence.
• Foster a warm, welcoming, and supportive environment that enables residents to strive to reach their potential and goals.
• Boost confidence, acknowledge genuine efforts, and praise achievements.
• Encourage involvement in future projects.

Empathy and generosity.

• Treat residents with respect and care, while recognizing their strengths and weaknesses.
• Understand them at both a professional and personal level.
• Support meaningful and suitable projects that residents are passionate about and at which they excel.
• Influence residents by helping them understand the impact they have on patients and the program.
• Demonstrate sensitivity to the individual needs of each resident and provide constructive feedback.

Easy accessibility.

• Build good rapport with residents.
• Listen carefully to the residents’ ideas and feedback.
• Reassure residents that they can ask any questions or raise any issues they want to address.

Leadership.

• Color/BlackUndertake a leadership role within multidisciplinary teams, and collaborate effectively with other medical specialties for continuity of care, mutual support, Color/Blackand interdisciplinary education and communication.
• Assert authority when needed, and make important decisions for the program.
• Manage conflicts effectively and timely.
• Strictly monitor duty hours.³

Education.

• Design an educational curriculum relevant to all clinical settings.
• Provide protected time for didactics and scholarlyColor/Black activities.
• Ensure that residents develop a comprehensive understanding of the field.
• Actively involve residents in teaching, and modify the curriculum based on residents’ input and feedback.
• Schedule classes for in-service exams (eg, Psychiatry Residency In-Service Training Exam) and for the board exam preparation.⁴
• Promote residents’ autonomy and sense of competence.

Promote residents well-being.

• Encourage a work–life balance.
• Focus on team building and communication, and organize process groups.
• Adopt innovative ways to enable residents in managing stress.
• Organize social events and group activities, and provide support groups.
• Ensure adequate sleep hours and time away from work to prevent burnout.

Career development.

• Provide career guidance, and connect residents to appropriate resources for further professional development.
• Recognize that mentoring is a lifelong activity that does not end with the completion of residency training.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

What I thought would be a typical morning at the major county hospital – if that were ever possible on a psychiatric emergency unit (EU) – quickly turned atypical when I encountered a patient whom I will call Olivia.

Olivia is a 51-year-old male-to-female transgender woman who has not yet undergone gender reassignment surgery. She was brought to the EU by police, after expressing suicidal ideation during a phone call with a tax accountant. This was Olivia’s third visit to the psychiatric emergency unit because of suicide threats within 2 months. Though she was chronically suicidal, her current visit was triggered by a tax audit, which led her to view herself as an unwanted burden on society.

Historical perspective

Societal views of transgendered people vary. On one end of the spectrum is acceptance; in the middle is perhaps tolerance or mild discomfort at perceived abnormality; and at the other extreme are virulent hatred, discrimination, and invalidation of these individuals’ gender-affirming efforts.

Awareness of these hostile attitudes creates a vicious cycle of marginalization and mental illness among many transgender individuals.

Controversies surrounding sexual minorities are rooted in societal perceptions of gender delineations, and prevailing societal norms surrounding ethical and moral conduct. Most societies have a narrow perspective on gender, and seek to maintain a strict delineation of male and female identities, which contributes to the rejection of those with gender identity issues.^1,2 This often results in the invalidation of or active opposition to transgender individuals’ transition efforts. The reasons behind the rejection of transgender men and women are multifactorial, and can include a lack of awareness, homophobia, religious dogma, social stigmatization, and perceived non-employability – all often stemming largely from the lack of awareness that sexual identity and orientation are not a choice, but rather are predetermined by biological mechanisms. The intensifying familial, societal, political, and financial pressures all contribute to increased mental health issues, including increased incidence of suicide among sexual minorities.

Globally, sexual minorities continue to be subjected to gross human rights violations. Against the backdrop of prevalent social discrimination, transgender people experience a roughly threefold increase in the risk of developing anxiety disorders, which impair self-esteem and interpersonal functioning.³ The lifetime risk of attempted suicide is four times higher among transgender men, and two times higher among transgender women, than it is among cisgender men and women, respectively. Institutional discrimination in the public and private sectors results from laws and policies that impose inequities, or fail to protect sexual minorities. Examples are current policies denying medical coverage for sex reassignment surgery, denying health care by a provider because of transgender identity and numerous obstacles to obtain health insurance coverage.⁴

Impact of low acceptance

Recall Olivia’s need to delay the vocal cord surgery that arguably would have had a positive impact on her self-esteem. The transgender population faces increased health risks and barriers to appropriate mental health evaluation and inclusive care, particularly individuals with low acceptance from family, friends, and partners.⁵

A century ago, changing one’s gender was considered both highly disreputable and an impossible feat.⁶ Today, sex reassignment is the focus of political debate, with activists seeking equal rights for transgender individuals, despite the high rate of mental disorders in the community. While there is some positive public perception of transgender people, most still hold religious or moral objections to sex reassignment. Olivia’s family, for example, is typical in their rejection of her gender-affirming efforts. One example of this rejection is forbidding her to wear women’s clothing, stating that it makes them feel ashamed and subjects them to social ridicule.

As a result, Olivia lacks the social support that could work to remedy, to some extent, her suicidal ideation. Efforts to alleviate financial burdens that result from workplace discrimination, impediments to the pursuit of health, security, and happiness and the bureaucratic hurdles to gender affirmation are needed.^7,8 According to research by Kristen Clements-Nolle, PhD, MPH, and her associates, suicidality may be largely a reaction to the absence of legally secure equal rights for transgender men and women.⁹ In Olivia’s case, financial struggles with her mortgage, medical expenses for her autistic son, and anxiety about potentially losing the disability benefits on which she depends have added to her insecurity.

Financial insecurity resulting from her unemployment likely has exacerbated her feelings of inadequacy and depression. For example, because of her lack of financial resources, she had to delay the vocal cord surgery she desired. What would her prognosis be if her legal rights, including employment protection, were firmly in place? Likewise, the demands of parenting an autistic son posed another significant stressor that likely contributes to reciprocal stress for the child, resulting in the worsening of his autism symptoms.

In summary, transgender individuals face bias and discrimination in response to their gender-affirming efforts, which creates a vicious cycle of mental illness, suicidality, and societal marginalization. Addressing these endemic issues requires a multifaceted approach. Preventive strategies, including identification of mental health issues, and integration of mental health service with primary health care, are needed. Case registration, as a research measure to help understand the prevalence and severity of suicide among the LGBT population, would be beneficial.

Monitoring and follow-up of identified cases for supportive care (for example, gatekeeper training similar to the World Health Organization’s Suicide Prevention Initiative) also are needed to identify protective factors, in order to foster resilience in LGBT individuals facing negative reactions to disclosure of their sexual minority status. Legislation aimed at better facilitating a seamless integration of transgender men and women into mainstream society also is necessary. Supportive measures, particularly social supports promoting better mental health in trans individuals, could help reduce suicide rates. Finally, governmental initiatives to protect the human and constitutional rights of transgender people are key to minimizing the incidence of mental health issues and suicides among this vulnerable sexual minority group.

The path to addressing the issues faced by transgender individuals begins with education, which then leads to understanding. From understanding comes acceptance. Acceptance leads to equality – social, legal, and thereby, economic. Ensuring acceptance of all sexes as equal could mitigate the marginalization – in all its forms – experienced by gender-affirming individuals, with the end result being less mental illness and reduced rates of suicidality in this vulnerable population.⁷

Dr. Ahmed is a second-year resident in the department of psychiatry at the Nassau University Medical Center, East Meadow, New York. His interests include public social psychiatry, health care policy, health disparities, mental health stigma, and addiction psychiatry. Dr. Ahmed is a member of the American Psychiatric Association, the American Society of Clinical Psychopharmacology, and the American Association for Social Psychiatry.

References

1. LGBT Health. 2014 Jun;1(2):98-106.

2. Signs: Journal of Women in Culture and Society. 2006;32(1):83-111.

3. Int J Transgenderism. 2016:18(1):16-26.

4. Am J Public Health. 2014 Mar;104(3):e31-8.

5. Int J Transgenderism. 2017;18(1):104-18.

6. “Suicide attempts among transgender and gender non-conforming adults,” American Foundation for Suicide Prevention, 2014.

7. “Injustice at every turn: A report of the national transgender discrimination survey,” National Center for Transgender Equality, 2011.

8. J Gay Lesbian Soc Serv. 2014;26(2):186-206.

9. J Homosex. 2006;51(3):53-69.

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

Dating during residency is a job unto itself – one that I didn’t expect to balance alongside my long and frequently odd hours of work. To make matters worse, I happen to be in a field where the examination is almost entirely through conversation, involving probing questions, where maintaining calm and strength is important in the face of patient stories that often tear at my heart. Then, on a date (first or otherwise) I spend more time listening to another person’s stories while trying hard not to interpret the information through the perspective of my profession. To orient my older readers, I primarily date using the Internet and dating applications. There, my profile names me as “Resident.” This title is unassuming and unintimidating. Resident of what, potential suitors wonder, while examining carefully curated pictures of travel to exotic places and of me smiling happily with friends. I swipe right and left, matching with people, chatting digitally at first, and, if there is mutual interest, arranging to meet in person.

I get a different reaction every time I tell a date I’m a psychiatrist. It seems each man has his own expectations of what it means to date a psychiatrist. This column is a shout-out to all the physicians, and especially psychiatrists, who have been single while practicing, required to pretend our work is just like everyone else’s. Because the truth is, our work is different. How can one really describe the goings-on at a psychiatric hospital to a potential partner? Or deal with fatigue that accompanies listening to emotional suffering while at work and then needing the energy to commiserate with the person across the table?

Dr. Posada is a second-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.

In my first year of residency I faced a steep learning curve. I learned a lot about psychiatry, but I learned so much more about myself. If I had known then what I know now, my internship would have been smoother and more enjoyable.

Be organized. Create systems to remember your patients’ information and your to-do list. I have templates of progress notes, psychiatry assessments, mental status assessments, “rounds sheets” (a sheet listing every patient on my floor, including their diagnoses, laboratories, medications, and other notes). Although my system involves lots of paper, I like it. Make a system that works for you. Go out and have fun. I know you are tired, you haven’t slept, and your apartment is a mess, but you won’t remember that time you went home, did laundry, and went to bed early. You will remember the fun night when you and other interns went out and explored the city.

Unplug from medicine. Nothing is more boring than working for 12 hours, only to go out for drinks with coworkers and talk about work. Although you need to vent, life is more than medicine. Find time for something else. Read a book, play a video game, hang out with people who are not doctors. I started a monthly book club with other women around my age. Make some time for something other than your profession.

Reach out to your senior colleagues. I was so concerned about making a good first impression that I didn’t share my concerns with others. I kept my head low because I always blame myself first when something is wrong.

During an off-service rotation, I was unable to finish my shift because I had food poisoning. To make up for that uncompleted shift, the chief from that service gave me 2 extra night shifts. I found the measure extreme, but thought it was my fault for going home early. A few days later, the Psychiatry Chief Resident approached me, after he had seen my schedule and spoke with the other chief because he found the situation unfair. He was reaching out to me saying, “We’ve got your back.” I realized that it wasn’t always my fault, and I could speak up when there was an issue. I was fortunate to have seniors and chiefs who looked out for me. I always found support, good advice, and respect for my feelings.

If you have questions or concerns, are anxious, or feel something is wrong, approach a senior or the chief. They were in your shoes once and will give you their best advice.

Medicine is different in the United States. As an international medical graduate from Colombia, I panicked on my first day when everyone was talking in acronyms. I did not have a lot of U.S. clinical experience, and back home it’s frowned upon to write full sentences in acronyms. My students helped me get over it. I started my internship in the general medical floor and felt so embarrassed. Then I realized that it didn’t matter because it did not affect how I cared for my patients.

People understand that you are from another country. At the beginning, I used Google to search for everything, and then I realized that my 2 wonderful students didn’t think less of me because I didn’t know what BKA (below knee amputation) means. Do not be ashamed if you don’t know how things work in a different country. You will find people who are willing to help you; you will learn, and it will be a minor thing a year from now.

Keep your support system. It was 3 am in the emergency department, and on my break I went running out to the hallway feeling overwhelmed, tired, and lonely. I called my best friend across the globe.

If you moved away from home for residency, you are surrounded by new faces and far from the people you are comfortable with. Do not lose touch with them because you never know when you might need them the most. I had a hard road getting to where I am now, and many people helped me. You have to be there for them, too; a text message takes 30 seconds, and an e-mail, 1 minute.

Remember, you need to take care of yourself before taking care of others. No matter how much the MD or DO degree makes you feel like a superhero, you are still human.

In my first year of residency I faced a steep learning curve. I learned a lot about psychiatry, but I learned so much more about myself. If I had known then what I know now, my internship would have been smoother and more enjoyable.

Be organized. Create systems to remember your patients’ information and your to-do list. I have templates of progress notes, psychiatry assessments, mental status assessments, “rounds sheets” (a sheet listing every patient on my floor, including their diagnoses, laboratories, medications, and other notes). Although my system involves lots of paper, I like it. Make a system that works for you. Go out and have fun. I know you are tired, you haven’t slept, and your apartment is a mess, but you won’t remember that time you went home, did laundry, and went to bed early. You will remember the fun night when you and other interns went out and explored the city.

Unplug from medicine. Nothing is more boring than working for 12 hours, only to go out for drinks with coworkers and talk about work. Although you need to vent, life is more than medicine. Find time for something else. Read a book, play a video game, hang out with people who are not doctors. I started a monthly book club with other women around my age. Make some time for something other than your profession.

Reach out to your senior colleagues. I was so concerned about making a good first impression that I didn’t share my concerns with others. I kept my head low because I always blame myself first when something is wrong.

During an off-service rotation, I was unable to finish my shift because I had food poisoning. To make up for that uncompleted shift, the chief from that service gave me 2 extra night shifts. I found the measure extreme, but thought it was my fault for going home early. A few days later, the Psychiatry Chief Resident approached me, after he had seen my schedule and spoke with the other chief because he found the situation unfair. He was reaching out to me saying, “We’ve got your back.” I realized that it wasn’t always my fault, and I could speak up when there was an issue. I was fortunate to have seniors and chiefs who looked out for me. I always found support, good advice, and respect for my feelings.

If you have questions or concerns, are anxious, or feel something is wrong, approach a senior or the chief. They were in your shoes once and will give you their best advice.

Medicine is different in the United States. As an international medical graduate from Colombia, I panicked on my first day when everyone was talking in acronyms. I did not have a lot of U.S. clinical experience, and back home it’s frowned upon to write full sentences in acronyms. My students helped me get over it. I started my internship in the general medical floor and felt so embarrassed. Then I realized that it didn’t matter because it did not affect how I cared for my patients.

People understand that you are from another country. At the beginning, I used Google to search for everything, and then I realized that my 2 wonderful students didn’t think less of me because I didn’t know what BKA (below knee amputation) means. Do not be ashamed if you don’t know how things work in a different country. You will find people who are willing to help you; you will learn, and it will be a minor thing a year from now.

Keep your support system. It was 3 am in the emergency department, and on my break I went running out to the hallway feeling overwhelmed, tired, and lonely. I called my best friend across the globe.

If you moved away from home for residency, you are surrounded by new faces and far from the people you are comfortable with. Do not lose touch with them because you never know when you might need them the most. I had a hard road getting to where I am now, and many people helped me. You have to be there for them, too; a text message takes 30 seconds, and an e-mail, 1 minute.

Remember, you need to take care of yourself before taking care of others. No matter how much the MD or DO degree makes you feel like a superhero, you are still human.

In my first year of residency I faced a steep learning curve. I learned a lot about psychiatry, but I learned so much more about myself. If I had known then what I know now, my internship would have been smoother and more enjoyable.

Be organized. Create systems to remember your patients’ information and your to-do list. I have templates of progress notes, psychiatry assessments, mental status assessments, “rounds sheets” (a sheet listing every patient on my floor, including their diagnoses, laboratories, medications, and other notes). Although my system involves lots of paper, I like it. Make a system that works for you. Go out and have fun. I know you are tired, you haven’t slept, and your apartment is a mess, but you won’t remember that time you went home, did laundry, and went to bed early. You will remember the fun night when you and other interns went out and explored the city.

Unplug from medicine. Nothing is more boring than working for 12 hours, only to go out for drinks with coworkers and talk about work. Although you need to vent, life is more than medicine. Find time for something else. Read a book, play a video game, hang out with people who are not doctors. I started a monthly book club with other women around my age. Make some time for something other than your profession.

Reach out to your senior colleagues. I was so concerned about making a good first impression that I didn’t share my concerns with others. I kept my head low because I always blame myself first when something is wrong.

During an off-service rotation, I was unable to finish my shift because I had food poisoning. To make up for that uncompleted shift, the chief from that service gave me 2 extra night shifts. I found the measure extreme, but thought it was my fault for going home early. A few days later, the Psychiatry Chief Resident approached me, after he had seen my schedule and spoke with the other chief because he found the situation unfair. He was reaching out to me saying, “We’ve got your back.” I realized that it wasn’t always my fault, and I could speak up when there was an issue. I was fortunate to have seniors and chiefs who looked out for me. I always found support, good advice, and respect for my feelings.

If you have questions or concerns, are anxious, or feel something is wrong, approach a senior or the chief. They were in your shoes once and will give you their best advice.

Medicine is different in the United States. As an international medical graduate from Colombia, I panicked on my first day when everyone was talking in acronyms. I did not have a lot of U.S. clinical experience, and back home it’s frowned upon to write full sentences in acronyms. My students helped me get over it. I started my internship in the general medical floor and felt so embarrassed. Then I realized that it didn’t matter because it did not affect how I cared for my patients.

People understand that you are from another country. At the beginning, I used Google to search for everything, and then I realized that my 2 wonderful students didn’t think less of me because I didn’t know what BKA (below knee amputation) means. Do not be ashamed if you don’t know how things work in a different country. You will find people who are willing to help you; you will learn, and it will be a minor thing a year from now.

Keep your support system. It was 3 am in the emergency department, and on my break I went running out to the hallway feeling overwhelmed, tired, and lonely. I called my best friend across the globe.

If you moved away from home for residency, you are surrounded by new faces and far from the people you are comfortable with. Do not lose touch with them because you never know when you might need them the most. I had a hard road getting to where I am now, and many people helped me. You have to be there for them, too; a text message takes 30 seconds, and an e-mail, 1 minute.

Remember, you need to take care of yourself before taking care of others. No matter how much the MD or DO degree makes you feel like a superhero, you are still human.

Urine drug screening (UDS) is an important tool in emergency settings and substance abuse or pain management clinics. According to the 2015 National Survey on Drug Use and Health, 9.2% of individuals age ≥12 used an illicit drug other than marijuana within the previous year.¹

There are 2 types of UDS: gas chromatography–mass spectroscopy (GC-MS) and enzymatic immunoassay (EIA). A GC-MS uses a 2-step mechanisms to detect chemical compounds. First the GC separate the illicit substance into molecules, which is then introduced to the MS, which then separates compounds depending on their mass and charge using magnetic fields.^2,3 Although GC-MS is a more definitive means to confirm the presence of a specific drug, it rarely is used in clinical settings because it is expensive and time-consuming.

EIA is an anti-drug antibody added to the patient’s urine that causes a positive indicator reaction that can be measured.^2,3 It is a rapid, accurate, and cost-effective way of detecting illicit substances.⁴ However, there are limitations to EIAs used in most hospital laboratories.

Limitations of EIAs

Timing. Results of the drug screen depend on the time and frequency of drug use (Table 1).⁵

Preventing false-negatives

Substance abusing individuals could try to avoid detection of illicit drug use by using the following techniques:

• In vivo methods, such as drinking a large amount of water or using herbal products, can lead to false-negative results because of dilution.⁸
• In vitro adulterants are substances added to urine samples after urination to avoid drug detection. Active ingredients include glutaraldehyde (Clean-X), sodium or potassium nitrate (Klear, Whizzies), pyridinium chlorochromate (Urine Luck), andj (Stealth).⁹
• Other methods used to avoid drug detection include substituting a urine sample with someone else’s clean urine or adding household products, such as bleach, vinegar, or pipe cleaner.

You can spot and prevent false-negatives by:

Directly observing the patient, which helps to prevent individuals from adding foreign materials or substituting the urine sample.

Visually inspecting the urine helps identify sample tampering. Adding household adulterants can produce unusually bubbly, cloudy, clear, or dark sample.

On-site analyses and laboratory analyses of samples. Commercially sold kits can detect adulterants by on-site analysis, such as Intect 7 and AdultaCheck 4 test strips.⁹ Simple on-site methods can help discover tampering, such as measuring the urine’s temperature and using pigmented toilet water. The U.S. Substance Abuse and Mental Health Services Administration recommends validity checks during laboratory analysis for all urine samples, including temperature, creatinine, specific gravity, pH, and tests for oxidizing adulterants.¹⁰

Considerations

The results of UDS should not be interpreted as absolute. Knowing the sensitivity and specificity of the UDS that your institution uses and the patient’s current medication regimen is valuable in distinguishing between true results and false-positives. False-positives can strain the relationship between patient and provider, thus compromising care. When EIA is positive and patient denies substance use, confirming the result with GC-MS may be a good clinical practice.³ Ordering a GC-MS test can be helpful in situations requiring greater precision, such as in methadone or pain management clinics, to verify if the patient is taking a prescribed medication properly or to rule out illicit exposures with greater certainty.

Acknowledgment
The authors would like to thank Steven Lippmann, MD, for his mentorship, encouragement, and editorial support.

Urine drug screening (UDS) is an important tool in emergency settings and substance abuse or pain management clinics. According to the 2015 National Survey on Drug Use and Health, 9.2% of individuals age ≥12 used an illicit drug other than marijuana within the previous year.¹

There are 2 types of UDS: gas chromatography–mass spectroscopy (GC-MS) and enzymatic immunoassay (EIA). A GC-MS uses a 2-step mechanisms to detect chemical compounds. First the GC separate the illicit substance into molecules, which is then introduced to the MS, which then separates compounds depending on their mass and charge using magnetic fields.^2,3 Although GC-MS is a more definitive means to confirm the presence of a specific drug, it rarely is used in clinical settings because it is expensive and time-consuming.

EIA is an anti-drug antibody added to the patient’s urine that causes a positive indicator reaction that can be measured.^2,3 It is a rapid, accurate, and cost-effective way of detecting illicit substances.⁴ However, there are limitations to EIAs used in most hospital laboratories.

Limitations of EIAs

Timing. Results of the drug screen depend on the time and frequency of drug use (Table 1).⁵

Preventing false-negatives

Substance abusing individuals could try to avoid detection of illicit drug use by using the following techniques:

• In vivo methods, such as drinking a large amount of water or using herbal products, can lead to false-negative results because of dilution.⁸
• In vitro adulterants are substances added to urine samples after urination to avoid drug detection. Active ingredients include glutaraldehyde (Clean-X), sodium or potassium nitrate (Klear, Whizzies), pyridinium chlorochromate (Urine Luck), andj (Stealth).⁹
• Other methods used to avoid drug detection include substituting a urine sample with someone else’s clean urine or adding household products, such as bleach, vinegar, or pipe cleaner.

You can spot and prevent false-negatives by:

Directly observing the patient, which helps to prevent individuals from adding foreign materials or substituting the urine sample.

Visually inspecting the urine helps identify sample tampering. Adding household adulterants can produce unusually bubbly, cloudy, clear, or dark sample.

On-site analyses and laboratory analyses of samples. Commercially sold kits can detect adulterants by on-site analysis, such as Intect 7 and AdultaCheck 4 test strips.⁹ Simple on-site methods can help discover tampering, such as measuring the urine’s temperature and using pigmented toilet water. The U.S. Substance Abuse and Mental Health Services Administration recommends validity checks during laboratory analysis for all urine samples, including temperature, creatinine, specific gravity, pH, and tests for oxidizing adulterants.¹⁰

Considerations

The results of UDS should not be interpreted as absolute. Knowing the sensitivity and specificity of the UDS that your institution uses and the patient’s current medication regimen is valuable in distinguishing between true results and false-positives. False-positives can strain the relationship between patient and provider, thus compromising care. When EIA is positive and patient denies substance use, confirming the result with GC-MS may be a good clinical practice.³ Ordering a GC-MS test can be helpful in situations requiring greater precision, such as in methadone or pain management clinics, to verify if the patient is taking a prescribed medication properly or to rule out illicit exposures with greater certainty.

Acknowledgment
The authors would like to thank Steven Lippmann, MD, for his mentorship, encouragement, and editorial support.

Urine drug screening (UDS) is an important tool in emergency settings and substance abuse or pain management clinics. According to the 2015 National Survey on Drug Use and Health, 9.2% of individuals age ≥12 used an illicit drug other than marijuana within the previous year.¹

There are 2 types of UDS: gas chromatography–mass spectroscopy (GC-MS) and enzymatic immunoassay (EIA). A GC-MS uses a 2-step mechanisms to detect chemical compounds. First the GC separate the illicit substance into molecules, which is then introduced to the MS, which then separates compounds depending on their mass and charge using magnetic fields.^2,3 Although GC-MS is a more definitive means to confirm the presence of a specific drug, it rarely is used in clinical settings because it is expensive and time-consuming.

EIA is an anti-drug antibody added to the patient’s urine that causes a positive indicator reaction that can be measured.^2,3 It is a rapid, accurate, and cost-effective way of detecting illicit substances.⁴ However, there are limitations to EIAs used in most hospital laboratories.

Limitations of EIAs

Timing. Results of the drug screen depend on the time and frequency of drug use (Table 1).⁵

Preventing false-negatives

Substance abusing individuals could try to avoid detection of illicit drug use by using the following techniques:

• In vivo methods, such as drinking a large amount of water or using herbal products, can lead to false-negative results because of dilution.⁸
• In vitro adulterants are substances added to urine samples after urination to avoid drug detection. Active ingredients include glutaraldehyde (Clean-X), sodium or potassium nitrate (Klear, Whizzies), pyridinium chlorochromate (Urine Luck), andj (Stealth).⁹
• Other methods used to avoid drug detection include substituting a urine sample with someone else’s clean urine or adding household products, such as bleach, vinegar, or pipe cleaner.

You can spot and prevent false-negatives by:

Directly observing the patient, which helps to prevent individuals from adding foreign materials or substituting the urine sample.

Visually inspecting the urine helps identify sample tampering. Adding household adulterants can produce unusually bubbly, cloudy, clear, or dark sample.

On-site analyses and laboratory analyses of samples. Commercially sold kits can detect adulterants by on-site analysis, such as Intect 7 and AdultaCheck 4 test strips.⁹ Simple on-site methods can help discover tampering, such as measuring the urine’s temperature and using pigmented toilet water. The U.S. Substance Abuse and Mental Health Services Administration recommends validity checks during laboratory analysis for all urine samples, including temperature, creatinine, specific gravity, pH, and tests for oxidizing adulterants.¹⁰

Considerations

The results of UDS should not be interpreted as absolute. Knowing the sensitivity and specificity of the UDS that your institution uses and the patient’s current medication regimen is valuable in distinguishing between true results and false-positives. False-positives can strain the relationship between patient and provider, thus compromising care. When EIA is positive and patient denies substance use, confirming the result with GC-MS may be a good clinical practice.³ Ordering a GC-MS test can be helpful in situations requiring greater precision, such as in methadone or pain management clinics, to verify if the patient is taking a prescribed medication properly or to rule out illicit exposures with greater certainty.

Acknowledgment
The authors would like to thank Steven Lippmann, MD, for his mentorship, encouragement, and editorial support.

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for the most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psycho­social therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on fellowship, accountability, monitoring, and anonymity; the forum can compete with motivational interviewing for efficacy in increasing abstinence and preventing relapse.

The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.

In July 2017, Dr. Stanciu will be entering PGY-5 Addiction Psychiatry Fellowship, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and Dr. Gnanasegaram has accepted a Clinical Instructor position, Department of Psychiatric Medicine, Dartmouth-Hitchcock, New Hampshire.

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for the most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psycho­social therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on fellowship, accountability, monitoring, and anonymity; the forum can compete with motivational interviewing for efficacy in increasing abstinence and preventing relapse.

The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.

In July 2017, Dr. Stanciu will be entering PGY-5 Addiction Psychiatry Fellowship, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and Dr. Gnanasegaram has accepted a Clinical Instructor position, Department of Psychiatric Medicine, Dartmouth-Hitchcock, New Hampshire.

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for the most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psycho­social therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on fellowship, accountability, monitoring, and anonymity; the forum can compete with motivational interviewing for efficacy in increasing abstinence and preventing relapse.

The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.

In July 2017, Dr. Stanciu will be entering PGY-5 Addiction Psychiatry Fellowship, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and Dr. Gnanasegaram has accepted a Clinical Instructor position, Department of Psychiatric Medicine, Dartmouth-Hitchcock, New Hampshire.