Commentary

After the teledermatology consultation, an x-ray was recommended. The x-ray showed an elongated irregular radiopaque mass projecting from the anterior medial aspect of the midshaft of the distal phalanx of the great toe (Picture 3). With these findings, subungual exostosis was suspected, and she was referred to orthopedic surgery for excision of the lesion. Histopathology showed a stack of trabecular bone with a fibrocartilaginous cap, confirming the diagnosis of subungual exostosis.

Courtesy Dr. Puong To, Southern California Medical Group

Subungual exostosis is a benign osteocartilaginous tumor, first described by Dupuytren in 1874. These lesions are rare and are seen mainly in children and young adults. Females appear to be affected more often than males.¹ In a systematic review by DaCambra and colleagues, 55% of the cases occur in patients aged younger than 18 years, and the hallux was the most commonly affected digit, though any finger or toe can be affected.² There are reported case of congenital multiple exostosis delineated to translocation t(X;6)(q22;q13-14).³

The exact cause of these lesions is unknown, but there are multiple theories, which include a reactive process secondary to trauma, infection, or genetic causes. Pathologic examination of the lesions shows an osseous center covered by a fibrocartilaginous cap. There is proliferation of spindle cells that generate cartilage, which later forms trabecular bone.⁴

On physical examination, subungual exostosis appear like a firm, fixed nodule with a hyperkeratotic smooth surface at the distal end of the nail bed, that slowly grows and can distort and lift up the nail. Dermoscopy features of these lesions include vascular ectasia, hyperkeratosis, onycholysis, and ulceration.

The differential diagnosis of subungual growths includes osteochondromas, which can present in a similar way but are rarer. Pathologic examination is usually required to differentiate between both lesions.⁵ In exostoses, bone is formed directly from fibrous tissue, whereas in osteochondromas they derive from enchondral ossification.⁶ The cartilaginous cap of this lesion is what helps to differentiate it in histopathology. In subungual exostosis, the cap is composed of fibrocartilage, while in osteochondromas it is made of hyaline cartilage similar to what is seen in normal growing epiphysis.⁵ Subungual exostosis can be confused with pyogenic granulomas and verruca, and often are treated as such, which delays appropriate surgical management.

Firm, slow-growing tumors in the fingers or toes of children should raise suspicion for underlying bony lesions like subungual exostosis and osteochondromas. X-rays of the lesion should be performed in order to clarify the diagnosis. Referral to orthopedic surgery is needed for definitive surgical management.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Zhang W et al. JAAD Case Rep. 2020 Jun 1;6(8):725-6.

2. DaCambra MP et al. Clin Orthop Relat Res. 2014 Apr;472(4):1251-9.

3. Torlazzi C et al. Int J Cancer. 2006;118:1972-6.

4. Calonje E et al. McKee’s pathology of the skin: With clinical correlations. (4th ed.) Philadelphia: Elsevier/Saunders, 2012.

5. Lee SK et al. Foot Ankle Int. 2007 May;28(5):595-601.

6. Mavrogenis A et al. Orthopedics. 2008 Oct;31(10).

After the teledermatology consultation, an x-ray was recommended. The x-ray showed an elongated irregular radiopaque mass projecting from the anterior medial aspect of the midshaft of the distal phalanx of the great toe (Picture 3). With these findings, subungual exostosis was suspected, and she was referred to orthopedic surgery for excision of the lesion. Histopathology showed a stack of trabecular bone with a fibrocartilaginous cap, confirming the diagnosis of subungual exostosis.

Courtesy Dr. Puong To, Southern California Medical Group

Subungual exostosis is a benign osteocartilaginous tumor, first described by Dupuytren in 1874. These lesions are rare and are seen mainly in children and young adults. Females appear to be affected more often than males.¹ In a systematic review by DaCambra and colleagues, 55% of the cases occur in patients aged younger than 18 years, and the hallux was the most commonly affected digit, though any finger or toe can be affected.² There are reported case of congenital multiple exostosis delineated to translocation t(X;6)(q22;q13-14).³

The exact cause of these lesions is unknown, but there are multiple theories, which include a reactive process secondary to trauma, infection, or genetic causes. Pathologic examination of the lesions shows an osseous center covered by a fibrocartilaginous cap. There is proliferation of spindle cells that generate cartilage, which later forms trabecular bone.⁴

On physical examination, subungual exostosis appear like a firm, fixed nodule with a hyperkeratotic smooth surface at the distal end of the nail bed, that slowly grows and can distort and lift up the nail. Dermoscopy features of these lesions include vascular ectasia, hyperkeratosis, onycholysis, and ulceration.

The differential diagnosis of subungual growths includes osteochondromas, which can present in a similar way but are rarer. Pathologic examination is usually required to differentiate between both lesions.⁵ In exostoses, bone is formed directly from fibrous tissue, whereas in osteochondromas they derive from enchondral ossification.⁶ The cartilaginous cap of this lesion is what helps to differentiate it in histopathology. In subungual exostosis, the cap is composed of fibrocartilage, while in osteochondromas it is made of hyaline cartilage similar to what is seen in normal growing epiphysis.⁵ Subungual exostosis can be confused with pyogenic granulomas and verruca, and often are treated as such, which delays appropriate surgical management.

Firm, slow-growing tumors in the fingers or toes of children should raise suspicion for underlying bony lesions like subungual exostosis and osteochondromas. X-rays of the lesion should be performed in order to clarify the diagnosis. Referral to orthopedic surgery is needed for definitive surgical management.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Zhang W et al. JAAD Case Rep. 2020 Jun 1;6(8):725-6.

2. DaCambra MP et al. Clin Orthop Relat Res. 2014 Apr;472(4):1251-9.

3. Torlazzi C et al. Int J Cancer. 2006;118:1972-6.

4. Calonje E et al. McKee’s pathology of the skin: With clinical correlations. (4th ed.) Philadelphia: Elsevier/Saunders, 2012.

5. Lee SK et al. Foot Ankle Int. 2007 May;28(5):595-601.

6. Mavrogenis A et al. Orthopedics. 2008 Oct;31(10).

After the teledermatology consultation, an x-ray was recommended. The x-ray showed an elongated irregular radiopaque mass projecting from the anterior medial aspect of the midshaft of the distal phalanx of the great toe (Picture 3). With these findings, subungual exostosis was suspected, and she was referred to orthopedic surgery for excision of the lesion. Histopathology showed a stack of trabecular bone with a fibrocartilaginous cap, confirming the diagnosis of subungual exostosis.

Courtesy Dr. Puong To, Southern California Medical Group

Subungual exostosis is a benign osteocartilaginous tumor, first described by Dupuytren in 1874. These lesions are rare and are seen mainly in children and young adults. Females appear to be affected more often than males.¹ In a systematic review by DaCambra and colleagues, 55% of the cases occur in patients aged younger than 18 years, and the hallux was the most commonly affected digit, though any finger or toe can be affected.² There are reported case of congenital multiple exostosis delineated to translocation t(X;6)(q22;q13-14).³

The exact cause of these lesions is unknown, but there are multiple theories, which include a reactive process secondary to trauma, infection, or genetic causes. Pathologic examination of the lesions shows an osseous center covered by a fibrocartilaginous cap. There is proliferation of spindle cells that generate cartilage, which later forms trabecular bone.⁴

On physical examination, subungual exostosis appear like a firm, fixed nodule with a hyperkeratotic smooth surface at the distal end of the nail bed, that slowly grows and can distort and lift up the nail. Dermoscopy features of these lesions include vascular ectasia, hyperkeratosis, onycholysis, and ulceration.

The differential diagnosis of subungual growths includes osteochondromas, which can present in a similar way but are rarer. Pathologic examination is usually required to differentiate between both lesions.⁵ In exostoses, bone is formed directly from fibrous tissue, whereas in osteochondromas they derive from enchondral ossification.⁶ The cartilaginous cap of this lesion is what helps to differentiate it in histopathology. In subungual exostosis, the cap is composed of fibrocartilage, while in osteochondromas it is made of hyaline cartilage similar to what is seen in normal growing epiphysis.⁵ Subungual exostosis can be confused with pyogenic granulomas and verruca, and often are treated as such, which delays appropriate surgical management.

Firm, slow-growing tumors in the fingers or toes of children should raise suspicion for underlying bony lesions like subungual exostosis and osteochondromas. X-rays of the lesion should be performed in order to clarify the diagnosis. Referral to orthopedic surgery is needed for definitive surgical management.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego.

References

1. Zhang W et al. JAAD Case Rep. 2020 Jun 1;6(8):725-6.

2. DaCambra MP et al. Clin Orthop Relat Res. 2014 Apr;472(4):1251-9.

3. Torlazzi C et al. Int J Cancer. 2006;118:1972-6.

4. Calonje E et al. McKee’s pathology of the skin: With clinical correlations. (4th ed.) Philadelphia: Elsevier/Saunders, 2012.

5. Lee SK et al. Foot Ankle Int. 2007 May;28(5):595-601.

6. Mavrogenis A et al. Orthopedics. 2008 Oct;31(10).

An overwhelmingly loud and high-pitched screech rattles against your hip. You startle and groan into the pillow as your thoughts settle into conscious awareness. It is 3 a.m. You are a 2nd-year resident trudging through the night shift, alerted to the presence of a new patient awaiting an emergency assessment. You are the only in-house physician. Walking steadfastly toward the emergency unit, you enter and greet the patient. Immediately, you observe a look of surprise followed immediately by a scowl.

You extend a hand, but your greeting is abruptly cut short with: “I want to see a doctor!” You pace your breaths to quell annoyance and resume your introduction, asserting that you are a doctor and indeed the only doctor on duty. After moments of deep sighs and questions regarding your credentials, you persuade the patient to start the interview.

It is now 8 a.m. The frustration of the night starts to ease as you prepare to leave. While gathering your things, a visitor is overheard inquiring the whereabouts of a hospital unit. Volunteering as a guide, you walk the person toward the opposite end of the hospital. Bleary eyed, muscle laxed, and bone weary, you point out the entrance, then turn to leave. The steady rhythm of your steps suddenly halts as you hear from behind: “Thank you! You speak English really well!” Blankly, you stare. Your voice remains mute while your brain screams: “What is that supposed to mean?” But you do not utter a sound, because intuitively, you know the answer.

While reading this scenario, what did you feel? Pride in knowing that the physician was able to successfully navigate a busy night? Relief in the physician’s ability to maintain a professional demeanor despite belittling microaggressions? Are you angry? Would you replay those moments like reruns of a bad TV show? Can you imagine entering your home and collapsing onto the bed as your tears of fury pool over your rumpled sheets?

The emotional release of that morning is seared into my memory. Over the years, I questioned my reactions. Was I too passive? Should I have schooled them on their ignorance? Had I done so, would I have incurred reprimands? Would standing up for myself cause years of hard work to fall away? Moreover, had I defended myself, would I forever have been viewed as “The Angry Black Woman?”

This story is more than a vignette. For me, it is another reminder that, despite how far we have come, we have much further to go. As a Black woman in a professional sphere, I stand upon the shoulders of those who sacrificed for a dream, a greater purpose. My foremothers and forefathers fought bravely and tirelessly so that we could attain levels of success that were only once but a dream. Despite this progress, a grimace, carelessly spoken words, or a mindless gesture remind me that, no matter how much I toil and what levels of success I achieve, when I meet someone for the first time or encounter someone from my past, I find myself wondering whether I am remembered for me or because I am “The Black One.”
 

Honest look at medicine is imperative

It is important to consider multiple facets of the super-doctor myth. We are dedicated, fearless, authoritative, ambitious individuals. We do not yield to sickness, family obligations, or fatigue. Medicine is a calling, and the patient deserves the utmost respect and professional behavior. Impervious to ethnicity, race, nationality, or creed, we are unbiased and always in service of the greater good. Often, however, I wonder how the expectations of patient-focused, patient-centered care can prevail without an honest look at the vicissitudes facing medicine.

We find ourselves amid a tumultuous year overshadowed by a devastating pandemic that skews heavily toward Black and Brown communities, in addition to political turmoil and racial reckoning that sprang forth from fear, anger, and determination ignited by the murders of Breonna Taylor and George Floyd – communities united in outrage lamenting the cries of Black Lives Matter.

I remember the tears briskly falling upon my blouse as I watched Mr. Floyd’s life violently ripped from this Earth. Shortly thereafter, I remember the phone calls, emails, and texts from close friends, acquaintances, and colleagues offering support, listening ears, pledging to learn and endeavoring to understand the struggle for recognition and the fight for human rights. Even so, the deafening support was clouded by the preternatural silence of some medical organizations. Within the Black physician community, outrage was palpable. We reflected upon years of sacrifice and perseverance despite the challenge of bigotry, ignorance, and racism – not only from patients and their families – but also colleagues and administrators. Yet, in our time of horror and need, in those moments of vulnerability ... silence. Eventually, lengthy proclamations of support were expressed through various media. However, it felt too safe, too corporate, and too generic and inauthentic. As a result, an exodus of Black physicians from leadership positions and academic medicine took hold as the blatant continuation of rhetoric – coupled with ineffective outreach and support – finally took its toll.

Frequently, I question how the obstacles of medical school, residency, and beyond are expected to be traversed while living in a world that consistently affords additional challenges to those who look, act, or speak in a manner that varies from the perceived standard. In a culture where the myth of the super doctor reigns, how do we reconcile attainment of a false and detrimental narrative while the overarching pressure acutely felt by Black physicians magnifies in the setting of stereotypes, sociopolitical turbulence, bigotry, and racism? How can one sacrifice for an entity that is unwilling to acknowledge the psychological implications of that sacrifice?

Throughout my medical career, I encountered, personally and remotely, various incidents that emphasize the unique struggles facing Black physicians. For instance, while in medical school, I transitioned my hair to its natural state but was counseled against doing so because of the risk of losing residency opportunities as a direct result of my “unprofessional” appearance. Throughout residency, multiple incidents come to mind, including frequent demands to see my hospital badge despite the same not being of asked of my White cohorts; denial of entry into physician entrance within the residency building because, despite my professional attire, I was presumed to be a member of the custodial staff; and patients being confused and asking for a doctor despite my long white coat and clear introductions.

Furthermore, the fluency of my speech and the absence of regional dialect or vernacular are quite often lauded by patients. Inquiries to touch my hair as well as hypotheses regarding my nationality or degree of “blackness” with respect to the shape of my nose, eyes, and lips are openly questioned. Unfortunately, those uncomfortable incidents have not been limited to patient encounters.

In one instance, while presenting a patient in the presence of my attending and a 3rd-year medical student, I was sternly admonished for disclosing the race of the patient. I sat still and resolute as this doctor spoke on increased risk of bias in diagnosis and treatment when race is identified. Outwardly, I projected patience but inside, I seethed. In that moment, I realized that I would never have the luxury of ignorance or denial. Although I desire to be valued for my prowess in medicine, the mythical status was not created with my skin color in mind. For is avoidance not but a reflection of denial?

In these chaotic and uncertain times, how can we continue to promote a pathological ideal when the roads traveled are so fundamentally skewed? If a White physician faces a belligerent and argumentative patient, there is opportunity for debriefing both individually and among a larger cohort via classes, conferences, and supervisions. Conversely, when a Black physician is derided with racist sentiment, will they have the same opportunity for reflection and support? Despite identical expectations of professionalism and growth, how can one be successful in a system that either directly or indirectly encourages the opposite?

As we try to shed the super-doctor myth, we must recognize that this unattainable and detrimental persona hinders progress. This myth undermines our ability to understand our fragility, the limitations of our capabilities, and the strength of our vulnerability. We must take an honest look at the manner in which our individual biases and the deeply ingrained (and potentially unconscious) systemic biases are counterintuitive to the success and support of physicians of color.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

An overwhelmingly loud and high-pitched screech rattles against your hip. You startle and groan into the pillow as your thoughts settle into conscious awareness. It is 3 a.m. You are a 2nd-year resident trudging through the night shift, alerted to the presence of a new patient awaiting an emergency assessment. You are the only in-house physician. Walking steadfastly toward the emergency unit, you enter and greet the patient. Immediately, you observe a look of surprise followed immediately by a scowl.

You extend a hand, but your greeting is abruptly cut short with: “I want to see a doctor!” You pace your breaths to quell annoyance and resume your introduction, asserting that you are a doctor and indeed the only doctor on duty. After moments of deep sighs and questions regarding your credentials, you persuade the patient to start the interview.

It is now 8 a.m. The frustration of the night starts to ease as you prepare to leave. While gathering your things, a visitor is overheard inquiring the whereabouts of a hospital unit. Volunteering as a guide, you walk the person toward the opposite end of the hospital. Bleary eyed, muscle laxed, and bone weary, you point out the entrance, then turn to leave. The steady rhythm of your steps suddenly halts as you hear from behind: “Thank you! You speak English really well!” Blankly, you stare. Your voice remains mute while your brain screams: “What is that supposed to mean?” But you do not utter a sound, because intuitively, you know the answer.

While reading this scenario, what did you feel? Pride in knowing that the physician was able to successfully navigate a busy night? Relief in the physician’s ability to maintain a professional demeanor despite belittling microaggressions? Are you angry? Would you replay those moments like reruns of a bad TV show? Can you imagine entering your home and collapsing onto the bed as your tears of fury pool over your rumpled sheets?

The emotional release of that morning is seared into my memory. Over the years, I questioned my reactions. Was I too passive? Should I have schooled them on their ignorance? Had I done so, would I have incurred reprimands? Would standing up for myself cause years of hard work to fall away? Moreover, had I defended myself, would I forever have been viewed as “The Angry Black Woman?”

This story is more than a vignette. For me, it is another reminder that, despite how far we have come, we have much further to go. As a Black woman in a professional sphere, I stand upon the shoulders of those who sacrificed for a dream, a greater purpose. My foremothers and forefathers fought bravely and tirelessly so that we could attain levels of success that were only once but a dream. Despite this progress, a grimace, carelessly spoken words, or a mindless gesture remind me that, no matter how much I toil and what levels of success I achieve, when I meet someone for the first time or encounter someone from my past, I find myself wondering whether I am remembered for me or because I am “The Black One.”
 

Honest look at medicine is imperative

It is important to consider multiple facets of the super-doctor myth. We are dedicated, fearless, authoritative, ambitious individuals. We do not yield to sickness, family obligations, or fatigue. Medicine is a calling, and the patient deserves the utmost respect and professional behavior. Impervious to ethnicity, race, nationality, or creed, we are unbiased and always in service of the greater good. Often, however, I wonder how the expectations of patient-focused, patient-centered care can prevail without an honest look at the vicissitudes facing medicine.

We find ourselves amid a tumultuous year overshadowed by a devastating pandemic that skews heavily toward Black and Brown communities, in addition to political turmoil and racial reckoning that sprang forth from fear, anger, and determination ignited by the murders of Breonna Taylor and George Floyd – communities united in outrage lamenting the cries of Black Lives Matter.

I remember the tears briskly falling upon my blouse as I watched Mr. Floyd’s life violently ripped from this Earth. Shortly thereafter, I remember the phone calls, emails, and texts from close friends, acquaintances, and colleagues offering support, listening ears, pledging to learn and endeavoring to understand the struggle for recognition and the fight for human rights. Even so, the deafening support was clouded by the preternatural silence of some medical organizations. Within the Black physician community, outrage was palpable. We reflected upon years of sacrifice and perseverance despite the challenge of bigotry, ignorance, and racism – not only from patients and their families – but also colleagues and administrators. Yet, in our time of horror and need, in those moments of vulnerability ... silence. Eventually, lengthy proclamations of support were expressed through various media. However, it felt too safe, too corporate, and too generic and inauthentic. As a result, an exodus of Black physicians from leadership positions and academic medicine took hold as the blatant continuation of rhetoric – coupled with ineffective outreach and support – finally took its toll.

Frequently, I question how the obstacles of medical school, residency, and beyond are expected to be traversed while living in a world that consistently affords additional challenges to those who look, act, or speak in a manner that varies from the perceived standard. In a culture where the myth of the super doctor reigns, how do we reconcile attainment of a false and detrimental narrative while the overarching pressure acutely felt by Black physicians magnifies in the setting of stereotypes, sociopolitical turbulence, bigotry, and racism? How can one sacrifice for an entity that is unwilling to acknowledge the psychological implications of that sacrifice?

Throughout my medical career, I encountered, personally and remotely, various incidents that emphasize the unique struggles facing Black physicians. For instance, while in medical school, I transitioned my hair to its natural state but was counseled against doing so because of the risk of losing residency opportunities as a direct result of my “unprofessional” appearance. Throughout residency, multiple incidents come to mind, including frequent demands to see my hospital badge despite the same not being of asked of my White cohorts; denial of entry into physician entrance within the residency building because, despite my professional attire, I was presumed to be a member of the custodial staff; and patients being confused and asking for a doctor despite my long white coat and clear introductions.

Furthermore, the fluency of my speech and the absence of regional dialect or vernacular are quite often lauded by patients. Inquiries to touch my hair as well as hypotheses regarding my nationality or degree of “blackness” with respect to the shape of my nose, eyes, and lips are openly questioned. Unfortunately, those uncomfortable incidents have not been limited to patient encounters.

In one instance, while presenting a patient in the presence of my attending and a 3rd-year medical student, I was sternly admonished for disclosing the race of the patient. I sat still and resolute as this doctor spoke on increased risk of bias in diagnosis and treatment when race is identified. Outwardly, I projected patience but inside, I seethed. In that moment, I realized that I would never have the luxury of ignorance or denial. Although I desire to be valued for my prowess in medicine, the mythical status was not created with my skin color in mind. For is avoidance not but a reflection of denial?

In these chaotic and uncertain times, how can we continue to promote a pathological ideal when the roads traveled are so fundamentally skewed? If a White physician faces a belligerent and argumentative patient, there is opportunity for debriefing both individually and among a larger cohort via classes, conferences, and supervisions. Conversely, when a Black physician is derided with racist sentiment, will they have the same opportunity for reflection and support? Despite identical expectations of professionalism and growth, how can one be successful in a system that either directly or indirectly encourages the opposite?

As we try to shed the super-doctor myth, we must recognize that this unattainable and detrimental persona hinders progress. This myth undermines our ability to understand our fragility, the limitations of our capabilities, and the strength of our vulnerability. We must take an honest look at the manner in which our individual biases and the deeply ingrained (and potentially unconscious) systemic biases are counterintuitive to the success and support of physicians of color.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

An overwhelmingly loud and high-pitched screech rattles against your hip. You startle and groan into the pillow as your thoughts settle into conscious awareness. It is 3 a.m. You are a 2nd-year resident trudging through the night shift, alerted to the presence of a new patient awaiting an emergency assessment. You are the only in-house physician. Walking steadfastly toward the emergency unit, you enter and greet the patient. Immediately, you observe a look of surprise followed immediately by a scowl.

You extend a hand, but your greeting is abruptly cut short with: “I want to see a doctor!” You pace your breaths to quell annoyance and resume your introduction, asserting that you are a doctor and indeed the only doctor on duty. After moments of deep sighs and questions regarding your credentials, you persuade the patient to start the interview.

It is now 8 a.m. The frustration of the night starts to ease as you prepare to leave. While gathering your things, a visitor is overheard inquiring the whereabouts of a hospital unit. Volunteering as a guide, you walk the person toward the opposite end of the hospital. Bleary eyed, muscle laxed, and bone weary, you point out the entrance, then turn to leave. The steady rhythm of your steps suddenly halts as you hear from behind: “Thank you! You speak English really well!” Blankly, you stare. Your voice remains mute while your brain screams: “What is that supposed to mean?” But you do not utter a sound, because intuitively, you know the answer.

While reading this scenario, what did you feel? Pride in knowing that the physician was able to successfully navigate a busy night? Relief in the physician’s ability to maintain a professional demeanor despite belittling microaggressions? Are you angry? Would you replay those moments like reruns of a bad TV show? Can you imagine entering your home and collapsing onto the bed as your tears of fury pool over your rumpled sheets?

The emotional release of that morning is seared into my memory. Over the years, I questioned my reactions. Was I too passive? Should I have schooled them on their ignorance? Had I done so, would I have incurred reprimands? Would standing up for myself cause years of hard work to fall away? Moreover, had I defended myself, would I forever have been viewed as “The Angry Black Woman?”

This story is more than a vignette. For me, it is another reminder that, despite how far we have come, we have much further to go. As a Black woman in a professional sphere, I stand upon the shoulders of those who sacrificed for a dream, a greater purpose. My foremothers and forefathers fought bravely and tirelessly so that we could attain levels of success that were only once but a dream. Despite this progress, a grimace, carelessly spoken words, or a mindless gesture remind me that, no matter how much I toil and what levels of success I achieve, when I meet someone for the first time or encounter someone from my past, I find myself wondering whether I am remembered for me or because I am “The Black One.”
 

Honest look at medicine is imperative

It is important to consider multiple facets of the super-doctor myth. We are dedicated, fearless, authoritative, ambitious individuals. We do not yield to sickness, family obligations, or fatigue. Medicine is a calling, and the patient deserves the utmost respect and professional behavior. Impervious to ethnicity, race, nationality, or creed, we are unbiased and always in service of the greater good. Often, however, I wonder how the expectations of patient-focused, patient-centered care can prevail without an honest look at the vicissitudes facing medicine.

We find ourselves amid a tumultuous year overshadowed by a devastating pandemic that skews heavily toward Black and Brown communities, in addition to political turmoil and racial reckoning that sprang forth from fear, anger, and determination ignited by the murders of Breonna Taylor and George Floyd – communities united in outrage lamenting the cries of Black Lives Matter.

I remember the tears briskly falling upon my blouse as I watched Mr. Floyd’s life violently ripped from this Earth. Shortly thereafter, I remember the phone calls, emails, and texts from close friends, acquaintances, and colleagues offering support, listening ears, pledging to learn and endeavoring to understand the struggle for recognition and the fight for human rights. Even so, the deafening support was clouded by the preternatural silence of some medical organizations. Within the Black physician community, outrage was palpable. We reflected upon years of sacrifice and perseverance despite the challenge of bigotry, ignorance, and racism – not only from patients and their families – but also colleagues and administrators. Yet, in our time of horror and need, in those moments of vulnerability ... silence. Eventually, lengthy proclamations of support were expressed through various media. However, it felt too safe, too corporate, and too generic and inauthentic. As a result, an exodus of Black physicians from leadership positions and academic medicine took hold as the blatant continuation of rhetoric – coupled with ineffective outreach and support – finally took its toll.

Frequently, I question how the obstacles of medical school, residency, and beyond are expected to be traversed while living in a world that consistently affords additional challenges to those who look, act, or speak in a manner that varies from the perceived standard. In a culture where the myth of the super doctor reigns, how do we reconcile attainment of a false and detrimental narrative while the overarching pressure acutely felt by Black physicians magnifies in the setting of stereotypes, sociopolitical turbulence, bigotry, and racism? How can one sacrifice for an entity that is unwilling to acknowledge the psychological implications of that sacrifice?

Throughout my medical career, I encountered, personally and remotely, various incidents that emphasize the unique struggles facing Black physicians. For instance, while in medical school, I transitioned my hair to its natural state but was counseled against doing so because of the risk of losing residency opportunities as a direct result of my “unprofessional” appearance. Throughout residency, multiple incidents come to mind, including frequent demands to see my hospital badge despite the same not being of asked of my White cohorts; denial of entry into physician entrance within the residency building because, despite my professional attire, I was presumed to be a member of the custodial staff; and patients being confused and asking for a doctor despite my long white coat and clear introductions.

Furthermore, the fluency of my speech and the absence of regional dialect or vernacular are quite often lauded by patients. Inquiries to touch my hair as well as hypotheses regarding my nationality or degree of “blackness” with respect to the shape of my nose, eyes, and lips are openly questioned. Unfortunately, those uncomfortable incidents have not been limited to patient encounters.

In one instance, while presenting a patient in the presence of my attending and a 3rd-year medical student, I was sternly admonished for disclosing the race of the patient. I sat still and resolute as this doctor spoke on increased risk of bias in diagnosis and treatment when race is identified. Outwardly, I projected patience but inside, I seethed. In that moment, I realized that I would never have the luxury of ignorance or denial. Although I desire to be valued for my prowess in medicine, the mythical status was not created with my skin color in mind. For is avoidance not but a reflection of denial?

In these chaotic and uncertain times, how can we continue to promote a pathological ideal when the roads traveled are so fundamentally skewed? If a White physician faces a belligerent and argumentative patient, there is opportunity for debriefing both individually and among a larger cohort via classes, conferences, and supervisions. Conversely, when a Black physician is derided with racist sentiment, will they have the same opportunity for reflection and support? Despite identical expectations of professionalism and growth, how can one be successful in a system that either directly or indirectly encourages the opposite?

As we try to shed the super-doctor myth, we must recognize that this unattainable and detrimental persona hinders progress. This myth undermines our ability to understand our fragility, the limitations of our capabilities, and the strength of our vulnerability. We must take an honest look at the manner in which our individual biases and the deeply ingrained (and potentially unconscious) systemic biases are counterintuitive to the success and support of physicians of color.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

Since the COVID-19 pandemic began, I have received a growing number of inquiries about collection issues. For a variety of reasons, many patients seem increasingly reluctant to pay their medical bills. I’ve written many columns on keeping credit card numbers on file, and other techniques for keeping your accounts receivable in check; but despite your best efforts, there will always be a few deadbeats that you will need to pursue.

For the record, I am not speaking about patients who lost income due to the pandemic and are now struggling with debts, or otherwise have fallen on hard times and are unable to pay. I am addressing the problem of patients who are able to pay, but for whatever reason, do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and keep them. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home repeatedly, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

With my credit-card-on-file system that I’ve described many times, patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases where you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at formswift.com, templates.office.com, and many other websites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for a nominal fee. The more financial information you have on file, the more leverage you have if a patient later balks at paying his or her balance.

For cosmetic work, always take before and after photos, and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of claiming ignorance of personal financial obligations and professing dissatisfaction with the results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You will need to learn the rules in your state, but in most states there is a small filing fee and a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you will still have to persuade the deadbeat to pay up. However, in many states a court order will give you the authority to attach a lien to property, or garnish wages, which often provides enough leverage to force payment.

What about those double-deadbeats who keep the insurance checks for themselves? First, check your third-party contract; sometimes the insurance company or HMO will be compelled to pay you directly and then go after the patient to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099 Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes the threat of such action will convince the individual to pay up; if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Since the COVID-19 pandemic began, I have received a growing number of inquiries about collection issues. For a variety of reasons, many patients seem increasingly reluctant to pay their medical bills. I’ve written many columns on keeping credit card numbers on file, and other techniques for keeping your accounts receivable in check; but despite your best efforts, there will always be a few deadbeats that you will need to pursue.

For the record, I am not speaking about patients who lost income due to the pandemic and are now struggling with debts, or otherwise have fallen on hard times and are unable to pay. I am addressing the problem of patients who are able to pay, but for whatever reason, do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and keep them. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home repeatedly, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

With my credit-card-on-file system that I’ve described many times, patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases where you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at formswift.com, templates.office.com, and many other websites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for a nominal fee. The more financial information you have on file, the more leverage you have if a patient later balks at paying his or her balance.

For cosmetic work, always take before and after photos, and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of claiming ignorance of personal financial obligations and professing dissatisfaction with the results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You will need to learn the rules in your state, but in most states there is a small filing fee and a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you will still have to persuade the deadbeat to pay up. However, in many states a court order will give you the authority to attach a lien to property, or garnish wages, which often provides enough leverage to force payment.

What about those double-deadbeats who keep the insurance checks for themselves? First, check your third-party contract; sometimes the insurance company or HMO will be compelled to pay you directly and then go after the patient to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099 Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes the threat of such action will convince the individual to pay up; if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Since the COVID-19 pandemic began, I have received a growing number of inquiries about collection issues. For a variety of reasons, many patients seem increasingly reluctant to pay their medical bills. I’ve written many columns on keeping credit card numbers on file, and other techniques for keeping your accounts receivable in check; but despite your best efforts, there will always be a few deadbeats that you will need to pursue.

For the record, I am not speaking about patients who lost income due to the pandemic and are now struggling with debts, or otherwise have fallen on hard times and are unable to pay. I am addressing the problem of patients who are able to pay, but for whatever reason, do not.

The worst kinds of deadbeats are the ones who rob you twice; they accept payments from insurance companies and keep them. Such crooks must be pursued aggressively, with all the means at your disposal; but to reiterate the point I’ve tried to drive home repeatedly, the best cure is prevention.

You already know that you should collect as many fees as possible at the time of service. For cosmetic procedures you should require a substantial deposit in advance, with the balance due at the time of service. When that is impossible, maximize the chances you will be paid by making sure all available payment mechanisms are in place.

With my credit-card-on-file system that I’ve described many times, patients who fail to pay their credit card bill are the credit card company’s problem, not yours. In cases where you suspect fees might exceed credit card limits, you can arrange a realistic payment schedule in advance and have the patient fill out a credit application. You can find forms for this online at formswift.com, templates.office.com, and many other websites.

In some cases, it may be worth the trouble to run a background check. There are easy and affordable ways to do this. Dunn & Bradstreet, for example, will furnish a report containing payment records and details of any lawsuits, liens, and other legal actions for a nominal fee. The more financial information you have on file, the more leverage you have if a patient later balks at paying his or her balance.

For cosmetic work, always take before and after photos, and have all patients sign a written consent giving permission for the procedure, assuming full financial responsibility, and acknowledging that no guarantees have been given or implied. This defuses the common deadbeat tactics of claiming ignorance of personal financial obligations and professing dissatisfaction with the results.

Despite all your precautions, a deadbeat will inevitably slip through on occasion; but even then, you have options for extracting payment. Collection agencies are the traditional first line of attack for most medical practices. Ideally, your agency should specialize in handling medical accounts, so it will know exactly how much pressure to exert to avoid charges of harassment. Delinquent accounts should be submitted earlier rather than later to maximize the chances of success; my manager never allows an account to age more than 90 days, and if circumstances dictate, she refers them sooner than that.

When collection agencies fail, think about small claims court. You will need to learn the rules in your state, but in most states there is a small filing fee and a limit of $5,000 or so on claims. No attorneys are involved. If your paperwork is in order, the court will nearly always rule in your favor, but it will not provide the means for actual collection. In other words, you will still have to persuade the deadbeat to pay up. However, in many states a court order will give you the authority to attach a lien to property, or garnish wages, which often provides enough leverage to force payment.

What about those double-deadbeats who keep the insurance checks for themselves? First, check your third-party contract; sometimes the insurance company or HMO will be compelled to pay you directly and then go after the patient to get back its money. (They won’t volunteer this service, however – you’ll have to ask for it.)

If that’s not an option, consider reporting the misdirected payment to the Internal Revenue Service as income to the patient, by submitting a 1099 Miscellaneous Income form. Be sure to notify the deadbeat that you will be doing this. Sometimes the threat of such action will convince the individual to pay up; if not, at least you’ll have the satisfaction of knowing he or she will have to pay taxes on the money.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

“I want my child to go back to school,” the mother said to me. “I just want you to tell me it will be safe.”

As the summer break winds down for children across the United States, pediatric COVID-19 cases are rising. According to the American Academy of Pediatrics, nearly 94,000 cases were reported for the week ending Aug. 5, more than double the case count from 2 weeks earlier.¹

Anecdotally, some children’s hospitals are reporting an increase in pediatric COVID-19 admissions. In the hospital in which I practice, we are seeing numbers similar to those we saw in December and January: a typical daily census of 10 kids admitted with COVID-19, with 4 of them in the intensive care unit. It is a stark contrast to June when, most days, we had no patients with COVID-19 in the hospital. About half of our hospitalized patients are too young to be vaccinated against COVID-19, while the rest are unvaccinated children 12 years and older.

Vaccination of eligible children and teachers is an essential strategy for preventing the spread of COVID-19 in schools, but as children head back to school, immunization rates of educators are largely unknown and are suboptimal among students in most states. As of Aug. 11, 10.7 million U.S. children had received at least one dose of COVID-19 vaccine, representing 43% of 12- to 15-year-olds and 53% of 16- to 17-year-olds.² Rates vary substantially by state, with more than 70% of kids in Vermont receiving at least one dose of vaccine, compared with less than 25% in Wyoming and Alabama.

Still, in the absence of robust immunization rates, we have data that schools can still reopen successfully. We need to follow the science and implement universal masking, a safe, effective, and practical mitigation strategy.

It worked in Wisconsin. Seventeen K-12 schools in rural Wisconsin opened last fall for in-person instruction.³ Reported compliance with masking was high, ranging from 92.1% to 97.4%, and in-school transmission of COVID-19 was low, with seven cases among 4,876 students.

It worked in Salt Lake City.⁴ In 20 elementary schools open for in-person instruction Dec. 3, 2020, to Jan. 31, 2021, compliance with mask-wearing was high and in-school transmission was very low, despite a high community incidence of COVID-19. Notably, students’ classroom seats were less than 6 feet apart, suggesting that consistent mask-wearing works even when physical distancing is challenging.

One of the best examples of successful school reopening happened in North Carolina, where pediatricians, pediatric infectious disease specialists, and other experts affiliated with Duke University formed the ABC Science Collaborative to support school districts that requested scientific input to help guide return-to-school policies during the COVID-19 pandemic. From Oct. 26, 2020, to Feb. 28, 2021, the ABC Science Collaborative worked with 13 school districts that were open for in-person instruction using basic mitigation strategies, including universal masking.⁵ During this time period, there were 4,969 community-acquired SARS-CoV-2 infections in the more than 100,000 students and staff present in schools. Transmission to school contacts was identified in only 209 individuals for a secondary attack rate of less than 1%.

Duke investigator Kanecia Zimmerman, MD, told Duke Today, “We know that, if our goal is to reduce transmission of COVID-19 in schools, there are two effective ways to do that: 1. vaccination, 2. masking. In the setting of schools ... the science suggests masking can be extremely effective, particularly for those who can’t get vaccinated while COVID-19 is still circulating.”

Both the AAP⁶ and the Pediatric Infectious Diseases Society⁷ have emphasized the importance of in-person instruction and endorsed universal masking in school. Mask-optional policies or “mask-if-you-are-unvaccinated” policies don’t work, as we have seen in society at large. They are likely to be especially challenging in school settings. Given an option, many, if not most kids, will take off their masks. Kids who leave them on run the risk of stigmatization or bullying.

On Aug. 4, the Centers for Disease Control and Prevention updated its guidance to recommend universal indoor masking for all students, staff, teachers, and visitors to K-12 schools, regardless of vaccination status. Now we’ll have to wait and see if school districts, elected officials, and parents will get on board with masks. ... and we’ll be left to count the number of rising COVID-19 cases that occur until they do.

Case in point: Kids in Greater Clark County, Ind., headed back to school on July 28. Masks were not required on school property, although unvaccinated students and teachers were “strongly encouraged” to wear them.⁸

Over the first 8 days of in-person instruction, schools in Greater Clark County identified 70 cases of COVID-19 in students and quarantined more than 1,100 of the district’s 10,300 students. Only the unvaccinated were required to quarantine. The district began requiring masks in all school buildings on Aug. 9.⁹

The worried mother had one last question for me. “What’s the best mask for a child to wear?” For most kids, a simple, well-fitting cloth mask is fine. The best mask is ultimately the mask a child will wear. A toolkit with practical tips for helping children successfully wear a mask is available on the ABC Science Collaborative website.
 

Dr. Bryant, president of the Pediatric Infectious Diseases Society, is a pediatrician at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. American Academy of Pediatrics. “Children and COVID-19: State-level data report.”

2. American Academy of Pediatrics. “Children and COVID-19 vaccination trends.”

3. Falk A et al. MMWR Morb Mortal Wkly Rep. 2021;70:136-40.

4. Hershow RB et al. MMWR Morb Mortal Wkly Rep 2021;70:442-8.

5. Zimmerman KO et al. Pediatrics. 2021 Jul;e2021052686. doi: 10.1542/peds.2021-052686.

6. American Academy of Pediatrics. “American Academy of Pediatrics updates recommendations for opening schools in fall 2021.”

7. Pediatric Infectious Diseases Society. “PIDS supports universal masking for students, school staff.”

8. Courtney Hayden. WHAS11. “Greater Clark County Schools return to class July 28.”

9. Dustin Vogt. WAVE3 News. “Greater Clark Country Schools to require masks amid 70 positive cases.”

“I want my child to go back to school,” the mother said to me. “I just want you to tell me it will be safe.”

As the summer break winds down for children across the United States, pediatric COVID-19 cases are rising. According to the American Academy of Pediatrics, nearly 94,000 cases were reported for the week ending Aug. 5, more than double the case count from 2 weeks earlier.¹

Anecdotally, some children’s hospitals are reporting an increase in pediatric COVID-19 admissions. In the hospital in which I practice, we are seeing numbers similar to those we saw in December and January: a typical daily census of 10 kids admitted with COVID-19, with 4 of them in the intensive care unit. It is a stark contrast to June when, most days, we had no patients with COVID-19 in the hospital. About half of our hospitalized patients are too young to be vaccinated against COVID-19, while the rest are unvaccinated children 12 years and older.

Vaccination of eligible children and teachers is an essential strategy for preventing the spread of COVID-19 in schools, but as children head back to school, immunization rates of educators are largely unknown and are suboptimal among students in most states. As of Aug. 11, 10.7 million U.S. children had received at least one dose of COVID-19 vaccine, representing 43% of 12- to 15-year-olds and 53% of 16- to 17-year-olds.² Rates vary substantially by state, with more than 70% of kids in Vermont receiving at least one dose of vaccine, compared with less than 25% in Wyoming and Alabama.

Still, in the absence of robust immunization rates, we have data that schools can still reopen successfully. We need to follow the science and implement universal masking, a safe, effective, and practical mitigation strategy.

It worked in Wisconsin. Seventeen K-12 schools in rural Wisconsin opened last fall for in-person instruction.³ Reported compliance with masking was high, ranging from 92.1% to 97.4%, and in-school transmission of COVID-19 was low, with seven cases among 4,876 students.

It worked in Salt Lake City.⁴ In 20 elementary schools open for in-person instruction Dec. 3, 2020, to Jan. 31, 2021, compliance with mask-wearing was high and in-school transmission was very low, despite a high community incidence of COVID-19. Notably, students’ classroom seats were less than 6 feet apart, suggesting that consistent mask-wearing works even when physical distancing is challenging.

One of the best examples of successful school reopening happened in North Carolina, where pediatricians, pediatric infectious disease specialists, and other experts affiliated with Duke University formed the ABC Science Collaborative to support school districts that requested scientific input to help guide return-to-school policies during the COVID-19 pandemic. From Oct. 26, 2020, to Feb. 28, 2021, the ABC Science Collaborative worked with 13 school districts that were open for in-person instruction using basic mitigation strategies, including universal masking.⁵ During this time period, there were 4,969 community-acquired SARS-CoV-2 infections in the more than 100,000 students and staff present in schools. Transmission to school contacts was identified in only 209 individuals for a secondary attack rate of less than 1%.

Duke investigator Kanecia Zimmerman, MD, told Duke Today, “We know that, if our goal is to reduce transmission of COVID-19 in schools, there are two effective ways to do that: 1. vaccination, 2. masking. In the setting of schools ... the science suggests masking can be extremely effective, particularly for those who can’t get vaccinated while COVID-19 is still circulating.”

Both the AAP⁶ and the Pediatric Infectious Diseases Society⁷ have emphasized the importance of in-person instruction and endorsed universal masking in school. Mask-optional policies or “mask-if-you-are-unvaccinated” policies don’t work, as we have seen in society at large. They are likely to be especially challenging in school settings. Given an option, many, if not most kids, will take off their masks. Kids who leave them on run the risk of stigmatization or bullying.

On Aug. 4, the Centers for Disease Control and Prevention updated its guidance to recommend universal indoor masking for all students, staff, teachers, and visitors to K-12 schools, regardless of vaccination status. Now we’ll have to wait and see if school districts, elected officials, and parents will get on board with masks. ... and we’ll be left to count the number of rising COVID-19 cases that occur until they do.

Case in point: Kids in Greater Clark County, Ind., headed back to school on July 28. Masks were not required on school property, although unvaccinated students and teachers were “strongly encouraged” to wear them.⁸

Over the first 8 days of in-person instruction, schools in Greater Clark County identified 70 cases of COVID-19 in students and quarantined more than 1,100 of the district’s 10,300 students. Only the unvaccinated were required to quarantine. The district began requiring masks in all school buildings on Aug. 9.⁹

The worried mother had one last question for me. “What’s the best mask for a child to wear?” For most kids, a simple, well-fitting cloth mask is fine. The best mask is ultimately the mask a child will wear. A toolkit with practical tips for helping children successfully wear a mask is available on the ABC Science Collaborative website.
 

Dr. Bryant, president of the Pediatric Infectious Diseases Society, is a pediatrician at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. American Academy of Pediatrics. “Children and COVID-19: State-level data report.”

2. American Academy of Pediatrics. “Children and COVID-19 vaccination trends.”

3. Falk A et al. MMWR Morb Mortal Wkly Rep. 2021;70:136-40.

4. Hershow RB et al. MMWR Morb Mortal Wkly Rep 2021;70:442-8.

5. Zimmerman KO et al. Pediatrics. 2021 Jul;e2021052686. doi: 10.1542/peds.2021-052686.

6. American Academy of Pediatrics. “American Academy of Pediatrics updates recommendations for opening schools in fall 2021.”

7. Pediatric Infectious Diseases Society. “PIDS supports universal masking for students, school staff.”

8. Courtney Hayden. WHAS11. “Greater Clark County Schools return to class July 28.”

9. Dustin Vogt. WAVE3 News. “Greater Clark Country Schools to require masks amid 70 positive cases.”

“I want my child to go back to school,” the mother said to me. “I just want you to tell me it will be safe.”

As the summer break winds down for children across the United States, pediatric COVID-19 cases are rising. According to the American Academy of Pediatrics, nearly 94,000 cases were reported for the week ending Aug. 5, more than double the case count from 2 weeks earlier.¹

Anecdotally, some children’s hospitals are reporting an increase in pediatric COVID-19 admissions. In the hospital in which I practice, we are seeing numbers similar to those we saw in December and January: a typical daily census of 10 kids admitted with COVID-19, with 4 of them in the intensive care unit. It is a stark contrast to June when, most days, we had no patients with COVID-19 in the hospital. About half of our hospitalized patients are too young to be vaccinated against COVID-19, while the rest are unvaccinated children 12 years and older.

Vaccination of eligible children and teachers is an essential strategy for preventing the spread of COVID-19 in schools, but as children head back to school, immunization rates of educators are largely unknown and are suboptimal among students in most states. As of Aug. 11, 10.7 million U.S. children had received at least one dose of COVID-19 vaccine, representing 43% of 12- to 15-year-olds and 53% of 16- to 17-year-olds.² Rates vary substantially by state, with more than 70% of kids in Vermont receiving at least one dose of vaccine, compared with less than 25% in Wyoming and Alabama.

Still, in the absence of robust immunization rates, we have data that schools can still reopen successfully. We need to follow the science and implement universal masking, a safe, effective, and practical mitigation strategy.

It worked in Wisconsin. Seventeen K-12 schools in rural Wisconsin opened last fall for in-person instruction.³ Reported compliance with masking was high, ranging from 92.1% to 97.4%, and in-school transmission of COVID-19 was low, with seven cases among 4,876 students.

It worked in Salt Lake City.⁴ In 20 elementary schools open for in-person instruction Dec. 3, 2020, to Jan. 31, 2021, compliance with mask-wearing was high and in-school transmission was very low, despite a high community incidence of COVID-19. Notably, students’ classroom seats were less than 6 feet apart, suggesting that consistent mask-wearing works even when physical distancing is challenging.

One of the best examples of successful school reopening happened in North Carolina, where pediatricians, pediatric infectious disease specialists, and other experts affiliated with Duke University formed the ABC Science Collaborative to support school districts that requested scientific input to help guide return-to-school policies during the COVID-19 pandemic. From Oct. 26, 2020, to Feb. 28, 2021, the ABC Science Collaborative worked with 13 school districts that were open for in-person instruction using basic mitigation strategies, including universal masking.⁵ During this time period, there were 4,969 community-acquired SARS-CoV-2 infections in the more than 100,000 students and staff present in schools. Transmission to school contacts was identified in only 209 individuals for a secondary attack rate of less than 1%.

Duke investigator Kanecia Zimmerman, MD, told Duke Today, “We know that, if our goal is to reduce transmission of COVID-19 in schools, there are two effective ways to do that: 1. vaccination, 2. masking. In the setting of schools ... the science suggests masking can be extremely effective, particularly for those who can’t get vaccinated while COVID-19 is still circulating.”

Both the AAP⁶ and the Pediatric Infectious Diseases Society⁷ have emphasized the importance of in-person instruction and endorsed universal masking in school. Mask-optional policies or “mask-if-you-are-unvaccinated” policies don’t work, as we have seen in society at large. They are likely to be especially challenging in school settings. Given an option, many, if not most kids, will take off their masks. Kids who leave them on run the risk of stigmatization or bullying.

On Aug. 4, the Centers for Disease Control and Prevention updated its guidance to recommend universal indoor masking for all students, staff, teachers, and visitors to K-12 schools, regardless of vaccination status. Now we’ll have to wait and see if school districts, elected officials, and parents will get on board with masks. ... and we’ll be left to count the number of rising COVID-19 cases that occur until they do.

Case in point: Kids in Greater Clark County, Ind., headed back to school on July 28. Masks were not required on school property, although unvaccinated students and teachers were “strongly encouraged” to wear them.⁸

Over the first 8 days of in-person instruction, schools in Greater Clark County identified 70 cases of COVID-19 in students and quarantined more than 1,100 of the district’s 10,300 students. Only the unvaccinated were required to quarantine. The district began requiring masks in all school buildings on Aug. 9.⁹

The worried mother had one last question for me. “What’s the best mask for a child to wear?” For most kids, a simple, well-fitting cloth mask is fine. The best mask is ultimately the mask a child will wear. A toolkit with practical tips for helping children successfully wear a mask is available on the ABC Science Collaborative website.
 

Dr. Bryant, president of the Pediatric Infectious Diseases Society, is a pediatrician at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

References

1. American Academy of Pediatrics. “Children and COVID-19: State-level data report.”

2. American Academy of Pediatrics. “Children and COVID-19 vaccination trends.”

3. Falk A et al. MMWR Morb Mortal Wkly Rep. 2021;70:136-40.

4. Hershow RB et al. MMWR Morb Mortal Wkly Rep 2021;70:442-8.

5. Zimmerman KO et al. Pediatrics. 2021 Jul;e2021052686. doi: 10.1542/peds.2021-052686.

6. American Academy of Pediatrics. “American Academy of Pediatrics updates recommendations for opening schools in fall 2021.”

7. Pediatric Infectious Diseases Society. “PIDS supports universal masking for students, school staff.”

8. Courtney Hayden. WHAS11. “Greater Clark County Schools return to class July 28.”

9. Dustin Vogt. WAVE3 News. “Greater Clark Country Schools to require masks amid 70 positive cases.”

Zinc deficiency may be inherited or acquired. Acrodermatitis enteropathica is an autosomal recessive genetic disorder caused by a mutation in the gene that encodes a zinc transporter. It presents in infancy with the classic triad of diarrhea, dermatitis, and alopecia. Acquired zinc deficiency is due to causes such as alcoholism, malabsorption disorders like cystic fibrosis, inflammatory disease, gastrointestinal surgery, metabolic stress following general surgery, eating disorders, infections, malignancy, or occasionally in pregnancy. Classically, the face, groin, and extremities are affected (often acral), with erythematous, scaly patches. Pustules and bullae may be present. Angular cheilitis is often seen.

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Our patient’s blood work was consistent with nutritional deficiency and revealed low levels of zinc, vitamin A, ceruloplasmin, albumin and prealbumin, total protein, calcium, selenium, vitamin E, vitamin K, and vitamin C. Her hemoglobin A1C was under 4. Her hepatitis serologies were negative. The patient received total parenteral nutrition with subsequent complete resolution of her rash. Follow up for gastric bypass patients should be performed long term as they are at risk for nutritional deficiencies.

Dr. Bilu Martin, and Andrew Harris, DO, Mount Sinai Medical Center, Aventura, Fla., provided the case and photos.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

References

Dermatol Online J. 2016 Nov 15; 22(11):13030.

Andrews’ Disease of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.

Bolognia et al. Dermatology. St. Louis: Mosby/Elsevier, 2008.

Zinc deficiency may be inherited or acquired. Acrodermatitis enteropathica is an autosomal recessive genetic disorder caused by a mutation in the gene that encodes a zinc transporter. It presents in infancy with the classic triad of diarrhea, dermatitis, and alopecia. Acquired zinc deficiency is due to causes such as alcoholism, malabsorption disorders like cystic fibrosis, inflammatory disease, gastrointestinal surgery, metabolic stress following general surgery, eating disorders, infections, malignancy, or occasionally in pregnancy. Classically, the face, groin, and extremities are affected (often acral), with erythematous, scaly patches. Pustules and bullae may be present. Angular cheilitis is often seen.

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Our patient’s blood work was consistent with nutritional deficiency and revealed low levels of zinc, vitamin A, ceruloplasmin, albumin and prealbumin, total protein, calcium, selenium, vitamin E, vitamin K, and vitamin C. Her hemoglobin A1C was under 4. Her hepatitis serologies were negative. The patient received total parenteral nutrition with subsequent complete resolution of her rash. Follow up for gastric bypass patients should be performed long term as they are at risk for nutritional deficiencies.

Dr. Bilu Martin, and Andrew Harris, DO, Mount Sinai Medical Center, Aventura, Fla., provided the case and photos.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

References

Dermatol Online J. 2016 Nov 15; 22(11):13030.

Andrews’ Disease of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.

Bolognia et al. Dermatology. St. Louis: Mosby/Elsevier, 2008.

Zinc deficiency may be inherited or acquired. Acrodermatitis enteropathica is an autosomal recessive genetic disorder caused by a mutation in the gene that encodes a zinc transporter. It presents in infancy with the classic triad of diarrhea, dermatitis, and alopecia. Acquired zinc deficiency is due to causes such as alcoholism, malabsorption disorders like cystic fibrosis, inflammatory disease, gastrointestinal surgery, metabolic stress following general surgery, eating disorders, infections, malignancy, or occasionally in pregnancy. Classically, the face, groin, and extremities are affected (often acral), with erythematous, scaly patches. Pustules and bullae may be present. Angular cheilitis is often seen.

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Courtesy Dr. Donna Bilu Martin and Dr. Andrew Harris

Our patient’s blood work was consistent with nutritional deficiency and revealed low levels of zinc, vitamin A, ceruloplasmin, albumin and prealbumin, total protein, calcium, selenium, vitamin E, vitamin K, and vitamin C. Her hemoglobin A1C was under 4. Her hepatitis serologies were negative. The patient received total parenteral nutrition with subsequent complete resolution of her rash. Follow up for gastric bypass patients should be performed long term as they are at risk for nutritional deficiencies.

Dr. Bilu Martin, and Andrew Harris, DO, Mount Sinai Medical Center, Aventura, Fla., provided the case and photos.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to dermnews@mdedge.com.

References

Dermatol Online J. 2016 Nov 15; 22(11):13030.

Andrews’ Disease of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.

Bolognia et al. Dermatology. St. Louis: Mosby/Elsevier, 2008.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Case vignette: Laura is a 14-year-old biological girl who presents to your office for a routine well-child visit. She is doing well medically but notes that over the past 3 months she has been having increasing thoughts of suicide and has self-harmed via cutting on her wrists with a blade removed from a shaving razor. You contemplate what the most salient questions are in order to determine the best disposition for your patient.

The case vignette above may sound like one that you have heard before, and if not, you undoubtedly will encounter such a situation moving forward. The rate of suicidal ideation amongst youth ages 10-24 has increased by 57.4% between 2007 and 2018.¹ Furthermore, suicide is the second leading cause of death in those aged 10 through young adulthood.² According to the Centers for Disease Control and Prevention’s 2019 High School Youth Risk Behavior Survey, 18.8% of high school students seriously considered attempting suicide, 15.7% made a plan about how they would attempt suicide, and 8.9% actually attempted suicide, with 2.5% having a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey.³ Children often present first to their primary care provider, and they may be the first individual who the child shares their suicidal or self-harm thoughts with. It may be useful to have a standardized approach, while using your own clinical judgment, to determine best next steps. Given the significant recent surge in children presenting to the emergency department for psychiatric needs and that environment having its own limitations (for example, long wait times, nontherapeutic space, etc.), a simple screen and brief assessment may lead to being able to maintain a patient safely outside of the hospital.
 

Screen all appropriate patients for suicide

There are, at minimum, three validated screening tools that can be used as to determine what the best next step should be. They include the Ask Suicide-Screening Questions (ASQ) developed by the National Institute of Mental Health, the Columbia-Suicide Severity Rating Scale (C-SSRS), and the PHQ-9 (modified for adolescents). We can highlight one of the screening tools here as noted below, but the choice of screener may be based on facility and/or clinician preference.

The Ask Suicide-Screening Questions

The ASQ, developed by the National Institute of Mental Health, include the following four binary questions plus a fifth acuity question, as follows:

1. In the past few weeks, have you wished you were dead?

2. In the past few weeks, have you felt that you or your family would be better off if you were dead?

3. In the past week, have you been having thoughts about killing yourself?

4. Have you ever tried to kill yourself?

a. If yes, how?

b. When?

The following acuity question is to be asked if any of the above are answered “yes”:

5. Are you having thoughts of killing yourself right now?

a. If yes, please describe.
 

Assess the level of risk

Once you have screened a patient, you need to assess the level of risk to help determine the level of care required. Returning to our original case vignette, does the patient warrant outpatient management, crisis evaluation, or an emergency psychiatric evaluation? You may have already decided that the patient needs an emergency mental health evaluation from a local crisis clinician evaluation and/or the emergency department. However, you may also find that the screen did not elicit imminent concern, but it does warrant a brief assessment to further elucidate the level of risk and proper disposition. One such instrument that may be helpful is the Brief Suicide Safety Assessment (BSSA) – also developed by the NIMH as a tool linked to the ASQ. There are clear and specific instructions in the BSSA with suggestions on how to ask questions. Important components to the BSSA include:

• A focus on a more thorough clinical history – including frequency of suicidal ideation, suicide plan, past behavior, associated symptoms, and social support/stressors
• Collateral information (e.g., further details from those who know the patient such as family/friends).
• Safety planning.
• Determining disposition.

The BSSA may suggest that a crisis/psychiatric evaluation is warranted or suggest that a safety plan with a mental health referral will likely be sufficient.
 

Triage and safety planning

A safety plan should be created if you determine that a patient can be safely maintained as an outpatient based on your screening, assessment, and triaging. Traditional safety plans come in many different forms and can be found online (Example of a Safety Plan Template). However, most safety plans include some version of the following:

• Increased supervision: 24/7 supervision with doors open/unlocked.
• Reduced access: medications (prescription and OTC) locked away; sharps and firearms secured.
• Adaptive coping strategies (e.g., relaxation techniques such as drawing or listening to music).
• Reliable persons for support (e.g., parent, therapist, school counselor).
• Outpatient mental health provider follow-up and/or referral.
• Provision of local crisis and national hotline contact information.
• Use of a safety plan phone app completed with patient.

Envision a safety plan as a living document that evolves, grows, and changes with your patient/family – one that can be easily reviewed/updated at each visit.
 

Returning to our case vignette

Laura returns to your office for a follow-up after a 10-day stay at a hospital-diversion program or inpatient psychiatric unit. The decision is made to use the primary care NIMH ASQ/BSSA algorithm, and you determine the patient to not be at imminent risk following the screen and assessment. Laura is triaged as appropriate for outpatient care, you collaborate to update the safety plan, regular follow-ups are scheduled, and a mental health referral has been placed. Thus, there are tools to assist with screening, assessing, and triaging pediatric patients with suicidal ideation that provide the patient with appropriate care and treatment and may help alleviate the need to have a patient present to the emergency department.

Dr. Abdul-Karim is a child psychiatrist at the University of Vermont University Children’s Hospital in Burlington.

Additional resources

The American Academy of Child and Adolescent Psychiatry has developed information that can be provided to families about suicide safety precautions that can be taken at home, which can be found here: Facts for Families. Suicide Safety: Precautions at Home.

Screening tools listed above can be found here:

ASQ Toolkit.

C-SSRS.

PHQ-9 Modified for Adolescents (PHQ-A).

References

1. Curtin SC. National Center for Health Statistics. “State Suicide Rates Among Adolescents and Young Adults Aged 10-24: United States, 2000-2018” National Vital Statistics Reports..

2. Centers for Disease Control and Prevention, National Center for Health Statistics. “Underlying Cause of Death 2018-2019” CDC WONDER Online Database. Accessed 2021 Jul 31, 6:57:39 p.m.

3. Centers for Disease Control and Prevention. 1991-2019 High School Youth Risk Behavior Survey Data.

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Traditionally, as the ides of August descend upon us we expect to be bombarded with advertisements encouraging parents and students to finish up their back-to-school shopping. But, this year the question on every parent and school administrator’s mind is not which color back pack will be the most popular this year but whether a mask should be a required part of the back-to-school ensemble.

The American Academy of Pediatrics has recommended that “All students older than 2 years and all school staff should wear a mask at school” (“American Academy of Pediatrics Updates Recommendations for Opening Schools in Fall 2021.” 2021 Jul 19). The academy’s statement includes a generous list of common sense caveats but it does not include a statement that masks have been shown to be protective for children in school environments. The Centers for Disease Control and Prevention “recommends” universal indoor masking along with keeping a 3-foot separation but again fails to include any references to support the effectiveness of masks (“Guidance for COVID-19 Prevention in K-12 Schools.” 2021 Aug 5).

Not surprisingly, into this void have stepped two pairs of experts – one group purporting to have evidence that masking is effective in school environments and the other warning that masks may not only be ineffective but that they also carry some significant downsides. And, where can you find these opposing positions? Not in The Lancet. Not in the New England Journal of Medicine. We don’t have time for any of that peer-reviewed monkey business. No, this is pandemic-era science where we have an abundance of opinions and paucity of facts. You will find these opposing articles on the op-ed pages of two of this country’s major newspapers.

In the Aug. 10, 2021, edition of the New York Times you will find an article (“We Studied One Million Students. This Is What We Learned About Masking”) by two pediatricians, Kanecia Zimmerman, MD, and Danny Benjamin Jr., MD, who have “studied” a million students in North Carolina school systems and tell us universal masking is “one of the most effective and efficient strategies for preventing SARS-CoV-2 transmission in schools. These investigators write that they “believe” the low rate of in school transmission they observed in North Carolina was “because of the mask-on-mask school environment.”

However, in the next paragraph the authors admit, “Because North Carolina had a mask mandate for all K-12 schools, we could not compare masked schools with unmasked schools.” They lean instead on studies from three other states with mask mandates that also had low transmission rates and a single report of an outbreak in Israel that employed neither masking nor safe distancing.

On the other side of the divide is an article in the Wall Street Journal titled “The Case Against Masks for Children” by Marty Makary, MD, and H. Cody Meissner, MD, (2021 Aug 9). The authors, one a pediatric infectious disease specialist, argue that there is “no science behind mask mandates for children.” And, observe that, of the $46 billion spent on research grants by the National Institutes of Health, “not a single grant was dedicated to studying masking in children.”

Dr. Makary and Dr. Meissner present a variety of concerns about the effects of masking including those on the development and communication skills of young children. None of their theoretical concerns of course are supported by controlled studies. They also observe that in previous studies children seem to be less likely to transmit COVID-19 than adults. Although we all know the landscape is changing with the emergence of the delta strain. In their strongest statement the authors claim, “It is abusive to force kids who struggle with them [masks] to sacrifice for the sake of unvaccinated adults.”

So there you have it. It is a situation we have come to expect over the last 2 years – plenty of opinions and too few facts supported by controlled studies. Both pairs of authors, however, agree on two things: Vaccination should continue to be considered our primary tool in prevention and control of COVID-19. and children need to be in school. Based on nothing more than a hunch and 7 decades of hunching, I tend to side with Dr. Makary and Dr. Meissner. Depending on the situation, I suggest masking but wouldn’t mandate it for children in school.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.