Perspectives

Over the last several decades science has fallen off this country’s radar screen. Yes, STEM (science, technology, engineering, and mathematics) has recently had a brief moment in the spotlight as a buzzword de jour. But the critical importance of careful and systematic investigation into the world around us using observation and trial and error is a tough sell to a large segment of our population.

SDI Productions/iStock/Getty Images

The COVID-19 pandemic is providing an excellent opportunity for science and medicine to showcase their star qualities. Of course some people in leadership positions persist in disregarding the value of scientific investigation. But I get the feeling that the fear generated by the pandemic is creating some converts among many previous science skeptics. This gathering enthusiasm among the general population is a predictably slow process because that’s the way science works. It often doesn’t provide quick answers. And it is difficult for the nonscientist to see the beauty in the reality that the things we thought were true 2 months ago are likely to be proven wrong today as more observations accumulate.

Unfortunately, even in this time of renewal, science and medicine continue to generate a bumper crop of bad apples. A recent New York Times article examines the career of one such unscrupulous physician/scientist whose recent exploits threaten to undo much of the positive image the pandemic has cast on science (“The Doctor Behind the Disputed Covid Data,” by Ellen Gabler and Roni Caryn Rabin, The New York Times, July 27, 2020). The subject of the article is the physician who was responsible for providing some of the large data sets on which several papers were published about the apparent ineffectiveness and danger of using hydroxychloroquine in COVID-19 patients. The authenticity of the data sets recently has been seriously questioned, and the articles have been retracted by the journals in which they had appeared.

Based on numerous interviews with coworkers, the Times reporters present a strong case that this individual’s long history of unreliability make his association with allegedly fraudulent data set not surprising but maybe even predictable. At one point in his training, there appears to have been serious questions about advancing the physician to the next level. Despite these concerns, he was allowed to continue and complete his specialty training. It is of note that in his last year of clinical practice, the physician became the subject of three serious malpractice claims that question his competence.

I suspect that some of you have crossed paths with physicians whose competence and/or moral character you found concerning. Were they peers? Were you the individual’s supervisor or was he or she your mentor? How did you respond? Did anyone respond at all?

There has been a lot written and said in recent months about how and when to respond to respond to sexual harassment in the workplace. But I don’t recall reading any articles that discuss how one should respond to incompetence. Of course competency can be a relative term, but in most cases significant incompetence is hard to miss because it tends to be repeated.

It is easy for the airports and subway systems to post signs that say “If you see something say something.” It’s a different story for hospitals and medical schools that may have systems in place for reporting and following up on poor practice. But my sense is that there are too many cases that slip through the cracks.

This is another example of a problem for which I don’t have a solution. However, if this column prompts just one of you who sees something to say something then I have had a good day.
 

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

Over the last several decades science has fallen off this country’s radar screen. Yes, STEM (science, technology, engineering, and mathematics) has recently had a brief moment in the spotlight as a buzzword de jour. But the critical importance of careful and systematic investigation into the world around us using observation and trial and error is a tough sell to a large segment of our population.

SDI Productions/iStock/Getty Images

The COVID-19 pandemic is providing an excellent opportunity for science and medicine to showcase their star qualities. Of course some people in leadership positions persist in disregarding the value of scientific investigation. But I get the feeling that the fear generated by the pandemic is creating some converts among many previous science skeptics. This gathering enthusiasm among the general population is a predictably slow process because that’s the way science works. It often doesn’t provide quick answers. And it is difficult for the nonscientist to see the beauty in the reality that the things we thought were true 2 months ago are likely to be proven wrong today as more observations accumulate.

Unfortunately, even in this time of renewal, science and medicine continue to generate a bumper crop of bad apples. A recent New York Times article examines the career of one such unscrupulous physician/scientist whose recent exploits threaten to undo much of the positive image the pandemic has cast on science (“The Doctor Behind the Disputed Covid Data,” by Ellen Gabler and Roni Caryn Rabin, The New York Times, July 27, 2020). The subject of the article is the physician who was responsible for providing some of the large data sets on which several papers were published about the apparent ineffectiveness and danger of using hydroxychloroquine in COVID-19 patients. The authenticity of the data sets recently has been seriously questioned, and the articles have been retracted by the journals in which they had appeared.

Based on numerous interviews with coworkers, the Times reporters present a strong case that this individual’s long history of unreliability make his association with allegedly fraudulent data set not surprising but maybe even predictable. At one point in his training, there appears to have been serious questions about advancing the physician to the next level. Despite these concerns, he was allowed to continue and complete his specialty training. It is of note that in his last year of clinical practice, the physician became the subject of three serious malpractice claims that question his competence.

I suspect that some of you have crossed paths with physicians whose competence and/or moral character you found concerning. Were they peers? Were you the individual’s supervisor or was he or she your mentor? How did you respond? Did anyone respond at all?

There has been a lot written and said in recent months about how and when to respond to respond to sexual harassment in the workplace. But I don’t recall reading any articles that discuss how one should respond to incompetence. Of course competency can be a relative term, but in most cases significant incompetence is hard to miss because it tends to be repeated.

It is easy for the airports and subway systems to post signs that say “If you see something say something.” It’s a different story for hospitals and medical schools that may have systems in place for reporting and following up on poor practice. But my sense is that there are too many cases that slip through the cracks.

This is another example of a problem for which I don’t have a solution. However, if this column prompts just one of you who sees something to say something then I have had a good day.
 

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

Over the last several decades science has fallen off this country’s radar screen. Yes, STEM (science, technology, engineering, and mathematics) has recently had a brief moment in the spotlight as a buzzword de jour. But the critical importance of careful and systematic investigation into the world around us using observation and trial and error is a tough sell to a large segment of our population.

SDI Productions/iStock/Getty Images

The COVID-19 pandemic is providing an excellent opportunity for science and medicine to showcase their star qualities. Of course some people in leadership positions persist in disregarding the value of scientific investigation. But I get the feeling that the fear generated by the pandemic is creating some converts among many previous science skeptics. This gathering enthusiasm among the general population is a predictably slow process because that’s the way science works. It often doesn’t provide quick answers. And it is difficult for the nonscientist to see the beauty in the reality that the things we thought were true 2 months ago are likely to be proven wrong today as more observations accumulate.

Unfortunately, even in this time of renewal, science and medicine continue to generate a bumper crop of bad apples. A recent New York Times article examines the career of one such unscrupulous physician/scientist whose recent exploits threaten to undo much of the positive image the pandemic has cast on science (“The Doctor Behind the Disputed Covid Data,” by Ellen Gabler and Roni Caryn Rabin, The New York Times, July 27, 2020). The subject of the article is the physician who was responsible for providing some of the large data sets on which several papers were published about the apparent ineffectiveness and danger of using hydroxychloroquine in COVID-19 patients. The authenticity of the data sets recently has been seriously questioned, and the articles have been retracted by the journals in which they had appeared.

Based on numerous interviews with coworkers, the Times reporters present a strong case that this individual’s long history of unreliability make his association with allegedly fraudulent data set not surprising but maybe even predictable. At one point in his training, there appears to have been serious questions about advancing the physician to the next level. Despite these concerns, he was allowed to continue and complete his specialty training. It is of note that in his last year of clinical practice, the physician became the subject of three serious malpractice claims that question his competence.

I suspect that some of you have crossed paths with physicians whose competence and/or moral character you found concerning. Were they peers? Were you the individual’s supervisor or was he or she your mentor? How did you respond? Did anyone respond at all?

There has been a lot written and said in recent months about how and when to respond to respond to sexual harassment in the workplace. But I don’t recall reading any articles that discuss how one should respond to incompetence. Of course competency can be a relative term, but in most cases significant incompetence is hard to miss because it tends to be repeated.

It is easy for the airports and subway systems to post signs that say “If you see something say something.” It’s a different story for hospitals and medical schools that may have systems in place for reporting and following up on poor practice. But my sense is that there are too many cases that slip through the cracks.

This is another example of a problem for which I don’t have a solution. However, if this column prompts just one of you who sees something to say something then I have had a good day.
 

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

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.

In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.

At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.

While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.¹ However, many chief residents feel their administrative roles outweigh their educational ones.^2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.

The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.⁴

However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.⁵ With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.

National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?

As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.

This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.

Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.

At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.

One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.⁶

We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.

Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.

Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.

References

1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.

2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.

3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.

4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.

6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.

These are unusually stressful days for everyone, especially our patients. We are all experiencing a turbulent mix of emotions as we try to cope with a confluence of threats to both our lives and to life as we know it. Peace of mind has become so elusive due to the relentless overlapping waves of fear, sadness, anger, and uncertainty. We are all grieving in a different way, but our psychiatric patients are suffering the most.

Fear. It only takes 1 traumatic event to trigger posttraumatic stress disorder (PTSD). Yet over the past few months, we have been afflicted by 4 jarring traumatic events, individually and as a society. Just a few months ago, it would have been impossible to imagine the conflux of 4 concurrent seismic threats to our well-being. A toxic political zeitgeist was the backdrop, which we bemoaned and tried to compartmentalize, despite the corrosive political environment shrouding the country. Then the deadly coronavirus disease 2019 (COVID-19) pandemic suddenly arrived, imposing draconian health-preserving measures that impacted every individual’s daily life in countless detrimental ways. Fear prevailed as we all sheltered at home, stopped commuting to work, canceled all trips, distanced ourselves from our friends and relatives, and watched depressing and anxiety-provoking television and read online news throughout our waking hours. Hoarding food and household supplies became endemic due to fear about survival.

Sadness. The agonizing prospect of a national financial necrosis followed the threat of serious illness or death. The economy came to a screeching halt, hemorrhaging millions of jobs. Unemployed parents stayed home with their morose children whose schools were shuttered, leaving them deprived of socializing with their friends. The government hurried with financial chemotherapy, printing trillions of dollars to prevent economic collapse, to avert potential poverty and hunger for many. The fear of the pandemic became coupled with sadness over the loss of livelihoods and grief for the loss of liberty and the ability to pursue happiness, or even small pleasures.

Anger. Then a tsunami of anger was generated by the brutal and sadistic death of a black man in police custody. This was a spark that ignited a massive amount of previously dormant racial tension dating back to the dark days of slavery. Peaceful protests were marred by destructive riots. The explosive fury was perhaps intensified by the protestors having been being locked up for weeks and having to wear masks, both of which were symbolic of being held down and “unable to breathe,” like the murdered Mr. George Floyd.

An epidemic of destroying statues followed. Heavy statues that appeared invincible for decades were dismantled from their plinth in a matter of minutes, signifying extreme frustration with the social injustice that remains despite the transformational laws of the Civil Rights Acts of 1960 and 1964. Suddenly—like falling dominoes—statues, flags, names of military bases, and previously venerated monuments were removed, changed, vandalized, or threatened with destruction. The founders of the republic were also maligned because they were slave owners 2 centuries ago. The paradigm shift spawned by the rage over racial inequality was disconcerting and dramatic. The anger and rampage spawned a sense that a tipping point in our society has been reached.

Uncertainty. The confluence of political instability, a deadly pandemic, economic collapse, and racial tensions were like the 4 horsemen of mass PTSD. The result was an agonizing uncertainty about the impact of these changes, and whether a sense of normalcy will ever return. It became apparent to all of us that our social structure has changed forever across multiple fundamental domains: public health, social, political, and financial. The wait for a vaccine for COVID-19 seems interminable, and racial healing and harmony seems elusive. Economic recovery may be possible, but political detoxification appears unlikely. The fate of police departments, condemned because of the deplorable and illegal acts of a few, and the safety of citizens, usually guaranteed by law and order, seem uncertain. Like COVID-19, angst has rapidly spread across the population.

The price our patients pay

The ingredients of a large-scale societal PTSD, similar to what probably happens during a world war, are now in place. Even resilient individuals may buckle during quadruple ordeals such as this one. So imagine what is happening to our patients, rendered fragile and vulnerable to threats by their pre-existing psychiatric illness. They all pay a heavy price. Patients with anxiety disorders will decompensate, with more panic attacks. Patients burdened by depression will worsen, with more hopelessness, despair, and suicidal ideation due to anxiety and loneliness. Patients with bipolar disorder will become more labile and irritable, and their comorbid anxiety will intensify. Patients with schizophrenia will become more paranoid, depressed, and anxious. Patients with autism will become more agitated and aggressive because their cherished daily routines are disrupted. Patients with obsessive-compulsive disorder will react to their germaphobia by washing their hands and cleaning everything around them even more frequently, and they (along with everyone else) will become hoarders.

Hope and healing

As psychiatrists, we are determined to transcend our own stress, rise above it all, and attend to the pervasive sadness, grief, anger, and uncertainty all around us, but especially among our patients, for whom the anguish of a psychiatric disorder is further compounded by 4 additional ordeals. This is our moment of truth as healers of our patients’ souls, because they look to us to provide them with hope to help navigate these trying times into full health. And we psychiatrists, along with fellow mental health professionals, are up to this unprecedented challenge.

These are unusually stressful days for everyone, especially our patients. We are all experiencing a turbulent mix of emotions as we try to cope with a confluence of threats to both our lives and to life as we know it. Peace of mind has become so elusive due to the relentless overlapping waves of fear, sadness, anger, and uncertainty. We are all grieving in a different way, but our psychiatric patients are suffering the most.

Fear. It only takes 1 traumatic event to trigger posttraumatic stress disorder (PTSD). Yet over the past few months, we have been afflicted by 4 jarring traumatic events, individually and as a society. Just a few months ago, it would have been impossible to imagine the conflux of 4 concurrent seismic threats to our well-being. A toxic political zeitgeist was the backdrop, which we bemoaned and tried to compartmentalize, despite the corrosive political environment shrouding the country. Then the deadly coronavirus disease 2019 (COVID-19) pandemic suddenly arrived, imposing draconian health-preserving measures that impacted every individual’s daily life in countless detrimental ways. Fear prevailed as we all sheltered at home, stopped commuting to work, canceled all trips, distanced ourselves from our friends and relatives, and watched depressing and anxiety-provoking television and read online news throughout our waking hours. Hoarding food and household supplies became endemic due to fear about survival.

Sadness. The agonizing prospect of a national financial necrosis followed the threat of serious illness or death. The economy came to a screeching halt, hemorrhaging millions of jobs. Unemployed parents stayed home with their morose children whose schools were shuttered, leaving them deprived of socializing with their friends. The government hurried with financial chemotherapy, printing trillions of dollars to prevent economic collapse, to avert potential poverty and hunger for many. The fear of the pandemic became coupled with sadness over the loss of livelihoods and grief for the loss of liberty and the ability to pursue happiness, or even small pleasures.

Anger. Then a tsunami of anger was generated by the brutal and sadistic death of a black man in police custody. This was a spark that ignited a massive amount of previously dormant racial tension dating back to the dark days of slavery. Peaceful protests were marred by destructive riots. The explosive fury was perhaps intensified by the protestors having been being locked up for weeks and having to wear masks, both of which were symbolic of being held down and “unable to breathe,” like the murdered Mr. George Floyd.

An epidemic of destroying statues followed. Heavy statues that appeared invincible for decades were dismantled from their plinth in a matter of minutes, signifying extreme frustration with the social injustice that remains despite the transformational laws of the Civil Rights Acts of 1960 and 1964. Suddenly—like falling dominoes—statues, flags, names of military bases, and previously venerated monuments were removed, changed, vandalized, or threatened with destruction. The founders of the republic were also maligned because they were slave owners 2 centuries ago. The paradigm shift spawned by the rage over racial inequality was disconcerting and dramatic. The anger and rampage spawned a sense that a tipping point in our society has been reached.

Uncertainty. The confluence of political instability, a deadly pandemic, economic collapse, and racial tensions were like the 4 horsemen of mass PTSD. The result was an agonizing uncertainty about the impact of these changes, and whether a sense of normalcy will ever return. It became apparent to all of us that our social structure has changed forever across multiple fundamental domains: public health, social, political, and financial. The wait for a vaccine for COVID-19 seems interminable, and racial healing and harmony seems elusive. Economic recovery may be possible, but political detoxification appears unlikely. The fate of police departments, condemned because of the deplorable and illegal acts of a few, and the safety of citizens, usually guaranteed by law and order, seem uncertain. Like COVID-19, angst has rapidly spread across the population.

The price our patients pay

The ingredients of a large-scale societal PTSD, similar to what probably happens during a world war, are now in place. Even resilient individuals may buckle during quadruple ordeals such as this one. So imagine what is happening to our patients, rendered fragile and vulnerable to threats by their pre-existing psychiatric illness. They all pay a heavy price. Patients with anxiety disorders will decompensate, with more panic attacks. Patients burdened by depression will worsen, with more hopelessness, despair, and suicidal ideation due to anxiety and loneliness. Patients with bipolar disorder will become more labile and irritable, and their comorbid anxiety will intensify. Patients with schizophrenia will become more paranoid, depressed, and anxious. Patients with autism will become more agitated and aggressive because their cherished daily routines are disrupted. Patients with obsessive-compulsive disorder will react to their germaphobia by washing their hands and cleaning everything around them even more frequently, and they (along with everyone else) will become hoarders.

Hope and healing

As psychiatrists, we are determined to transcend our own stress, rise above it all, and attend to the pervasive sadness, grief, anger, and uncertainty all around us, but especially among our patients, for whom the anguish of a psychiatric disorder is further compounded by 4 additional ordeals. This is our moment of truth as healers of our patients’ souls, because they look to us to provide them with hope to help navigate these trying times into full health. And we psychiatrists, along with fellow mental health professionals, are up to this unprecedented challenge.

These are unusually stressful days for everyone, especially our patients. We are all experiencing a turbulent mix of emotions as we try to cope with a confluence of threats to both our lives and to life as we know it. Peace of mind has become so elusive due to the relentless overlapping waves of fear, sadness, anger, and uncertainty. We are all grieving in a different way, but our psychiatric patients are suffering the most.

Fear. It only takes 1 traumatic event to trigger posttraumatic stress disorder (PTSD). Yet over the past few months, we have been afflicted by 4 jarring traumatic events, individually and as a society. Just a few months ago, it would have been impossible to imagine the conflux of 4 concurrent seismic threats to our well-being. A toxic political zeitgeist was the backdrop, which we bemoaned and tried to compartmentalize, despite the corrosive political environment shrouding the country. Then the deadly coronavirus disease 2019 (COVID-19) pandemic suddenly arrived, imposing draconian health-preserving measures that impacted every individual’s daily life in countless detrimental ways. Fear prevailed as we all sheltered at home, stopped commuting to work, canceled all trips, distanced ourselves from our friends and relatives, and watched depressing and anxiety-provoking television and read online news throughout our waking hours. Hoarding food and household supplies became endemic due to fear about survival.

Sadness. The agonizing prospect of a national financial necrosis followed the threat of serious illness or death. The economy came to a screeching halt, hemorrhaging millions of jobs. Unemployed parents stayed home with their morose children whose schools were shuttered, leaving them deprived of socializing with their friends. The government hurried with financial chemotherapy, printing trillions of dollars to prevent economic collapse, to avert potential poverty and hunger for many. The fear of the pandemic became coupled with sadness over the loss of livelihoods and grief for the loss of liberty and the ability to pursue happiness, or even small pleasures.

Anger. Then a tsunami of anger was generated by the brutal and sadistic death of a black man in police custody. This was a spark that ignited a massive amount of previously dormant racial tension dating back to the dark days of slavery. Peaceful protests were marred by destructive riots. The explosive fury was perhaps intensified by the protestors having been being locked up for weeks and having to wear masks, both of which were symbolic of being held down and “unable to breathe,” like the murdered Mr. George Floyd.

An epidemic of destroying statues followed. Heavy statues that appeared invincible for decades were dismantled from their plinth in a matter of minutes, signifying extreme frustration with the social injustice that remains despite the transformational laws of the Civil Rights Acts of 1960 and 1964. Suddenly—like falling dominoes—statues, flags, names of military bases, and previously venerated monuments were removed, changed, vandalized, or threatened with destruction. The founders of the republic were also maligned because they were slave owners 2 centuries ago. The paradigm shift spawned by the rage over racial inequality was disconcerting and dramatic. The anger and rampage spawned a sense that a tipping point in our society has been reached.

Uncertainty. The confluence of political instability, a deadly pandemic, economic collapse, and racial tensions were like the 4 horsemen of mass PTSD. The result was an agonizing uncertainty about the impact of these changes, and whether a sense of normalcy will ever return. It became apparent to all of us that our social structure has changed forever across multiple fundamental domains: public health, social, political, and financial. The wait for a vaccine for COVID-19 seems interminable, and racial healing and harmony seems elusive. Economic recovery may be possible, but political detoxification appears unlikely. The fate of police departments, condemned because of the deplorable and illegal acts of a few, and the safety of citizens, usually guaranteed by law and order, seem uncertain. Like COVID-19, angst has rapidly spread across the population.

The price our patients pay

The ingredients of a large-scale societal PTSD, similar to what probably happens during a world war, are now in place. Even resilient individuals may buckle during quadruple ordeals such as this one. So imagine what is happening to our patients, rendered fragile and vulnerable to threats by their pre-existing psychiatric illness. They all pay a heavy price. Patients with anxiety disorders will decompensate, with more panic attacks. Patients burdened by depression will worsen, with more hopelessness, despair, and suicidal ideation due to anxiety and loneliness. Patients with bipolar disorder will become more labile and irritable, and their comorbid anxiety will intensify. Patients with schizophrenia will become more paranoid, depressed, and anxious. Patients with autism will become more agitated and aggressive because their cherished daily routines are disrupted. Patients with obsessive-compulsive disorder will react to their germaphobia by washing their hands and cleaning everything around them even more frequently, and they (along with everyone else) will become hoarders.

Hope and healing

As psychiatrists, we are determined to transcend our own stress, rise above it all, and attend to the pervasive sadness, grief, anger, and uncertainty all around us, but especially among our patients, for whom the anguish of a psychiatric disorder is further compounded by 4 additional ordeals. This is our moment of truth as healers of our patients’ souls, because they look to us to provide them with hope to help navigate these trying times into full health. And we psychiatrists, along with fellow mental health professionals, are up to this unprecedented challenge.

In the wake of Dr. Nasrallah’s recent editorial “Stop calling it ‘behavioral health:’ Psychiatry is much more” (From the Editor, Current Psychiatry. June 2020, p. 9-7,38), we offer an alternative viewpoint as members of a multi­hospital (academic and community), multifaceted, multidisciplinary behavioral health institute.

Naming a field, institute, department, or group of collaborators is crucially important, and must be undertaken with care. We all are familiar with Departments of Psychiatry, Departments of Psychiatry and Psychology, and Institutes for everything from Behavioral Health to Living. Even within the discipline of psychiatry, there have been adjustments over time in subspecialties (as seen with consultation-liaison psychiatry becoming psychosomatic medicine and then back again).

In our hospital system, we have recently adopted the term “Behavioral Health Institute” to denote the work and worth of significant numbers of caregivers (psychiatrists, psychologists, chemical dependency counselors, social workers, child life workers, advanced practice nurses, and others) who strive to improve the health and well-being of patients with both substance abuse and mental illness. We endeavor to remain mindful that a diversity of providers are involved in caring for and about our patients, and that “psychiatry” cannot—and should not—be the extent of how we conceptualize our services.

We submit that the modern view of behavioral health is ahead of other fields of medicine in recognizing that concepts, such as teamwork and diversity, are key to achieving positive patient outcomes. By identifying our providers as part of a Behavioral Health Institute, we acknowledge that not all mental distress is psychiatric illness but may still benefit from intervention and, importantly, that psychiatrists are not the center of the mental health (behavioral health) world. Treatments ranging from medication management to psychiatric procedures to psychotherapeutic modalities show the depth and breadth of our field, and the multiplicity of providers and modalities should be considered laudable. Recognizing the complexities inherent in behavioral health and its varied treatment options does not diminish but, in fact, elevates the field of psychiatry—and psychiatrists themselves.

Further, we note that behavioral health is not the only term that casts a larger net than the physician in a respective field. Does the term “primary care” insult internal medicine, family medicine, and pediatric physicians? Physicians and health care teams join in partnership with patients and families, either to cure or learn how to manage disease. We believe that constructing a health care system centered on physicians and their identities, rather than on patients and treatment outcomes, has been foolish. To that end, the tenor of Dr. Nasrallah’s editorial runs counter to the overall efforts of our field to improve collaboration, and, at its extreme, such articles promote the antiquated notion of physician elitism.

The editorial’s historical context is of course important, and the caution not to water down what “we” do (as psychiatrists) is appropriate. However, instead of comporting ourselves in a psychiatry-centric way, the use of the term behavioral health allows all of us to acknowledge (with appreciation and humility) the many contributors who work in our field. The use of a broad-minded, inclusive term neither minimizes nor trivializes psychiatry as a medical specialty. Rather, accepting this term and this mindset can place psychiatrists in the unique role of being innovators for the rest of medicine, because we embrace multidisciplinary teams and the value that interdisciplinary care can bring to patients and colleagues alike.

Jeanne Lackamp, MD, DFAPA, FACLP
Director, Pain Management Institute
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Patrick Runnels, MD, MBA
Chief Medical Officer, Population Health – Behavioral Health
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Lori Locke, RN, MSN
Director, Psychiatry Service Line and Nursing Practice
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Erum Ahmad, MD
Director, Child and Adolescent Psychiatry Unit
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Robert Ronis, MD, MPH
Douglas Danford Bond Professor and Chairman
Psychiatrist-in-Chief
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Continue to: Dr. Nasrallah responds

I thank my Cleveland colleagues for their letter, and I welcome their disagreement with the tenets of my editorial. I still insist that the term “behavioral health” has a very narrow meaning that is not equivalent to psychiatry or psychology or social work or psychiatric nursing practice. This term should not be conflated with the widely used “mental health,” which is used as an overarching term for all professionals involved in the care of psychiatric brain disorders that manifest as various mental illnesses and substance use disorders.

While I am an advocate for multidisciplinary collaborations that benefit our patients, I will always uphold psychiatry as a medical specialty whose unique identity should not be sacrificed on the altar of politically correct egalitarianism of the mental health disciplines. Call it elitist if you like, but the fact is that the extensive medical school, residency, and fellowship training of psychiatrists stand out among all the other mental health disciplines. Psychiatrists are the best trained in all components of the biopsychosocial model (which I acquired many years ago from the father of the concept, George Engel, one of my teachers at the University of Rochester Residency Program).

You bring up primary care as an analogy for behavioral health. I assure you, none of the medical specialists included under that umbrella term refer to themselves as primary care physicians (PCPs) (or, God forbid, providers!). They identify themselves as family physicians, internists, pediatricians, and gynecologists. It is for the convenience of the health care systems and insurance companies that clinicians are called PCPs, which homogenizes them into a fuzzy amalgam and disguises their true medical identities as specialists.

So we agree to disagree. Diversity of opinions is a sacred principle. But I still think that a more accurate name for your Behavioral Health Institute would be “Institute of Psychiatric Medicine and Brain Health.” Behavioral health, which actually refers to educating people about implementing principles of evidence-based healthy habits and behaviors that prevent or reduce the risk of mental illness and/or substance use, is a small sliver of your overall mission. As you’ll notice from the other letters we’ve received, the vast majority of our readers agree that psychiatric medicine is far more than behavioral health.

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Continue to: I thoroughly enjoyed...

I thoroughly enjoyed Dr. Nasrallah’s editorial and agree completely. Veterans Affairs, my employer for the last 12 years, has fully bought into the use of “behavioral health” and its implications for its many psychiatrists. I have grown very tired of the constant minimization of psychiatric practice, and it is so good to hear from an affirming voice.

Barbara Day, MD
US Department of Veterans Affairs
Ann Arbor, Michigan

Dr. Nasrallah’s editorial made my heart sing! I have been practicing psychiatry since 1979, and have always bristled when called a “provider” or any of the other terms Dr. Nasrallah described. As a graduate of Johns Hopkins Medical School, I had professors who themselves had been taught by Harry Stack Sullivan and Frida Fromm Reichman, and during my residency at the University of Chicago, I sat in discussions with both Bruno Bettelheim and Heinz Kohut. I felt part of an honorable tradition, and even though biological psychiatry was on the ascendency, these analytical luminaries were part of my learning the “art” of psychiatry. It is not so easy to feel good about a specialty that has had such a history as ours, but my own experiences could never be reduced to being called a behavioral health provider. Dr. Nasrallah’s thoughts are very encouraging, and I thank him!

John Engers, MD
Private psychiatric practice (retired)
Fremont, California

Dr. Nasrallah’s editorial resonated with one of my pet peeves. I’ve been telling my medical students for years that we psychiatrists treat disorders of thinking, emotions, and behavior associated with mental illness, and that the term “behavioral health,” though possibly well intentioned, is a euphemism to reduce stigma.

Irl Extein, MD
Private psychiatric practice
Delray Beach, Florida
Clinical Affiliate Associate Professor, Florida
Atlantic University College of Medicine
Boca Raton, Florida

Continue to: I enjoyed...

Stu Gitlow, MD, MPH
Executive Director
Annenberg Physician Training Program in Addictive Disease
Woonsocket, Rhode Island

I was grateful for Dr. Nasrallah’s editorial regarding the misnomer of referring to psychiatry as “behavioral health.” Until this editorial, I had wondered if I was the only one bothered by the term. Many people are under the assumption that behavioral health is a politically correct term that helps to lessen stigmatism. I completely disagree. Without question, it adds to the stigmatism. The term behavioral health is belittling to our patients. For example, calling a psychiatric inpatient unit a “behavioral health unit” implies that if patients would just change their behaviors, they wouldn’t have serious biological psychiatric illness. It insinuates that the patients cause and perpetuate their illnesses, such as schizophrenia or bipolar disorder, by behaving poorly. Granted, we teach behavior modification to help manage psychiatric illness, but so, too, do our colleagues in other medical fields teach behavior modification to manage other organ-related illnesses. Some nearly ubiquitous examples include doctors advising patients to lower stress, modify diet, exercise, and take medications as prescribed. Yet, for example, in the case of a patient with diabetes, we don’t refer to diabetic ketoacidosis treatment as behavioral health treatment, though the patient’s behavior no doubt contributes to this condition. And we certainly would never call the ICU or stepdown unit the “behavioral health unit,” even though adequate holistic treatment in these settings includes counseling the patient with diabetes on changing his/her behaviors that led to the ketoacidosis. Just as in diabetes, the underlying basis of psychiatric illness is biologic processes gone awry. First and foremost, a psychiatric medical illness requires complicated and often precarious medications to treat. As in other medical specialties, modifying behavior does not treat the illness, but merely serves to help transmute the course.

In sum, I wholly agree with Dr. Nasrallah’s eloquent assessment regarding the problems with the title behavioral health in lieu of psychiatry. I also might have taken the discussion a step a further: Because psychiatric illness affects every aspect of a person’s life—such as work, social, and personal—it requires a terminology commensurate with the medical gravity it warrants. So in addition to not referring to the specialty as behavioral health, I have wondered if the name psychiatry could be replaced with a more medical-sounding term such as “cerebrology” or something of the sort. But one step at time.

Stacie Lauro, MD, ABPN
Attending in Psychiatry, Emergency Room, and Consultation Liaison
Mindcare Solutions
Tampa, Florida

The evolution within our field of the use of “behavioral health” has disturbed me to the same extent it has for Dr. Nasrallah. I founded and direct a psychiatric treatment facility in Florida. We are a teaching facility affiliated with 3 psychiatric residencies, 8 medical schools, and 60 physician assistant (PA) schools. In all of the literature (eg, evaluations) from the PA schools, they refer to their rotation with my program as “behavioral health.” I have been attempting to correct them for years! I teach all residents and students to correctly use the terms “psychiatry” and “psychiatric.” I understand there may be stigma associated with the latter terms, but the field reinforces that stigma by avoiding the use of these terms.

Robert A. Moran, MD, FAPA, FASAM
CEO and Medical Director, Family Center for Recovery
Lantana, Florida

Continue to: Pre-authorization and 'hold harmless' clauses

Regarding Dr. Nasrallah’s editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor, Current Psychiatry. April 2020, p. 5,10-11), I am so glad he wrote about this egregious, illegal, unethical, and grossly disruptive practice. I would like to suggest an angle to our organized response to this trend based on my experience as a member on the Committee on Managed Care of the American Psychiatric Association from 1991 through 1993 as a Burroughs Wellcome Fellow. The chair of the Committee and President and CEO of Sheppard Pratt Health System at the time, Steve Sharfstein, MD, MPA, underscored the importance of not signing a “hold harmless” clause on any contract whatsoever.

Recently to my surprise, while navigating a pre-authorization request for a young patient with bipolar disorder who had accepted the inclusion of lurasidone in his treatment regimen while hospitalized, I found that the CoverMyMeds Business Associate Agreement is required for a user to accomplish pre-authorization online. Having a little extra time for due diligence that day, I read this lengthy agreement carefully. The CoverMyMeds user agreement purports not to offer “medical advice, does not determine medical necessity, insurance coverage or copays and does not otherwise engage in the practice of medicine” (see www.covermymeds.com/main/about/privacy/tos/). Interestingly, the agreement goes on to purport that the whole process is for informational purposes only, not a substitute for clinicians, professional medical judgment, or for individual patient assessments and examinations. Of course, another factor is that the information provided by the process is “solely at the user’s and health care provider’s own risk.” Finally, the agreement requires the user to agree to “indemnify, defend, and hold harmless CoverMyMeds and its affiliates … from any demands, claims, damages, liabilities, expenses, or harms (including attorneys’ fees) arising out of or related to your use of our Services or breach of these Terms of Service.”

Throughout my 25 years of solo private practice, I have refused to sign hold harmless clauses and I refused to sign the CoverMyMeds user agreement. I have made it my practice never to obtain pre-authorization unless the patient is with me in the room during an appointment because the process of navigating pre-authorization does become part of the treatment, however unfortunately. As an alternative, for my patient with bipolar disorder, I was able to use a phone number to talk to a representative of the pharmacy benefit plan that was contracted with CoverMyMeds. Without signing on to be a Business Associate, we accomplished the goal of continuing with the medication as recommended and implemented for 2 preceding months (often pre-authorization actually means continuing authorization, doesn’t it?). I believe if all psychiatrists were to adopt this kind of stance, we could make a change. I know there are anti-trust considerations involved in fee negotiations, but when it comes to the egregious practices of managed care, pre-authorization, and hold harmless clauses, it seems to me that we can mount a counteroffensive to great effect.

Further, I want to stand in strong support of Dr. Nasrallah’s editorial “Stop calling it ‘behavioral health’: Psychiatry is much more.” When I began my first job post-fellowship, I was alarmed to find that our outpatient offices had been named a “counseling center.” Due to such misleading, stigmatizing characterizations, as Dr. Nasrallah pointed out, we have only slid further down the slope into the realm of “providers of behavioral health services.” As an old hand working psychiatric locum tenens told me, we psychiatrists had long since missed the chance to “band together like musk oxen” to defend our profession.

However, I believe it is not too late. With the strength of Dr. Nasrallah’s leadership and a more overt, collective stubbornness coupled with an undying commitment to excellence, we can and must push hard against the insurance and hospital entities, which continue to profiteer from the practice of medicine without a license—using the tools of hold harmless clauses, anti-trust laws in their favor, and misinformation about the scope and efficacy of practicing psychiatry per se. The challenge is to figure out exactly how to proceed.

Although some manage to thrive in independent practice, collectively our struggle seems considerable, but not insurmountable.

David B. Robinson, MD, MPH
Diplomate, American Board of Psychiatry and Neurology in Child, Adolescent and Adult Psychiatry
Fellow, American Psychiatric Association
Private psychiatric practice
Alaska Psychiatric Concepts
Juneau, Alaska

In the wake of Dr. Nasrallah’s recent editorial “Stop calling it ‘behavioral health:’ Psychiatry is much more” (From the Editor, Current Psychiatry. June 2020, p. 9-7,38), we offer an alternative viewpoint as members of a multi­hospital (academic and community), multifaceted, multidisciplinary behavioral health institute.

Naming a field, institute, department, or group of collaborators is crucially important, and must be undertaken with care. We all are familiar with Departments of Psychiatry, Departments of Psychiatry and Psychology, and Institutes for everything from Behavioral Health to Living. Even within the discipline of psychiatry, there have been adjustments over time in subspecialties (as seen with consultation-liaison psychiatry becoming psychosomatic medicine and then back again).

In our hospital system, we have recently adopted the term “Behavioral Health Institute” to denote the work and worth of significant numbers of caregivers (psychiatrists, psychologists, chemical dependency counselors, social workers, child life workers, advanced practice nurses, and others) who strive to improve the health and well-being of patients with both substance abuse and mental illness. We endeavor to remain mindful that a diversity of providers are involved in caring for and about our patients, and that “psychiatry” cannot—and should not—be the extent of how we conceptualize our services.

We submit that the modern view of behavioral health is ahead of other fields of medicine in recognizing that concepts, such as teamwork and diversity, are key to achieving positive patient outcomes. By identifying our providers as part of a Behavioral Health Institute, we acknowledge that not all mental distress is psychiatric illness but may still benefit from intervention and, importantly, that psychiatrists are not the center of the mental health (behavioral health) world. Treatments ranging from medication management to psychiatric procedures to psychotherapeutic modalities show the depth and breadth of our field, and the multiplicity of providers and modalities should be considered laudable. Recognizing the complexities inherent in behavioral health and its varied treatment options does not diminish but, in fact, elevates the field of psychiatry—and psychiatrists themselves.

Further, we note that behavioral health is not the only term that casts a larger net than the physician in a respective field. Does the term “primary care” insult internal medicine, family medicine, and pediatric physicians? Physicians and health care teams join in partnership with patients and families, either to cure or learn how to manage disease. We believe that constructing a health care system centered on physicians and their identities, rather than on patients and treatment outcomes, has been foolish. To that end, the tenor of Dr. Nasrallah’s editorial runs counter to the overall efforts of our field to improve collaboration, and, at its extreme, such articles promote the antiquated notion of physician elitism.

The editorial’s historical context is of course important, and the caution not to water down what “we” do (as psychiatrists) is appropriate. However, instead of comporting ourselves in a psychiatry-centric way, the use of the term behavioral health allows all of us to acknowledge (with appreciation and humility) the many contributors who work in our field. The use of a broad-minded, inclusive term neither minimizes nor trivializes psychiatry as a medical specialty. Rather, accepting this term and this mindset can place psychiatrists in the unique role of being innovators for the rest of medicine, because we embrace multidisciplinary teams and the value that interdisciplinary care can bring to patients and colleagues alike.

Jeanne Lackamp, MD, DFAPA, FACLP
Director, Pain Management Institute
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Patrick Runnels, MD, MBA
Chief Medical Officer, Population Health – Behavioral Health
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Lori Locke, RN, MSN
Director, Psychiatry Service Line and Nursing Practice
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Erum Ahmad, MD
Director, Child and Adolescent Psychiatry Unit
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Robert Ronis, MD, MPH
Douglas Danford Bond Professor and Chairman
Psychiatrist-in-Chief
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Continue to: Dr. Nasrallah responds

I thank my Cleveland colleagues for their letter, and I welcome their disagreement with the tenets of my editorial. I still insist that the term “behavioral health” has a very narrow meaning that is not equivalent to psychiatry or psychology or social work or psychiatric nursing practice. This term should not be conflated with the widely used “mental health,” which is used as an overarching term for all professionals involved in the care of psychiatric brain disorders that manifest as various mental illnesses and substance use disorders.

While I am an advocate for multidisciplinary collaborations that benefit our patients, I will always uphold psychiatry as a medical specialty whose unique identity should not be sacrificed on the altar of politically correct egalitarianism of the mental health disciplines. Call it elitist if you like, but the fact is that the extensive medical school, residency, and fellowship training of psychiatrists stand out among all the other mental health disciplines. Psychiatrists are the best trained in all components of the biopsychosocial model (which I acquired many years ago from the father of the concept, George Engel, one of my teachers at the University of Rochester Residency Program).

You bring up primary care as an analogy for behavioral health. I assure you, none of the medical specialists included under that umbrella term refer to themselves as primary care physicians (PCPs) (or, God forbid, providers!). They identify themselves as family physicians, internists, pediatricians, and gynecologists. It is for the convenience of the health care systems and insurance companies that clinicians are called PCPs, which homogenizes them into a fuzzy amalgam and disguises their true medical identities as specialists.

So we agree to disagree. Diversity of opinions is a sacred principle. But I still think that a more accurate name for your Behavioral Health Institute would be “Institute of Psychiatric Medicine and Brain Health.” Behavioral health, which actually refers to educating people about implementing principles of evidence-based healthy habits and behaviors that prevent or reduce the risk of mental illness and/or substance use, is a small sliver of your overall mission. As you’ll notice from the other letters we’ve received, the vast majority of our readers agree that psychiatric medicine is far more than behavioral health.

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Continue to: I thoroughly enjoyed...

I thoroughly enjoyed Dr. Nasrallah’s editorial and agree completely. Veterans Affairs, my employer for the last 12 years, has fully bought into the use of “behavioral health” and its implications for its many psychiatrists. I have grown very tired of the constant minimization of psychiatric practice, and it is so good to hear from an affirming voice.

Barbara Day, MD
US Department of Veterans Affairs
Ann Arbor, Michigan

Dr. Nasrallah’s editorial made my heart sing! I have been practicing psychiatry since 1979, and have always bristled when called a “provider” or any of the other terms Dr. Nasrallah described. As a graduate of Johns Hopkins Medical School, I had professors who themselves had been taught by Harry Stack Sullivan and Frida Fromm Reichman, and during my residency at the University of Chicago, I sat in discussions with both Bruno Bettelheim and Heinz Kohut. I felt part of an honorable tradition, and even though biological psychiatry was on the ascendency, these analytical luminaries were part of my learning the “art” of psychiatry. It is not so easy to feel good about a specialty that has had such a history as ours, but my own experiences could never be reduced to being called a behavioral health provider. Dr. Nasrallah’s thoughts are very encouraging, and I thank him!

John Engers, MD
Private psychiatric practice (retired)
Fremont, California

Dr. Nasrallah’s editorial resonated with one of my pet peeves. I’ve been telling my medical students for years that we psychiatrists treat disorders of thinking, emotions, and behavior associated with mental illness, and that the term “behavioral health,” though possibly well intentioned, is a euphemism to reduce stigma.

Irl Extein, MD
Private psychiatric practice
Delray Beach, Florida
Clinical Affiliate Associate Professor, Florida
Atlantic University College of Medicine
Boca Raton, Florida

Continue to: I enjoyed...

Stu Gitlow, MD, MPH
Executive Director
Annenberg Physician Training Program in Addictive Disease
Woonsocket, Rhode Island

I was grateful for Dr. Nasrallah’s editorial regarding the misnomer of referring to psychiatry as “behavioral health.” Until this editorial, I had wondered if I was the only one bothered by the term. Many people are under the assumption that behavioral health is a politically correct term that helps to lessen stigmatism. I completely disagree. Without question, it adds to the stigmatism. The term behavioral health is belittling to our patients. For example, calling a psychiatric inpatient unit a “behavioral health unit” implies that if patients would just change their behaviors, they wouldn’t have serious biological psychiatric illness. It insinuates that the patients cause and perpetuate their illnesses, such as schizophrenia or bipolar disorder, by behaving poorly. Granted, we teach behavior modification to help manage psychiatric illness, but so, too, do our colleagues in other medical fields teach behavior modification to manage other organ-related illnesses. Some nearly ubiquitous examples include doctors advising patients to lower stress, modify diet, exercise, and take medications as prescribed. Yet, for example, in the case of a patient with diabetes, we don’t refer to diabetic ketoacidosis treatment as behavioral health treatment, though the patient’s behavior no doubt contributes to this condition. And we certainly would never call the ICU or stepdown unit the “behavioral health unit,” even though adequate holistic treatment in these settings includes counseling the patient with diabetes on changing his/her behaviors that led to the ketoacidosis. Just as in diabetes, the underlying basis of psychiatric illness is biologic processes gone awry. First and foremost, a psychiatric medical illness requires complicated and often precarious medications to treat. As in other medical specialties, modifying behavior does not treat the illness, but merely serves to help transmute the course.

In sum, I wholly agree with Dr. Nasrallah’s eloquent assessment regarding the problems with the title behavioral health in lieu of psychiatry. I also might have taken the discussion a step a further: Because psychiatric illness affects every aspect of a person’s life—such as work, social, and personal—it requires a terminology commensurate with the medical gravity it warrants. So in addition to not referring to the specialty as behavioral health, I have wondered if the name psychiatry could be replaced with a more medical-sounding term such as “cerebrology” or something of the sort. But one step at time.

Stacie Lauro, MD, ABPN
Attending in Psychiatry, Emergency Room, and Consultation Liaison
Mindcare Solutions
Tampa, Florida

The evolution within our field of the use of “behavioral health” has disturbed me to the same extent it has for Dr. Nasrallah. I founded and direct a psychiatric treatment facility in Florida. We are a teaching facility affiliated with 3 psychiatric residencies, 8 medical schools, and 60 physician assistant (PA) schools. In all of the literature (eg, evaluations) from the PA schools, they refer to their rotation with my program as “behavioral health.” I have been attempting to correct them for years! I teach all residents and students to correctly use the terms “psychiatry” and “psychiatric.” I understand there may be stigma associated with the latter terms, but the field reinforces that stigma by avoiding the use of these terms.

Robert A. Moran, MD, FAPA, FASAM
CEO and Medical Director, Family Center for Recovery
Lantana, Florida

Continue to: Pre-authorization and 'hold harmless' clauses

Regarding Dr. Nasrallah’s editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor, Current Psychiatry. April 2020, p. 5,10-11), I am so glad he wrote about this egregious, illegal, unethical, and grossly disruptive practice. I would like to suggest an angle to our organized response to this trend based on my experience as a member on the Committee on Managed Care of the American Psychiatric Association from 1991 through 1993 as a Burroughs Wellcome Fellow. The chair of the Committee and President and CEO of Sheppard Pratt Health System at the time, Steve Sharfstein, MD, MPA, underscored the importance of not signing a “hold harmless” clause on any contract whatsoever.

Recently to my surprise, while navigating a pre-authorization request for a young patient with bipolar disorder who had accepted the inclusion of lurasidone in his treatment regimen while hospitalized, I found that the CoverMyMeds Business Associate Agreement is required for a user to accomplish pre-authorization online. Having a little extra time for due diligence that day, I read this lengthy agreement carefully. The CoverMyMeds user agreement purports not to offer “medical advice, does not determine medical necessity, insurance coverage or copays and does not otherwise engage in the practice of medicine” (see www.covermymeds.com/main/about/privacy/tos/). Interestingly, the agreement goes on to purport that the whole process is for informational purposes only, not a substitute for clinicians, professional medical judgment, or for individual patient assessments and examinations. Of course, another factor is that the information provided by the process is “solely at the user’s and health care provider’s own risk.” Finally, the agreement requires the user to agree to “indemnify, defend, and hold harmless CoverMyMeds and its affiliates … from any demands, claims, damages, liabilities, expenses, or harms (including attorneys’ fees) arising out of or related to your use of our Services or breach of these Terms of Service.”

Throughout my 25 years of solo private practice, I have refused to sign hold harmless clauses and I refused to sign the CoverMyMeds user agreement. I have made it my practice never to obtain pre-authorization unless the patient is with me in the room during an appointment because the process of navigating pre-authorization does become part of the treatment, however unfortunately. As an alternative, for my patient with bipolar disorder, I was able to use a phone number to talk to a representative of the pharmacy benefit plan that was contracted with CoverMyMeds. Without signing on to be a Business Associate, we accomplished the goal of continuing with the medication as recommended and implemented for 2 preceding months (often pre-authorization actually means continuing authorization, doesn’t it?). I believe if all psychiatrists were to adopt this kind of stance, we could make a change. I know there are anti-trust considerations involved in fee negotiations, but when it comes to the egregious practices of managed care, pre-authorization, and hold harmless clauses, it seems to me that we can mount a counteroffensive to great effect.

Further, I want to stand in strong support of Dr. Nasrallah’s editorial “Stop calling it ‘behavioral health’: Psychiatry is much more.” When I began my first job post-fellowship, I was alarmed to find that our outpatient offices had been named a “counseling center.” Due to such misleading, stigmatizing characterizations, as Dr. Nasrallah pointed out, we have only slid further down the slope into the realm of “providers of behavioral health services.” As an old hand working psychiatric locum tenens told me, we psychiatrists had long since missed the chance to “band together like musk oxen” to defend our profession.

However, I believe it is not too late. With the strength of Dr. Nasrallah’s leadership and a more overt, collective stubbornness coupled with an undying commitment to excellence, we can and must push hard against the insurance and hospital entities, which continue to profiteer from the practice of medicine without a license—using the tools of hold harmless clauses, anti-trust laws in their favor, and misinformation about the scope and efficacy of practicing psychiatry per se. The challenge is to figure out exactly how to proceed.

Although some manage to thrive in independent practice, collectively our struggle seems considerable, but not insurmountable.

David B. Robinson, MD, MPH
Diplomate, American Board of Psychiatry and Neurology in Child, Adolescent and Adult Psychiatry
Fellow, American Psychiatric Association
Private psychiatric practice
Alaska Psychiatric Concepts
Juneau, Alaska

In the wake of Dr. Nasrallah’s recent editorial “Stop calling it ‘behavioral health:’ Psychiatry is much more” (From the Editor, Current Psychiatry. June 2020, p. 9-7,38), we offer an alternative viewpoint as members of a multi­hospital (academic and community), multifaceted, multidisciplinary behavioral health institute.

Naming a field, institute, department, or group of collaborators is crucially important, and must be undertaken with care. We all are familiar with Departments of Psychiatry, Departments of Psychiatry and Psychology, and Institutes for everything from Behavioral Health to Living. Even within the discipline of psychiatry, there have been adjustments over time in subspecialties (as seen with consultation-liaison psychiatry becoming psychosomatic medicine and then back again).

In our hospital system, we have recently adopted the term “Behavioral Health Institute” to denote the work and worth of significant numbers of caregivers (psychiatrists, psychologists, chemical dependency counselors, social workers, child life workers, advanced practice nurses, and others) who strive to improve the health and well-being of patients with both substance abuse and mental illness. We endeavor to remain mindful that a diversity of providers are involved in caring for and about our patients, and that “psychiatry” cannot—and should not—be the extent of how we conceptualize our services.

We submit that the modern view of behavioral health is ahead of other fields of medicine in recognizing that concepts, such as teamwork and diversity, are key to achieving positive patient outcomes. By identifying our providers as part of a Behavioral Health Institute, we acknowledge that not all mental distress is psychiatric illness but may still benefit from intervention and, importantly, that psychiatrists are not the center of the mental health (behavioral health) world. Treatments ranging from medication management to psychiatric procedures to psychotherapeutic modalities show the depth and breadth of our field, and the multiplicity of providers and modalities should be considered laudable. Recognizing the complexities inherent in behavioral health and its varied treatment options does not diminish but, in fact, elevates the field of psychiatry—and psychiatrists themselves.

Further, we note that behavioral health is not the only term that casts a larger net than the physician in a respective field. Does the term “primary care” insult internal medicine, family medicine, and pediatric physicians? Physicians and health care teams join in partnership with patients and families, either to cure or learn how to manage disease. We believe that constructing a health care system centered on physicians and their identities, rather than on patients and treatment outcomes, has been foolish. To that end, the tenor of Dr. Nasrallah’s editorial runs counter to the overall efforts of our field to improve collaboration, and, at its extreme, such articles promote the antiquated notion of physician elitism.

The editorial’s historical context is of course important, and the caution not to water down what “we” do (as psychiatrists) is appropriate. However, instead of comporting ourselves in a psychiatry-centric way, the use of the term behavioral health allows all of us to acknowledge (with appreciation and humility) the many contributors who work in our field. The use of a broad-minded, inclusive term neither minimizes nor trivializes psychiatry as a medical specialty. Rather, accepting this term and this mindset can place psychiatrists in the unique role of being innovators for the rest of medicine, because we embrace multidisciplinary teams and the value that interdisciplinary care can bring to patients and colleagues alike.

Jeanne Lackamp, MD, DFAPA, FACLP
Director, Pain Management Institute
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Patrick Runnels, MD, MBA
Chief Medical Officer, Population Health – Behavioral Health
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Lori Locke, RN, MSN
Director, Psychiatry Service Line and Nursing Practice
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Erum Ahmad, MD
Director, Child and Adolescent Psychiatry Unit
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Robert Ronis, MD, MPH
Douglas Danford Bond Professor and Chairman
Psychiatrist-in-Chief
University Hospitals Health System
Case Western Reserve University School of Medicine
Cleveland, Ohio

Continue to: Dr. Nasrallah responds

I thank my Cleveland colleagues for their letter, and I welcome their disagreement with the tenets of my editorial. I still insist that the term “behavioral health” has a very narrow meaning that is not equivalent to psychiatry or psychology or social work or psychiatric nursing practice. This term should not be conflated with the widely used “mental health,” which is used as an overarching term for all professionals involved in the care of psychiatric brain disorders that manifest as various mental illnesses and substance use disorders.

While I am an advocate for multidisciplinary collaborations that benefit our patients, I will always uphold psychiatry as a medical specialty whose unique identity should not be sacrificed on the altar of politically correct egalitarianism of the mental health disciplines. Call it elitist if you like, but the fact is that the extensive medical school, residency, and fellowship training of psychiatrists stand out among all the other mental health disciplines. Psychiatrists are the best trained in all components of the biopsychosocial model (which I acquired many years ago from the father of the concept, George Engel, one of my teachers at the University of Rochester Residency Program).

You bring up primary care as an analogy for behavioral health. I assure you, none of the medical specialists included under that umbrella term refer to themselves as primary care physicians (PCPs) (or, God forbid, providers!). They identify themselves as family physicians, internists, pediatricians, and gynecologists. It is for the convenience of the health care systems and insurance companies that clinicians are called PCPs, which homogenizes them into a fuzzy amalgam and disguises their true medical identities as specialists.

So we agree to disagree. Diversity of opinions is a sacred principle. But I still think that a more accurate name for your Behavioral Health Institute would be “Institute of Psychiatric Medicine and Brain Health.” Behavioral health, which actually refers to educating people about implementing principles of evidence-based healthy habits and behaviors that prevent or reduce the risk of mental illness and/or substance use, is a small sliver of your overall mission. As you’ll notice from the other letters we’ve received, the vast majority of our readers agree that psychiatric medicine is far more than behavioral health.

Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri

Continue to: I thoroughly enjoyed...

I thoroughly enjoyed Dr. Nasrallah’s editorial and agree completely. Veterans Affairs, my employer for the last 12 years, has fully bought into the use of “behavioral health” and its implications for its many psychiatrists. I have grown very tired of the constant minimization of psychiatric practice, and it is so good to hear from an affirming voice.

Barbara Day, MD
US Department of Veterans Affairs
Ann Arbor, Michigan

Dr. Nasrallah’s editorial made my heart sing! I have been practicing psychiatry since 1979, and have always bristled when called a “provider” or any of the other terms Dr. Nasrallah described. As a graduate of Johns Hopkins Medical School, I had professors who themselves had been taught by Harry Stack Sullivan and Frida Fromm Reichman, and during my residency at the University of Chicago, I sat in discussions with both Bruno Bettelheim and Heinz Kohut. I felt part of an honorable tradition, and even though biological psychiatry was on the ascendency, these analytical luminaries were part of my learning the “art” of psychiatry. It is not so easy to feel good about a specialty that has had such a history as ours, but my own experiences could never be reduced to being called a behavioral health provider. Dr. Nasrallah’s thoughts are very encouraging, and I thank him!

John Engers, MD
Private psychiatric practice (retired)
Fremont, California

Dr. Nasrallah’s editorial resonated with one of my pet peeves. I’ve been telling my medical students for years that we psychiatrists treat disorders of thinking, emotions, and behavior associated with mental illness, and that the term “behavioral health,” though possibly well intentioned, is a euphemism to reduce stigma.

Irl Extein, MD
Private psychiatric practice
Delray Beach, Florida
Clinical Affiliate Associate Professor, Florida
Atlantic University College of Medicine
Boca Raton, Florida

Continue to: I enjoyed...

Stu Gitlow, MD, MPH
Executive Director
Annenberg Physician Training Program in Addictive Disease
Woonsocket, Rhode Island

I was grateful for Dr. Nasrallah’s editorial regarding the misnomer of referring to psychiatry as “behavioral health.” Until this editorial, I had wondered if I was the only one bothered by the term. Many people are under the assumption that behavioral health is a politically correct term that helps to lessen stigmatism. I completely disagree. Without question, it adds to the stigmatism. The term behavioral health is belittling to our patients. For example, calling a psychiatric inpatient unit a “behavioral health unit” implies that if patients would just change their behaviors, they wouldn’t have serious biological psychiatric illness. It insinuates that the patients cause and perpetuate their illnesses, such as schizophrenia or bipolar disorder, by behaving poorly. Granted, we teach behavior modification to help manage psychiatric illness, but so, too, do our colleagues in other medical fields teach behavior modification to manage other organ-related illnesses. Some nearly ubiquitous examples include doctors advising patients to lower stress, modify diet, exercise, and take medications as prescribed. Yet, for example, in the case of a patient with diabetes, we don’t refer to diabetic ketoacidosis treatment as behavioral health treatment, though the patient’s behavior no doubt contributes to this condition. And we certainly would never call the ICU or stepdown unit the “behavioral health unit,” even though adequate holistic treatment in these settings includes counseling the patient with diabetes on changing his/her behaviors that led to the ketoacidosis. Just as in diabetes, the underlying basis of psychiatric illness is biologic processes gone awry. First and foremost, a psychiatric medical illness requires complicated and often precarious medications to treat. As in other medical specialties, modifying behavior does not treat the illness, but merely serves to help transmute the course.

In sum, I wholly agree with Dr. Nasrallah’s eloquent assessment regarding the problems with the title behavioral health in lieu of psychiatry. I also might have taken the discussion a step a further: Because psychiatric illness affects every aspect of a person’s life—such as work, social, and personal—it requires a terminology commensurate with the medical gravity it warrants. So in addition to not referring to the specialty as behavioral health, I have wondered if the name psychiatry could be replaced with a more medical-sounding term such as “cerebrology” or something of the sort. But one step at time.

Stacie Lauro, MD, ABPN
Attending in Psychiatry, Emergency Room, and Consultation Liaison
Mindcare Solutions
Tampa, Florida

The evolution within our field of the use of “behavioral health” has disturbed me to the same extent it has for Dr. Nasrallah. I founded and direct a psychiatric treatment facility in Florida. We are a teaching facility affiliated with 3 psychiatric residencies, 8 medical schools, and 60 physician assistant (PA) schools. In all of the literature (eg, evaluations) from the PA schools, they refer to their rotation with my program as “behavioral health.” I have been attempting to correct them for years! I teach all residents and students to correctly use the terms “psychiatry” and “psychiatric.” I understand there may be stigma associated with the latter terms, but the field reinforces that stigma by avoiding the use of these terms.

Robert A. Moran, MD, FAPA, FASAM
CEO and Medical Director, Family Center for Recovery
Lantana, Florida

Continue to: Pre-authorization and 'hold harmless' clauses

Regarding Dr. Nasrallah’s editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor, Current Psychiatry. April 2020, p. 5,10-11), I am so glad he wrote about this egregious, illegal, unethical, and grossly disruptive practice. I would like to suggest an angle to our organized response to this trend based on my experience as a member on the Committee on Managed Care of the American Psychiatric Association from 1991 through 1993 as a Burroughs Wellcome Fellow. The chair of the Committee and President and CEO of Sheppard Pratt Health System at the time, Steve Sharfstein, MD, MPA, underscored the importance of not signing a “hold harmless” clause on any contract whatsoever.

Recently to my surprise, while navigating a pre-authorization request for a young patient with bipolar disorder who had accepted the inclusion of lurasidone in his treatment regimen while hospitalized, I found that the CoverMyMeds Business Associate Agreement is required for a user to accomplish pre-authorization online. Having a little extra time for due diligence that day, I read this lengthy agreement carefully. The CoverMyMeds user agreement purports not to offer “medical advice, does not determine medical necessity, insurance coverage or copays and does not otherwise engage in the practice of medicine” (see www.covermymeds.com/main/about/privacy/tos/). Interestingly, the agreement goes on to purport that the whole process is for informational purposes only, not a substitute for clinicians, professional medical judgment, or for individual patient assessments and examinations. Of course, another factor is that the information provided by the process is “solely at the user’s and health care provider’s own risk.” Finally, the agreement requires the user to agree to “indemnify, defend, and hold harmless CoverMyMeds and its affiliates … from any demands, claims, damages, liabilities, expenses, or harms (including attorneys’ fees) arising out of or related to your use of our Services or breach of these Terms of Service.”

Throughout my 25 years of solo private practice, I have refused to sign hold harmless clauses and I refused to sign the CoverMyMeds user agreement. I have made it my practice never to obtain pre-authorization unless the patient is with me in the room during an appointment because the process of navigating pre-authorization does become part of the treatment, however unfortunately. As an alternative, for my patient with bipolar disorder, I was able to use a phone number to talk to a representative of the pharmacy benefit plan that was contracted with CoverMyMeds. Without signing on to be a Business Associate, we accomplished the goal of continuing with the medication as recommended and implemented for 2 preceding months (often pre-authorization actually means continuing authorization, doesn’t it?). I believe if all psychiatrists were to adopt this kind of stance, we could make a change. I know there are anti-trust considerations involved in fee negotiations, but when it comes to the egregious practices of managed care, pre-authorization, and hold harmless clauses, it seems to me that we can mount a counteroffensive to great effect.

Further, I want to stand in strong support of Dr. Nasrallah’s editorial “Stop calling it ‘behavioral health’: Psychiatry is much more.” When I began my first job post-fellowship, I was alarmed to find that our outpatient offices had been named a “counseling center.” Due to such misleading, stigmatizing characterizations, as Dr. Nasrallah pointed out, we have only slid further down the slope into the realm of “providers of behavioral health services.” As an old hand working psychiatric locum tenens told me, we psychiatrists had long since missed the chance to “band together like musk oxen” to defend our profession.

However, I believe it is not too late. With the strength of Dr. Nasrallah’s leadership and a more overt, collective stubbornness coupled with an undying commitment to excellence, we can and must push hard against the insurance and hospital entities, which continue to profiteer from the practice of medicine without a license—using the tools of hold harmless clauses, anti-trust laws in their favor, and misinformation about the scope and efficacy of practicing psychiatry per se. The challenge is to figure out exactly how to proceed.

Although some manage to thrive in independent practice, collectively our struggle seems considerable, but not insurmountable.

David B. Robinson, MD, MPH
Diplomate, American Board of Psychiatry and Neurology in Child, Adolescent and Adult Psychiatry
Fellow, American Psychiatric Association
Private psychiatric practice
Alaska Psychiatric Concepts
Juneau, Alaska

Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.

Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.

In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.

The following findings from this study are striking:

• 92% of the published images of COVID-associated skin manifestations were in I-III.
• Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
• None showed COVID skin lesions in skin types V or VI.
• Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.

These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
 

As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.

These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin. This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.

Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.

Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
 

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

Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.

Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.

In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.

The following findings from this study are striking:

• 92% of the published images of COVID-associated skin manifestations were in I-III.
• Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
• None showed COVID skin lesions in skin types V or VI.
• Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.

These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
 

As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.

These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin. This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.

Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.

Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
 

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

Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.

Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.

In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.

The following findings from this study are striking:

• 92% of the published images of COVID-associated skin manifestations were in I-III.
• Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
• None showed COVID skin lesions in skin types V or VI.
• Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.

These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
 

As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.

These investigators have identified a damning lack of images of COVID-19–associated skin manifestations in patients with darker skin. This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.

Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.

Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
 

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

When the pandemic was just emerging from its infancy and we were just beginning to think about social distancing, I was sitting around enjoying an adult beverage and some gluten free (not my choice) snacks with some friends. A retired nurse who had just celebrated her 80th birthday said, “I can’t wait until they’ve developed a vaccine.” A former electrical engineer sitting just short of 2 meters to her left responded, “Don’t save me a place near the front of the line for something that is being developed in a program called Warp Speed.”

Micah Young/istockphoto.com

How do you feel about the potential SARS-CoV-2 vaccine? Are you going to roll up your sleeve as soon as the vaccine becomes available in your community? What are you going to suggest to your patients, your children? I suspect many of you will answer, “It depends.” What factors will you be considering when you try to decide between what is likely to be several competing SARS-CoV-2 vaccines?

Will it make any difference to you which biochemical-immune-bending strategy is being used to make the vaccine? All of them will probably be the result of a clever sounding but novel technique, all of them with a track record that is measured in months and not years. Will you be swayed by how large the trials were? Or how long the follow-up lasted? How effective must the vaccine be to convince you that it is worth receiving or recommending? Do you have the tools and experience to make a decision like that? I know I don’t. And should you and I even be put in a position to make that decision?

In the past, you and I may have relied on the Centers for Disease Control and Prevention for advice. But given the somewhat murky and stormy relationship between the CDC and the president, the vaccine recommendation may be issued by the White House and not the CDC.

For those of us who were practicing medicine during the Swine Flu fiasco of 1976, the pace and the politics surrounding the development of a SARS-CoV-2 vaccine has a discomforting déjà vu quality about it. The fact that like this year 1976 was an election year that infused the development process with a sense of urgency above and beyond any of the concerns about the pandemic that never happened. Although causality was never proven, there was a surge in Guillain-Barré syndrome cases that had been linked temporally to the vaccine.

Of course, our pandemic is real, and it would be imprudent to wait a year or more to watch for long-term vaccine sequelae. However, I am more than a little concerned that fast tracking the development process may result in unfortunate consequences in the short term that could have been avoided with a more measured approach to trialing the vaccines.

The sad reality is that as a nation we tend to be impatient. We are drawn to quick fixes that come in a vial or a capsule. We are learning that simple measures like mask wearing and social distancing can make a difference in slowing the spread of the virus. It would be tragic to rush a vaccine into production that at best turns out to simply be an expensive alternative to the measures that we know work or at worst injures more of us than it saves.
 

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

When the pandemic was just emerging from its infancy and we were just beginning to think about social distancing, I was sitting around enjoying an adult beverage and some gluten free (not my choice) snacks with some friends. A retired nurse who had just celebrated her 80th birthday said, “I can’t wait until they’ve developed a vaccine.” A former electrical engineer sitting just short of 2 meters to her left responded, “Don’t save me a place near the front of the line for something that is being developed in a program called Warp Speed.”

Micah Young/istockphoto.com

How do you feel about the potential SARS-CoV-2 vaccine? Are you going to roll up your sleeve as soon as the vaccine becomes available in your community? What are you going to suggest to your patients, your children? I suspect many of you will answer, “It depends.” What factors will you be considering when you try to decide between what is likely to be several competing SARS-CoV-2 vaccines?

Will it make any difference to you which biochemical-immune-bending strategy is being used to make the vaccine? All of them will probably be the result of a clever sounding but novel technique, all of them with a track record that is measured in months and not years. Will you be swayed by how large the trials were? Or how long the follow-up lasted? How effective must the vaccine be to convince you that it is worth receiving or recommending? Do you have the tools and experience to make a decision like that? I know I don’t. And should you and I even be put in a position to make that decision?

In the past, you and I may have relied on the Centers for Disease Control and Prevention for advice. But given the somewhat murky and stormy relationship between the CDC and the president, the vaccine recommendation may be issued by the White House and not the CDC.

For those of us who were practicing medicine during the Swine Flu fiasco of 1976, the pace and the politics surrounding the development of a SARS-CoV-2 vaccine has a discomforting déjà vu quality about it. The fact that like this year 1976 was an election year that infused the development process with a sense of urgency above and beyond any of the concerns about the pandemic that never happened. Although causality was never proven, there was a surge in Guillain-Barré syndrome cases that had been linked temporally to the vaccine.

Of course, our pandemic is real, and it would be imprudent to wait a year or more to watch for long-term vaccine sequelae. However, I am more than a little concerned that fast tracking the development process may result in unfortunate consequences in the short term that could have been avoided with a more measured approach to trialing the vaccines.

The sad reality is that as a nation we tend to be impatient. We are drawn to quick fixes that come in a vial or a capsule. We are learning that simple measures like mask wearing and social distancing can make a difference in slowing the spread of the virus. It would be tragic to rush a vaccine into production that at best turns out to simply be an expensive alternative to the measures that we know work or at worst injures more of us than it saves.
 

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

When the pandemic was just emerging from its infancy and we were just beginning to think about social distancing, I was sitting around enjoying an adult beverage and some gluten free (not my choice) snacks with some friends. A retired nurse who had just celebrated her 80th birthday said, “I can’t wait until they’ve developed a vaccine.” A former electrical engineer sitting just short of 2 meters to her left responded, “Don’t save me a place near the front of the line for something that is being developed in a program called Warp Speed.”

Micah Young/istockphoto.com

How do you feel about the potential SARS-CoV-2 vaccine? Are you going to roll up your sleeve as soon as the vaccine becomes available in your community? What are you going to suggest to your patients, your children? I suspect many of you will answer, “It depends.” What factors will you be considering when you try to decide between what is likely to be several competing SARS-CoV-2 vaccines?

Will it make any difference to you which biochemical-immune-bending strategy is being used to make the vaccine? All of them will probably be the result of a clever sounding but novel technique, all of them with a track record that is measured in months and not years. Will you be swayed by how large the trials were? Or how long the follow-up lasted? How effective must the vaccine be to convince you that it is worth receiving or recommending? Do you have the tools and experience to make a decision like that? I know I don’t. And should you and I even be put in a position to make that decision?

In the past, you and I may have relied on the Centers for Disease Control and Prevention for advice. But given the somewhat murky and stormy relationship between the CDC and the president, the vaccine recommendation may be issued by the White House and not the CDC.

For those of us who were practicing medicine during the Swine Flu fiasco of 1976, the pace and the politics surrounding the development of a SARS-CoV-2 vaccine has a discomforting déjà vu quality about it. The fact that like this year 1976 was an election year that infused the development process with a sense of urgency above and beyond any of the concerns about the pandemic that never happened. Although causality was never proven, there was a surge in Guillain-Barré syndrome cases that had been linked temporally to the vaccine.

Of course, our pandemic is real, and it would be imprudent to wait a year or more to watch for long-term vaccine sequelae. However, I am more than a little concerned that fast tracking the development process may result in unfortunate consequences in the short term that could have been avoided with a more measured approach to trialing the vaccines.

The sad reality is that as a nation we tend to be impatient. We are drawn to quick fixes that come in a vial or a capsule. We are learning that simple measures like mask wearing and social distancing can make a difference in slowing the spread of the virus. It would be tragic to rush a vaccine into production that at best turns out to simply be an expensive alternative to the measures that we know work or at worst injures more of us than it saves.
 

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

It turns out that a pandemic, at least this COVID-19 version, can be a challenge for folks like me who are seldom at a loss for words. The pandemic has so overwhelmed every corner of our lives that it is hard to think of another topic on which to pontificate and still not tromp on someone’s political toes. One can always write about the pandemic itself, and I’ve tried that, but as the curtain is gradually being pulled back on this crafty little germ one runs the risk of making an observation today that will be disproved in a week or 2. However, I can’t suppress my urge to write, and so I have decided to share a few brief random observations. Of course they are related to the pandemic. And of course I realize that there is a better than fifty percent chance that they will be proved wrong by the time you read my next Letters from Maine.

Under the radar

Phynart Studio/Getty Images

Two of the many mysteries about SARS-CoV-2 involve young children who as a group appear to be less easily infected than adults and even when infected seem to be less likely to spread the disease to other people, particularly adults. One explanation posited by some researchers in France is that young children are less likely to have symptoms such as cough and are less powerful speakers and so might be less likely to spew out a significant number of infected aerosolized droplets (“How to Reopen Schools: What Science and Other Countries Teach Us.” By Pam Belluck, Apoorva Mandavill, and Benedict Carey. New York Times, July 11, 2020). While there are probably several factors to explain this observation, one may be that young children are short, seldom taller than an adult waistline. I suspect the majority of aerosols they emit fall and inactivate harmlessly to the floor several feet below an adult’s nose and mouth. Regardless of the explanation, it appears to be good news for the opening of schools, at least for the early grades.

Forget the deep cleaning

There has been a glut of news stories about reopening schools, and many of these stories are accompanied by images of school custodians with buckets, mops, spray bottles, and sponges scouring desks and walls. The most recent image in our local newspaper was of someone scrubbing the underside of a desk. I know it’s taking the World Health Organization an unconscionable period of time to acknowledge that SARS-CoV-2 is airborne, but the rest of us should have gotten the message long ago and been directing our attention to air handling and ventilation. The urge to scrub and deep clean is a hard habit to break, but this nasty bug is not like influenza or a flesh eating bacteria in which deep cleaning might help. A better image to attach to a story on school reopening would be one of a custodian with a screwdriver struggling to pry open a classroom window that had been painted shut a decade ago.

Managing the inevitable

Middlebury College in Vermont and Bowdoin College here in Brunswick, Maine, are similar in many respects because they are small and situated in relatively isolated small New England towns with good track records for pandemic management. Middlebury has elected to invite all its 2,750 students back to campus, whereas Bowdoin has decided to allow only incoming first years and transfer students (for a total of about 600) to return. Both schools will institute similar testing and social distancing protocols and restrict students from access to their respective towns (“A Tale of 2 Colleges.” By Bill Burger. Inside Higher Ed, June 29,2020). It will be an interesting experiment. I’m voting for Middlebury and not because my son and daughter-in-law are alums, but because I think Middlebury seems to have acknowledged that no matter how diligent one is in creating a SARS-CoV-2–free environment at the outset, these are college kids and there will be some cases on both campuses. It is on how those inevitable realities are managed and contained that an institution should be judged.

Patience

Unfortunately, the pandemic has exposed some of our weaknesses as a nation. We always have been a restless and impatient population eager to get moving and it has driven us to greatness. Hopefully, patience will be a lesson that we will learn, along with many others.

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

It turns out that a pandemic, at least this COVID-19 version, can be a challenge for folks like me who are seldom at a loss for words. The pandemic has so overwhelmed every corner of our lives that it is hard to think of another topic on which to pontificate and still not tromp on someone’s political toes. One can always write about the pandemic itself, and I’ve tried that, but as the curtain is gradually being pulled back on this crafty little germ one runs the risk of making an observation today that will be disproved in a week or 2. However, I can’t suppress my urge to write, and so I have decided to share a few brief random observations. Of course they are related to the pandemic. And of course I realize that there is a better than fifty percent chance that they will be proved wrong by the time you read my next Letters from Maine.

Under the radar

Phynart Studio/Getty Images

Two of the many mysteries about SARS-CoV-2 involve young children who as a group appear to be less easily infected than adults and even when infected seem to be less likely to spread the disease to other people, particularly adults. One explanation posited by some researchers in France is that young children are less likely to have symptoms such as cough and are less powerful speakers and so might be less likely to spew out a significant number of infected aerosolized droplets (“How to Reopen Schools: What Science and Other Countries Teach Us.” By Pam Belluck, Apoorva Mandavill, and Benedict Carey. New York Times, July 11, 2020). While there are probably several factors to explain this observation, one may be that young children are short, seldom taller than an adult waistline. I suspect the majority of aerosols they emit fall and inactivate harmlessly to the floor several feet below an adult’s nose and mouth. Regardless of the explanation, it appears to be good news for the opening of schools, at least for the early grades.

Forget the deep cleaning

There has been a glut of news stories about reopening schools, and many of these stories are accompanied by images of school custodians with buckets, mops, spray bottles, and sponges scouring desks and walls. The most recent image in our local newspaper was of someone scrubbing the underside of a desk. I know it’s taking the World Health Organization an unconscionable period of time to acknowledge that SARS-CoV-2 is airborne, but the rest of us should have gotten the message long ago and been directing our attention to air handling and ventilation. The urge to scrub and deep clean is a hard habit to break, but this nasty bug is not like influenza or a flesh eating bacteria in which deep cleaning might help. A better image to attach to a story on school reopening would be one of a custodian with a screwdriver struggling to pry open a classroom window that had been painted shut a decade ago.

Managing the inevitable

Middlebury College in Vermont and Bowdoin College here in Brunswick, Maine, are similar in many respects because they are small and situated in relatively isolated small New England towns with good track records for pandemic management. Middlebury has elected to invite all its 2,750 students back to campus, whereas Bowdoin has decided to allow only incoming first years and transfer students (for a total of about 600) to return. Both schools will institute similar testing and social distancing protocols and restrict students from access to their respective towns (“A Tale of 2 Colleges.” By Bill Burger. Inside Higher Ed, June 29,2020). It will be an interesting experiment. I’m voting for Middlebury and not because my son and daughter-in-law are alums, but because I think Middlebury seems to have acknowledged that no matter how diligent one is in creating a SARS-CoV-2–free environment at the outset, these are college kids and there will be some cases on both campuses. It is on how those inevitable realities are managed and contained that an institution should be judged.

Patience

Unfortunately, the pandemic has exposed some of our weaknesses as a nation. We always have been a restless and impatient population eager to get moving and it has driven us to greatness. Hopefully, patience will be a lesson that we will learn, along with many others.

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

It turns out that a pandemic, at least this COVID-19 version, can be a challenge for folks like me who are seldom at a loss for words. The pandemic has so overwhelmed every corner of our lives that it is hard to think of another topic on which to pontificate and still not tromp on someone’s political toes. One can always write about the pandemic itself, and I’ve tried that, but as the curtain is gradually being pulled back on this crafty little germ one runs the risk of making an observation today that will be disproved in a week or 2. However, I can’t suppress my urge to write, and so I have decided to share a few brief random observations. Of course they are related to the pandemic. And of course I realize that there is a better than fifty percent chance that they will be proved wrong by the time you read my next Letters from Maine.

Under the radar

Phynart Studio/Getty Images

Two of the many mysteries about SARS-CoV-2 involve young children who as a group appear to be less easily infected than adults and even when infected seem to be less likely to spread the disease to other people, particularly adults. One explanation posited by some researchers in France is that young children are less likely to have symptoms such as cough and are less powerful speakers and so might be less likely to spew out a significant number of infected aerosolized droplets (“How to Reopen Schools: What Science and Other Countries Teach Us.” By Pam Belluck, Apoorva Mandavill, and Benedict Carey. New York Times, July 11, 2020). While there are probably several factors to explain this observation, one may be that young children are short, seldom taller than an adult waistline. I suspect the majority of aerosols they emit fall and inactivate harmlessly to the floor several feet below an adult’s nose and mouth. Regardless of the explanation, it appears to be good news for the opening of schools, at least for the early grades.

Forget the deep cleaning

There has been a glut of news stories about reopening schools, and many of these stories are accompanied by images of school custodians with buckets, mops, spray bottles, and sponges scouring desks and walls. The most recent image in our local newspaper was of someone scrubbing the underside of a desk. I know it’s taking the World Health Organization an unconscionable period of time to acknowledge that SARS-CoV-2 is airborne, but the rest of us should have gotten the message long ago and been directing our attention to air handling and ventilation. The urge to scrub and deep clean is a hard habit to break, but this nasty bug is not like influenza or a flesh eating bacteria in which deep cleaning might help. A better image to attach to a story on school reopening would be one of a custodian with a screwdriver struggling to pry open a classroom window that had been painted shut a decade ago.

Managing the inevitable

Middlebury College in Vermont and Bowdoin College here in Brunswick, Maine, are similar in many respects because they are small and situated in relatively isolated small New England towns with good track records for pandemic management. Middlebury has elected to invite all its 2,750 students back to campus, whereas Bowdoin has decided to allow only incoming first years and transfer students (for a total of about 600) to return. Both schools will institute similar testing and social distancing protocols and restrict students from access to their respective towns (“A Tale of 2 Colleges.” By Bill Burger. Inside Higher Ed, June 29,2020). It will be an interesting experiment. I’m voting for Middlebury and not because my son and daughter-in-law are alums, but because I think Middlebury seems to have acknowledged that no matter how diligent one is in creating a SARS-CoV-2–free environment at the outset, these are college kids and there will be some cases on both campuses. It is on how those inevitable realities are managed and contained that an institution should be judged.

Patience

Unfortunately, the pandemic has exposed some of our weaknesses as a nation. We always have been a restless and impatient population eager to get moving and it has driven us to greatness. Hopefully, patience will be a lesson that we will learn, along with many others.

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

Have you every wondered whether you have an attention deficit disorder? I have and I suspect that there are plenty of folks who share my curiosity. Realistically I’m pretty sure I don’t have ADD because while I enjoy being physically active my folks never described me as “bouncing off the walls.” Although I think I am very aware of my surroundings and observant, I wouldn’t say I am unusually distractible. I can multitask reasonably well and have been reasonably successful academically and professionally. But the one characteristic I do share with most ADD patients is a short attention span.

©Digital Vision/Thinkstock.com

Short, of course, is a relative term. Any academic class longer than 45 minutes pushes me past my limit. The same goes for movies and television documentaries. Reading always has been a challenge for me, and 20 minutes is about as long as I can sit with a book or magazine article – even if it’s about a topic that interests me.

Even when I am painting or wood carving, I need to put down my brushes and knives after 20 minutes and do something else. I am a one-set tennis player and about a seven-hole golfer. I have the physical stamina to go much longer, but by the second set or the 10th hole I would prefer to be moving on to some other activity.

In college, I quickly learned that all-nighters were counterproductive. My usual study pattern evolved into one in which I would spend about 20 minutes on one course, take a trip to the refrigerator and return to studying on another course for 20 minutes, then take a break outside to shoot some hoops and return to work for 20 minutes on a third course. This pattern of relatively short bouts of work punctuated by brief snack or exercise breaks seemed to be my most efficient, productive, and mental health–sparing strategy.

Just last week, I learned that there is a name associated with my system. It’s called the Pomodoro technique and was “invented” by a student in an Italian business school in the 1980s (“This Time-Management Trick Changed My Whole Relationship With Time,”By Dean Kissick, The New York Times, June 23, 2020). At its core is a rigid pattern of 25 minutes of work punctuated by 5-minute breaks. The name comes from the tomato-shaped kitchen timer the inventor used to keep himself on a schedule that kept him at optimal efficiency. Of course I have never needed a timer to prompt me to move to another task. My short attention span always has taken care of that.

It turns out that by stumbling into a career in outpatient general pediatrics I found a perfect fit for my truncated attention span. Visits seldom lasted more than 15 minutes followed by a quick sprint to the next room and a fresh and stimulating set of faces and complaints. You may think I should have been spending a minimum of 20 or 25 minutes, but visits of that length seldom fit the realities of my usual day.

There is a myth floating around that there is always a direct correlation between the length of an office visit and its quality. The patient’s perception of quality is most important, and it is based on multiple factors – not the least of which is the level of engagement the physician exhibits. For many pediatric visits, the complaint and management are straightforward. The problem comes when – for whatever reason – closure can’t be achieved in even a 35- or 40-minute visit. Here is when the provider must fall back on her/his clinical artistry by first acknowledging that neither patient nor provider is content with the current situation, but that a follow-up call that evening or an office visit in a day or two will continue the process.

Of course, there were always days when I wish had more time to devote to certain office visits. But for the most part, the hectic pace of outpatient pediatrics fit with my need for a rapidly changing stream of fresh challenges to keep my attention.
 

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

Have you every wondered whether you have an attention deficit disorder? I have and I suspect that there are plenty of folks who share my curiosity. Realistically I’m pretty sure I don’t have ADD because while I enjoy being physically active my folks never described me as “bouncing off the walls.” Although I think I am very aware of my surroundings and observant, I wouldn’t say I am unusually distractible. I can multitask reasonably well and have been reasonably successful academically and professionally. But the one characteristic I do share with most ADD patients is a short attention span.

©Digital Vision/Thinkstock.com

Short, of course, is a relative term. Any academic class longer than 45 minutes pushes me past my limit. The same goes for movies and television documentaries. Reading always has been a challenge for me, and 20 minutes is about as long as I can sit with a book or magazine article – even if it’s about a topic that interests me.

Even when I am painting or wood carving, I need to put down my brushes and knives after 20 minutes and do something else. I am a one-set tennis player and about a seven-hole golfer. I have the physical stamina to go much longer, but by the second set or the 10th hole I would prefer to be moving on to some other activity.

In college, I quickly learned that all-nighters were counterproductive. My usual study pattern evolved into one in which I would spend about 20 minutes on one course, take a trip to the refrigerator and return to studying on another course for 20 minutes, then take a break outside to shoot some hoops and return to work for 20 minutes on a third course. This pattern of relatively short bouts of work punctuated by brief snack or exercise breaks seemed to be my most efficient, productive, and mental health–sparing strategy.

Just last week, I learned that there is a name associated with my system. It’s called the Pomodoro technique and was “invented” by a student in an Italian business school in the 1980s (“This Time-Management Trick Changed My Whole Relationship With Time,”By Dean Kissick, The New York Times, June 23, 2020). At its core is a rigid pattern of 25 minutes of work punctuated by 5-minute breaks. The name comes from the tomato-shaped kitchen timer the inventor used to keep himself on a schedule that kept him at optimal efficiency. Of course I have never needed a timer to prompt me to move to another task. My short attention span always has taken care of that.

It turns out that by stumbling into a career in outpatient general pediatrics I found a perfect fit for my truncated attention span. Visits seldom lasted more than 15 minutes followed by a quick sprint to the next room and a fresh and stimulating set of faces and complaints. You may think I should have been spending a minimum of 20 or 25 minutes, but visits of that length seldom fit the realities of my usual day.

There is a myth floating around that there is always a direct correlation between the length of an office visit and its quality. The patient’s perception of quality is most important, and it is based on multiple factors – not the least of which is the level of engagement the physician exhibits. For many pediatric visits, the complaint and management are straightforward. The problem comes when – for whatever reason – closure can’t be achieved in even a 35- or 40-minute visit. Here is when the provider must fall back on her/his clinical artistry by first acknowledging that neither patient nor provider is content with the current situation, but that a follow-up call that evening or an office visit in a day or two will continue the process.

Of course, there were always days when I wish had more time to devote to certain office visits. But for the most part, the hectic pace of outpatient pediatrics fit with my need for a rapidly changing stream of fresh challenges to keep my attention.
 

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

Have you every wondered whether you have an attention deficit disorder? I have and I suspect that there are plenty of folks who share my curiosity. Realistically I’m pretty sure I don’t have ADD because while I enjoy being physically active my folks never described me as “bouncing off the walls.” Although I think I am very aware of my surroundings and observant, I wouldn’t say I am unusually distractible. I can multitask reasonably well and have been reasonably successful academically and professionally. But the one characteristic I do share with most ADD patients is a short attention span.

©Digital Vision/Thinkstock.com

Short, of course, is a relative term. Any academic class longer than 45 minutes pushes me past my limit. The same goes for movies and television documentaries. Reading always has been a challenge for me, and 20 minutes is about as long as I can sit with a book or magazine article – even if it’s about a topic that interests me.

Even when I am painting or wood carving, I need to put down my brushes and knives after 20 minutes and do something else. I am a one-set tennis player and about a seven-hole golfer. I have the physical stamina to go much longer, but by the second set or the 10th hole I would prefer to be moving on to some other activity.

In college, I quickly learned that all-nighters were counterproductive. My usual study pattern evolved into one in which I would spend about 20 minutes on one course, take a trip to the refrigerator and return to studying on another course for 20 minutes, then take a break outside to shoot some hoops and return to work for 20 minutes on a third course. This pattern of relatively short bouts of work punctuated by brief snack or exercise breaks seemed to be my most efficient, productive, and mental health–sparing strategy.

Just last week, I learned that there is a name associated with my system. It’s called the Pomodoro technique and was “invented” by a student in an Italian business school in the 1980s (“This Time-Management Trick Changed My Whole Relationship With Time,”By Dean Kissick, The New York Times, June 23, 2020). At its core is a rigid pattern of 25 minutes of work punctuated by 5-minute breaks. The name comes from the tomato-shaped kitchen timer the inventor used to keep himself on a schedule that kept him at optimal efficiency. Of course I have never needed a timer to prompt me to move to another task. My short attention span always has taken care of that.

It turns out that by stumbling into a career in outpatient general pediatrics I found a perfect fit for my truncated attention span. Visits seldom lasted more than 15 minutes followed by a quick sprint to the next room and a fresh and stimulating set of faces and complaints. You may think I should have been spending a minimum of 20 or 25 minutes, but visits of that length seldom fit the realities of my usual day.

There is a myth floating around that there is always a direct correlation between the length of an office visit and its quality. The patient’s perception of quality is most important, and it is based on multiple factors – not the least of which is the level of engagement the physician exhibits. For many pediatric visits, the complaint and management are straightforward. The problem comes when – for whatever reason – closure can’t be achieved in even a 35- or 40-minute visit. Here is when the provider must fall back on her/his clinical artistry by first acknowledging that neither patient nor provider is content with the current situation, but that a follow-up call that evening or an office visit in a day or two will continue the process.

Of course, there were always days when I wish had more time to devote to certain office visits. But for the most part, the hectic pace of outpatient pediatrics fit with my need for a rapidly changing stream of fresh challenges to keep my attention.
 

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

From the Multi-County eConsult Initiative, Rancho Cucamonga, CA.

The COVID-19 pandemic has forced many health care professionals and their patients to use telehealth and virtual care to address care needs in new ways.¹ To shed light on care coordination decisions with respect to specialty resource access, we analyzed data collected from the Multi-County eConsult Initiative (MCeI)—the second-largest electronic consultation (eConsult) program in the United States—before and during the COVID-19 pandemic. Our analysis of these data suggests opportunities for improving access to care and reducing unnecessary costs in the health system nationally.

The Inland Empire Health Plan (IEHP) launched MCeI (econsultie.com) in 2018. The initiative is a partnership between IEHP, Arrowhead Regional Medical Center, and Riverside University Health System aimed at improving access to specialty care for the safety-net population across San Bernardino and Riverside counties. IEHP is 1 of the 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country, serving more than 1.2 million members.² Data from MCel reveal the impacts of COVID-19 on eConsult use and offer insights into specialty resource availability during and outside of a crisis.

At the time of this analysis, 86 IEHP clinics in rural and urban settings across 38 specialties used the eConsult process to provide and obtain virtual specialty care, as well as timely appointments for in-person specialty care.³ eConsults are facilitated through a HIPAA-secure web-based portal that enables communication and sharing of information between the primary care provider (PCP) and a specialist. eConsult gives PCPs virtual access to specialists to coordinate care for their patients and determine the need for in-person specialty visits. Through the PCP-specialist eConsult dialogue, patients gain virtual access to specialty care. If a PCP-specialist care team determines the patient needs an in-person visit, that specialty referral is automatically authorized by IEHP, without the need for further review. At IEHP, eConsult is the primary method used for obtaining outpatient specialty referrals.

To analyze eConsult utilization before and during the pandemic, we gathered data from the MCeI program for the periods February 20–March 19, 2020, and March 20–April 19, 2020. Measures included eConsult volume and outcomes of eConsults (eConsults closed as referrals for face-to-face specialist visits versus eConsults closed without resulting in referrals for face-to-face specialist visits). Statistical analysis using chi-square tests for independence was performed using IBM SPSS Statistics 25 (IBM, Armonk, NY).

The data show that after California’s stay-at-home order, issued on March 19, 2020,⁴ eConsult volumes initially decreased, reflecting a similar decrease in clinic visits and authorization requests submitted to IEHP. We observed a 4-week average of 1100 eConsults processed before the pandemic, and then a steep drop to a 4-week average of 500 eConsults processed after the stay-at-home order was issued. Despite the overall drop in the volume of eConsults submitted, demand for specialties like hematology and neurology remained high throughout the pandemic.

During the pandemic, certain specialties displayed rising rates of eConsults completed with specialists providing care recommendations to the PCP instead of resulting in a recommendation for a face-to-face (in-person or via telehealth) visit with a specialist (see Figure and Table). The trend of increasing eConsults that concluded without a face-to-face visit suggests newfound clinical consideration of limited medical resources, along with the desire to eliminate unnecessary risks of infection.

eConsults between PCPs and specialist reviewers via the IEHP portal resulted in higher rates of non-face-to-face recommendations. The specialist reviewers were able to provide treatment plans for PCPs to take care of patients without having to refer their patients to a specialist. This increase was significant across most of the specialties live on the MCeI program.

We believe that clinicians’ heightened awareness of the limitations of the US health care system should remain a key consideration and factor in medical decision-making about appropriate referrals after the pandemic has passed. The data demonstrate that the pandemic drove clinicians to make different decisions about referrals and care coordination. Physicians scrutinized individual cases more keenly and were not as quick to recommend a face-to-face visit. This awareness and consideration of specialty access before making a referral provides a valuable lesson. If this approach is applied to health care delivery post-pandemic, eConsults will help reduce unnecessary in-person specialist visits and will free up space and time for patients who genuinely do need in-person specialty care. In this way, eConsult will improve appropriate access to care for everyone and reduce unnecessary costs to the health care system at large.

An examination of eConsult utilization trends across Riverside and San Bernardino counties before and during the COVID-19 pandemic provides useful insights into how to reduce costs and improve access to care. Although the risk of exposure to COVID-19 currently presents a significant obstacle to obtaining in-person specialty care, pre-existing and long-standing barriers, such as long wait times and scarcity of specialists, remain critical issues to receiving care during and after the pandemic. The pandemic has proven eConsult’s value as a tool for effective care coordination. Leveraging provider-to-provider asynchronous communication offers an opportunity to reduce unnecessary utilization of scarce resources during and beyond the pandemic.

Corresponding author: Lisa Aubry, Aubry-L@iehp.org.

Financial disclosures: None.

Keywords: electronic consultation; care coordination; telehealth; telemedicine; virtual care.

From the Multi-County eConsult Initiative, Rancho Cucamonga, CA.

The COVID-19 pandemic has forced many health care professionals and their patients to use telehealth and virtual care to address care needs in new ways.¹ To shed light on care coordination decisions with respect to specialty resource access, we analyzed data collected from the Multi-County eConsult Initiative (MCeI)—the second-largest electronic consultation (eConsult) program in the United States—before and during the COVID-19 pandemic. Our analysis of these data suggests opportunities for improving access to care and reducing unnecessary costs in the health system nationally.

The Inland Empire Health Plan (IEHP) launched MCeI (econsultie.com) in 2018. The initiative is a partnership between IEHP, Arrowhead Regional Medical Center, and Riverside University Health System aimed at improving access to specialty care for the safety-net population across San Bernardino and Riverside counties. IEHP is 1 of the 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country, serving more than 1.2 million members.² Data from MCel reveal the impacts of COVID-19 on eConsult use and offer insights into specialty resource availability during and outside of a crisis.

At the time of this analysis, 86 IEHP clinics in rural and urban settings across 38 specialties used the eConsult process to provide and obtain virtual specialty care, as well as timely appointments for in-person specialty care.³ eConsults are facilitated through a HIPAA-secure web-based portal that enables communication and sharing of information between the primary care provider (PCP) and a specialist. eConsult gives PCPs virtual access to specialists to coordinate care for their patients and determine the need for in-person specialty visits. Through the PCP-specialist eConsult dialogue, patients gain virtual access to specialty care. If a PCP-specialist care team determines the patient needs an in-person visit, that specialty referral is automatically authorized by IEHP, without the need for further review. At IEHP, eConsult is the primary method used for obtaining outpatient specialty referrals.

To analyze eConsult utilization before and during the pandemic, we gathered data from the MCeI program for the periods February 20–March 19, 2020, and March 20–April 19, 2020. Measures included eConsult volume and outcomes of eConsults (eConsults closed as referrals for face-to-face specialist visits versus eConsults closed without resulting in referrals for face-to-face specialist visits). Statistical analysis using chi-square tests for independence was performed using IBM SPSS Statistics 25 (IBM, Armonk, NY).

The data show that after California’s stay-at-home order, issued on March 19, 2020,⁴ eConsult volumes initially decreased, reflecting a similar decrease in clinic visits and authorization requests submitted to IEHP. We observed a 4-week average of 1100 eConsults processed before the pandemic, and then a steep drop to a 4-week average of 500 eConsults processed after the stay-at-home order was issued. Despite the overall drop in the volume of eConsults submitted, demand for specialties like hematology and neurology remained high throughout the pandemic.

During the pandemic, certain specialties displayed rising rates of eConsults completed with specialists providing care recommendations to the PCP instead of resulting in a recommendation for a face-to-face (in-person or via telehealth) visit with a specialist (see Figure and Table). The trend of increasing eConsults that concluded without a face-to-face visit suggests newfound clinical consideration of limited medical resources, along with the desire to eliminate unnecessary risks of infection.

eConsults between PCPs and specialist reviewers via the IEHP portal resulted in higher rates of non-face-to-face recommendations. The specialist reviewers were able to provide treatment plans for PCPs to take care of patients without having to refer their patients to a specialist. This increase was significant across most of the specialties live on the MCeI program.

We believe that clinicians’ heightened awareness of the limitations of the US health care system should remain a key consideration and factor in medical decision-making about appropriate referrals after the pandemic has passed. The data demonstrate that the pandemic drove clinicians to make different decisions about referrals and care coordination. Physicians scrutinized individual cases more keenly and were not as quick to recommend a face-to-face visit. This awareness and consideration of specialty access before making a referral provides a valuable lesson. If this approach is applied to health care delivery post-pandemic, eConsults will help reduce unnecessary in-person specialist visits and will free up space and time for patients who genuinely do need in-person specialty care. In this way, eConsult will improve appropriate access to care for everyone and reduce unnecessary costs to the health care system at large.

An examination of eConsult utilization trends across Riverside and San Bernardino counties before and during the COVID-19 pandemic provides useful insights into how to reduce costs and improve access to care. Although the risk of exposure to COVID-19 currently presents a significant obstacle to obtaining in-person specialty care, pre-existing and long-standing barriers, such as long wait times and scarcity of specialists, remain critical issues to receiving care during and after the pandemic. The pandemic has proven eConsult’s value as a tool for effective care coordination. Leveraging provider-to-provider asynchronous communication offers an opportunity to reduce unnecessary utilization of scarce resources during and beyond the pandemic.

Corresponding author: Lisa Aubry, Aubry-L@iehp.org.

Financial disclosures: None.

Keywords: electronic consultation; care coordination; telehealth; telemedicine; virtual care.

From the Multi-County eConsult Initiative, Rancho Cucamonga, CA.

The COVID-19 pandemic has forced many health care professionals and their patients to use telehealth and virtual care to address care needs in new ways.¹ To shed light on care coordination decisions with respect to specialty resource access, we analyzed data collected from the Multi-County eConsult Initiative (MCeI)—the second-largest electronic consultation (eConsult) program in the United States—before and during the COVID-19 pandemic. Our analysis of these data suggests opportunities for improving access to care and reducing unnecessary costs in the health system nationally.

The Inland Empire Health Plan (IEHP) launched MCeI (econsultie.com) in 2018. The initiative is a partnership between IEHP, Arrowhead Regional Medical Center, and Riverside University Health System aimed at improving access to specialty care for the safety-net population across San Bernardino and Riverside counties. IEHP is 1 of the 10 largest Medicaid health plans and the largest not-for-profit Medicare-Medicaid plan in the country, serving more than 1.2 million members.² Data from MCel reveal the impacts of COVID-19 on eConsult use and offer insights into specialty resource availability during and outside of a crisis.

At the time of this analysis, 86 IEHP clinics in rural and urban settings across 38 specialties used the eConsult process to provide and obtain virtual specialty care, as well as timely appointments for in-person specialty care.³ eConsults are facilitated through a HIPAA-secure web-based portal that enables communication and sharing of information between the primary care provider (PCP) and a specialist. eConsult gives PCPs virtual access to specialists to coordinate care for their patients and determine the need for in-person specialty visits. Through the PCP-specialist eConsult dialogue, patients gain virtual access to specialty care. If a PCP-specialist care team determines the patient needs an in-person visit, that specialty referral is automatically authorized by IEHP, without the need for further review. At IEHP, eConsult is the primary method used for obtaining outpatient specialty referrals.

To analyze eConsult utilization before and during the pandemic, we gathered data from the MCeI program for the periods February 20–March 19, 2020, and March 20–April 19, 2020. Measures included eConsult volume and outcomes of eConsults (eConsults closed as referrals for face-to-face specialist visits versus eConsults closed without resulting in referrals for face-to-face specialist visits). Statistical analysis using chi-square tests for independence was performed using IBM SPSS Statistics 25 (IBM, Armonk, NY).

The data show that after California’s stay-at-home order, issued on March 19, 2020,⁴ eConsult volumes initially decreased, reflecting a similar decrease in clinic visits and authorization requests submitted to IEHP. We observed a 4-week average of 1100 eConsults processed before the pandemic, and then a steep drop to a 4-week average of 500 eConsults processed after the stay-at-home order was issued. Despite the overall drop in the volume of eConsults submitted, demand for specialties like hematology and neurology remained high throughout the pandemic.

During the pandemic, certain specialties displayed rising rates of eConsults completed with specialists providing care recommendations to the PCP instead of resulting in a recommendation for a face-to-face (in-person or via telehealth) visit with a specialist (see Figure and Table). The trend of increasing eConsults that concluded without a face-to-face visit suggests newfound clinical consideration of limited medical resources, along with the desire to eliminate unnecessary risks of infection.

eConsults between PCPs and specialist reviewers via the IEHP portal resulted in higher rates of non-face-to-face recommendations. The specialist reviewers were able to provide treatment plans for PCPs to take care of patients without having to refer their patients to a specialist. This increase was significant across most of the specialties live on the MCeI program.

We believe that clinicians’ heightened awareness of the limitations of the US health care system should remain a key consideration and factor in medical decision-making about appropriate referrals after the pandemic has passed. The data demonstrate that the pandemic drove clinicians to make different decisions about referrals and care coordination. Physicians scrutinized individual cases more keenly and were not as quick to recommend a face-to-face visit. This awareness and consideration of specialty access before making a referral provides a valuable lesson. If this approach is applied to health care delivery post-pandemic, eConsults will help reduce unnecessary in-person specialist visits and will free up space and time for patients who genuinely do need in-person specialty care. In this way, eConsult will improve appropriate access to care for everyone and reduce unnecessary costs to the health care system at large.

An examination of eConsult utilization trends across Riverside and San Bernardino counties before and during the COVID-19 pandemic provides useful insights into how to reduce costs and improve access to care. Although the risk of exposure to COVID-19 currently presents a significant obstacle to obtaining in-person specialty care, pre-existing and long-standing barriers, such as long wait times and scarcity of specialists, remain critical issues to receiving care during and after the pandemic. The pandemic has proven eConsult’s value as a tool for effective care coordination. Leveraging provider-to-provider asynchronous communication offers an opportunity to reduce unnecessary utilization of scarce resources during and beyond the pandemic.

Corresponding author: Lisa Aubry, Aubry-L@iehp.org.

Financial disclosures: None.

Keywords: electronic consultation; care coordination; telehealth; telemedicine; virtual care.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.