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Thank you for following the Me&MyDoctor blog. I'm writing to let you know we are moving the public health stories authored by Texas physicians, residents, and medical students, and patients to the Texas Medical Association's social media channels. Be sure to follow us on all our social media accounts (Facebook, Twitter, Instagram) as well as Texas Medicine Today to access these stories and more. We look forward to seeing you there.
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Olivia Suarez
Me&My Doctor Editor
How does the COVID-19 pandemic factor into potentially abusive situations?
To stop the spread of COVID-19, we have isolated ourselves into small family units to avoid catching and transmitting the virus. While saving so many from succumbing to a severe illness, socially isolating has unfortunately posed its own problems. Among those is the increased threat of harm from intimate partner violence, which includes physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. Potential child abuse is an increased threat as well. The impact of this virus happened so rapidly that society did not have time to think about all the consequences of social isolation before implementing it. Now those consequences are becoming clear.
Social isolation due to the pandemic is forcing victims to stay home indefinitely with their abusers. Children and adolescents also have been forced to stay at home since many school districts have made education virtual to keep everyone safe from the virus. Caregivers are also home because they are working remotely or because they are unemployed. With the increase in the number of COVID-19 cases, financial strain due to the economic downturn, and concerns of contracting the virus and potentially spreading it to family members, these are highly stressful times. Stress leads to an increase in the rate of intimate partner violence. Even those who suffer from it can begin to become abusive to other household members, thus amplifying the abuse in the household. Some abuse may go unrecognized by the victims themselves. For example, one important and less well-known type of abuse is coercive control. It’s the type of abuse that doesn’t leave a physical mark, but it’s emotional, verbal, and controlling. Victims often know that something is wrong – but can’t quite identify what it is. Coercive control can still lead to violent physical abuse, and murder.
The way in which people report abuse has also been altered by the pandemic.
People lacking usual in-person contacts (with teachers, co-workers, or doctors) and the fact that some types of coercive abuse are less recognized lead to fewer people reporting that type of abuse.
Child abuse often is discovered during pediatricians’ well-child visits, but the pandemic has limited those visits. Many teachers, who might also notice signs of abuse, also are not able to see their students on a daily basis. Some abuse victims visit emergency departments (EDs) in normal times, but ED visits are also down due to COVID-19.
Local police in China report that intimate partner violence has tripled in the Hubei province. The United Nations reports it also increased 30% in France as of March 2020 and increased 25% in Argentina. In the U.S. the conversation about increased intimate partner violence during these times has just now started, and we are beginning to gather data. Preliminary analysis shows police reports of intimate partner violence have increased by 18% to 27% across several U.S. cities. Individuals affected by addiction have additional stressors and cannot meet with support groups. Children and adolescents who might otherwise use school as a form of escape from addicted caregivers are no longer able to do so. Financial distress can also play a factor. According to research, the rate of violence among couples with more financial struggles is nearly three and a half times higher than couples with fewer financial concerns.
Abuse also can come from siblings. Any child or adolescent with preexisting behavioral issues is more likely to act out due to seclusion, decreased physical activity, or fewer positive distractions. This could increase risk for others in the household, especially in foster home situations. These other residents might be subject to increased sexual and physical abuse with fewer easy ways to report it.
What can we do about this while abiding by the rules of the pandemic? How can physicians help?
Patients who are victims of intimate partner violence are encouraged to reach out to their doctor. A doctor visit may be either in person or virtual due to the safety precautions many doctors’ offices are enforcing due to COVID-19. During telehealth visits, physicians should always ask standard questions to screen for potential abuse. They can offer information to all patients, regardless of whether they suspect abuse.
People could receive more support if we were to expand access to virtual addiction counseling, increase abuse counseling, and launch more campaigns against intimate partner violence. The best solution might involve a multidisciplinary team, including psychiatrists, social workers, child abuse teams and Child Protective Services, and local school boards.
Physicians can help in other ways, too. Doctors can focus on assessing mental health during well-child and acute clinic visits and telehealth visits. A temporary screening tool for behavioral health during the pandemic might be beneficial. Governments could consider allocating resources to telepsychiatry. Many paths can be taken to reduce the burden of mental health issues, and this is an ongoing discussion.
How should physicians approach patients who have or may have experienced intimate partner violence?
Victims of domestic assault can always turn to their physician for guidance on next steps. In response, doctors can:
To my fellow physicians, I suggest recognizing and talking about the issue with families.
Medical professionals take certain steps if they suspect their patient’s injuries are a result of family violence, or if the patient discloses family violence. Physicians will likely screen a patient, document their conversation with the patient, and offer support and inform the patient of the health risks of staying in an abusive environment, such as severe injuries or even death. A doctor’s priority is his or her patient’s safety, regardless of why the victim might feel forced to remain in an abusive environment. While physicians only report child and elderly abuse, they should encourage any abused patient to report her or his own case, while also understanding the complexity of the issue.
Under no circumstance should any form of abuse be tolerated or suffered. Any intimate partner violence should be avoided, and reported if possible and safe. My hope is that with more awareness of this rising public health concern, potential victims can better deal with the threat of abuse during this stressful pandemic – and hopefully avoid it.
This Sunday is Super Bowl Sunday. Millions of people will settle in to watch the big game, but COVID-19 won’t be taking a football break. With variants of the virus spreading and vaccine distribution still in its early phases, the Centers for Disease Control and Prevention (CDC) is urging Americans to celebrate this year’s game in a safe, nontraditional way.
Have you ever attended a Super Bowl party? Traditionally, millions of people watch the game in large gatherings. However – no surprise – doctors and health care workers are strongly discouraging people from attending parties involving a lot of people in close contact with one another. That doesn’t mean you can’t still meet to watch the game. Just like most events, the safest option is hosting a virtual party or gathering only with your live-in family/roommates.
If you opt for a virtual Super Bowl watch party, connect with friends via a text group or video chat. You can still don your favorite team’s logo or colors and make appetizers for the people you live with.
If you do throw a game-watching party in person, take your TV outside or display the game outside using a projector, and have people sit at least 6 feet apart – especially if they don’t live together. CDC developed a list of tips to make small gatherings safer.
If you’re lucky enough to be among the 25,000 or so fans going to the Super Bowl in Tampa, or if you’re attending another large Super Bowl event, you should take extra precautions to avoid getting sick: Call the venue in advance or check online about the safety measures being taken; arrive at the venue early to avoid crowds; and practice socially distancing at all times. Gotta cheer? Stomp, clap, or use noisemakers instead of yelling and cheering, to reduce transmission of droplets.
And as always, people who attend any kind of gathering should wear a face mask, physically distance from others, and wash hands frequently.
Although Super Bowl Sunday is considered an unofficial holiday for many, it’s best for people to approach it like this past holiday season – with extra precautions – to help reduce the spread of COVID-19.
For a summary of these safety tips, check out the graphic below:
People across the world are suffering from a lack of sleep amidst the COVID-19 pandemic. Children and teens suffer from sleep problems, and parents must recognize and address these issues while the world restlessly awaits the resolution of this health crisis. Good sleep is essential for everyone, young people in particular.
More and more, we hear about the negative impacts of the pandemic on mental health. Sleep plays a critical role here. Severe sleep disturbances such as insomnia contribute to psychological stress, depression, and anxiety. The longer someone’s sleep disorders persist, the greater the impact they have on mental and physical health.
Even before the pandemic, insomnia and delayed sleep-phase disorder (when a person routinely falls asleep two hours or longer after he or she should) were particularly prevalent among teens, but these issues have been worsened by the coronavirus.
Whether teenagers are back to in-person learning or attending school virtually, they need to be in prime shape to thrive and learn. Teens, in particular, need about nine to nine and a half hours of high-quality sleep on a nightly basis to keep their minds sharp and their bodies healthy.
During our teenage years, most of us experienced a natural shift of our circadian rhythm, or sleep cycle, that delayed our internal bedtime to 11 pm or later. Couple this with early school start times, usually between 7 and 8 am, and it becomes clear why so many of us were groggy during our first few classes in high school. Sleep time was also scrunched by the time demanded for extracurriculars, sports, jobs, etc.
Given these facts, what can we do to promote healthy sleep for our children, particularly teenagers, during and after the pandemic?
Here are a few quick tips to help teens get that much-needed sleep:
1. Help them to buy into the idea. Most teens like to feel a sense of autonomy over their ideas and decisions. Drop hints and clues that will help your teen to see how quality sleep will help to achieve his or her goals. When they feel like it’s their own idea, teens are more likely to change their behavior.
2. Get some sun exposure. Make sure your teen is getting some sun early in the day to help keep their biological (circadian) clock well-regulated. This internal clock, which uses light and darkness to help prepare you to be active or sleep, is most sensitive to light (or darkness) from about two hours before the usual bedtime until the hour before usual wake-up time in the morning. The earlier they’re exposed to bright light, the earlier their body will set them up for sleep hours later.
3. No caffeine after lunchtime. Stimulating substances like caffeine will delay your teen’s natural bedtime. Studies show teens’ caffeine intake leads to an increase in sleep difficulties, sleep disturbances, and morning tiredness.
4. Set a daily bedtime and wake time. Keeping a consistent routine plays a key role in maintaining good, healthy sleep habits.
5. No screens allowed in the bedroom at night. This includes cell phones, computers, tablets, televisions, etc. The blue light from the screen, and looking at virtual/online content, will keep your teen up late into the night.
6. Keep the bedroom cool and dark. To fall asleep, our core body temperature needs to drop somewhat, so cooler bedroom temperatures will be helpful. The experts suggest a temperature of around 65 degrees Fahrenheit.
 |
| The blue light that comes from devices like cell phones has been known to keep people from falling sleep, according to studies. |
8. Know when to ask for help. If your teen is suffering from insomnia despite trying the tips above and other tips for good sleep hygiene, it may be worthwhile to speak to their primary care physician about getting the help of a sleep expert.
A good night’s sleep benefits our bodies more than we realize. When we sleep, we give our mind a chance to restore and boost memory and learning abilities – and for teenagers, who are still developing both physically and mentally – sleep is particularly important. The COVID-19 pandemic has thrown a wrench into a lot of aspects of their daily lives, sleep likely being one of them. However, if we help our teens build better sleeping habits, they can develop both mental and physical resilience that will boost their well-being, especially during this uncertain time.
While traditional obstetric care often focuses on the time of a woman’s pregnancy through the time of the delivery of the baby, there is a growing recognition about the need for more attention to the time after she delivers. During this postpartum period – increasingly referred to as the fourth trimester – a new mother will need medical care, and she needs health insurance to help her obtain that care. Medicaid, which covers 53% of all Texas births, should cover women not only throughout their pregnancies but also for a full year after they give birth.
During the pregnancy, women see the physician more frequently than at any other time of a typical healthy person’s life. Visits ramp up near the end of pregnancy, as physicians who provide obstetrical care and their medical teams are looking for any condition that may affect the mother or an infant and might change their recommendation about the baby’s delivery. After delivery, the postpartum period is a time of potential vulnerability for the new mother. As every parent knows, the arrival of a newborn, no matter how loved, means many sleepless nights, new stress, and relationship challenges; but this period is especially dangerous for those who might have unstable insurance coverage or who are uninsured. Even before the pandemic, one-quarter of Texas women of reproductive age lacked health insurance. Without coverage, women are less likely to access primary, specialty, and preventive care services to be healthy, increasing the risk of preventable issues and tragedies.
Following childbirth, postpartum women need ongoing treatment for any underlying chronic health conditions, such as hypertension or diabetes, or to treat complications that might arise in the following year, some of which are life-threatening if untreated. These complications include severe postpartum depression and heart disease.
In addition, healthy pregnancies do not begin at conception, but well before. Once a woman becomes pregnant, an obstetrician-gynecologist or family physician caring for her cannot undo cumulative years of poor health stemming from little or no care prior to getting pregnant. For example, if a woman has had uncontrolled diabetes, this can increase the risk of birth defects in the infant and the risk of complications. One example is shoulder dystocia (a condition when one or both of a baby’s shoulders get caught inside the mother’s pelvis during labor); another is a potentially greater need for the mother to have a cesarean delivery (commonly known as a C-section, surgically delivering the baby). Also, if deliveries are less than 18 months apart, there can be a higher risk of preterm labor, growth issues, and placental issues.
According to Texas’s own expert panel, women’s lack of access to regular, preventive primary and specialty care before and after pregnancy contributes to Texas’ high rate of maternal deaths. Nearly one-third of new mothers’ deaths occur 60 days or more postpartum – the same time many low-income women lose their pregnancy-related Medicaid coverage. Among Black women, the numbers are far worse: Black women account for 31% of maternal deaths but only 11% of births.
As tragic as maternal deaths are, they are only one part of the story. For every woman who dies in conjunction with having a baby, 50 to 100 women suffer a severe illness or complication, often with lasting consequences. According to the American College of Obstetricians and Gynecologists, nearly seven in 10 women report at least one physical problem in the first year after delivery, and one in nine women may experience symptoms of postpartum depression. Extending women’s Medicaid coverage for a full year after they have their baby would prolong their care to help address and resolve these complications.
Fortunately, the Healthy Texas Women (HTW) program – and the new Healthy Texas Women Plus program – help fill the coverage gap by providing low-income women preventive and basic primary care before and after pregnancy as well as some specialty services for the 12 months following delivery. HTW Plus, launched in September 2020, builds on HTW by providing one year of limited specialty care coverage for the three conditions and illnesses most likely to contribute to maternal mortality or morbidity: postpartum depression, which one in eight women develop; cardiovascular and other coronary conditions; and substance abuse disorders.
However, these programs do not provide comprehensive coverage like Medicaid does, meaning women with complex medical needs will not have coverage for all the services they need.
Comprehensive coverage matters. Women who live in states with prolonged coverage are more likely to have ongoing access to health care before, during, and after pregnancy, and they are more likely to get postpartum treatment when they suffer severe complications. They also are less likely to die after having their baby.
Extending postpartum Medicaid coverage would give eligible women health insurance longer, allowing them to continue treatment for any known health conditions. Women also could obtain treatment for any other conditions that may develop, such as diabetes or cancer. Protecting continuity of care also would allow women to have one fewer transition in the tumultuous time of the first year after delivery and bolster their ability to have the continued support of their medical team. Extending postpartum Medicaid coverage for a year would align mothers’ care with that of their infants, who have guaranteed Medicaid coverage for the first year of their lives. This improvement might also decrease the likelihood the mother would need to seek emergency care (and face that extra expense) as women probably could be cared for in outpatient offices and clinics rather than having to rush to the hospital with an emergency.
It is for these reasons that the Texas Medical Association supports enactment of comprehensive health care coverage initiatives, including extending full Medicaid coverage for 12 months to postpartum women who otherwise lose coverage 60 days postpartum, as well as extending comprehensive coverage to low-income, uninsured, working-age adults.* Extending postpartum Medicaid coverage has wide support among many physicians, medical societies, and hospitals, including the Texas Pediatric Society, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists District XI (Texas), Texas Academy of Family Physicians, and Texas Hospital Association, along with numerous national societies. There also is bipartisan congressional support. By extending postpartum Medicaid coverage to a full year, we can better support the health of Texan mothers, infants, and families.
*As a result of federal public health emergency (PHE) COVID-19 legislation, states must maintain Medicaid coverage for anyone enrolled in Medicaid on or after March 18, 2020, including postpartum women. This temporary coverage extension is currently set to expire in June 2021, but will renew with every extension of the PHE.
Table One: Type of Medical Care Skipped or Delayed by Texans Due to COVID-19 by Race/Ethnicity
|
Total |
White |
Hispanic |
Black |
|
|
Skipped or
postponed regular check-ups of exams |
69% |
66% |
70% |
77% |
|
Skipped or
postponed dental check-ups of exams |
70% |
68% |
73% |
65% |
|
Preventative
screenings such as mammograms, colonoscopies, or other
screenings |
38% |
41% |
37% |
31% |
|
Doctor visits
for chronic conditions such as diabetes and high blood
conditions |
28% |
29% |
29% |
25% |
|
Doctor visits
for symptoms you were experiencing |
39% |
37% |
44% |
43% |
|
Reproductive
health care visits |
20% |
18% |
23% |
15% |
|
Immunizations
for your child or other child wellness visits |
30% |
23% |
30% |
28% |
|
Mental health
care |
19% |
22% |
17% |
12% |
|
Physical
therapy or rehabilitation care |
17% |
14% |
21% |
16% |
|
Surgery |
17% |
16% |
18% |
11% |
|
Cancer
treatments* |
4% |
3% |
9% |
1% |
|
Total |
Under $75K |
$75K + |
|
|
Skipped or
postponed regular check-ups of exams |
69% |
71% |
70% |
|
Skipped or
postponed dental check-ups of exams |
70% |
69% |
71% |
|
Preventative
screenings such as mammograms, colonoscopies, or other screenings |
38% |
37% |
39% |
|
Doctor visits
for chronic conditions such as diabetes and high blood conditions* |
28% |
34% |
21% |
|
Doctor visits
for symptoms you were experiencing |
39% |
43% |
38% |
|
Reproductive
health care visits |
20% |
33% |
29% |
|
Immunizations
for your child or other child wellness visits |
30% |
26% |
16% |
|
Mental health
care |
19% |
19% |
15% |
|
Physical
therapy or rehabilitation care |
17% |
18% |
15% |
|
Surgery |
17% |
19% |
16% |
|
Cancer
treatments |
4% |
5% |
4% |
|
Total |
Less than
college |
College+ |
|
|
Skipped or
postponed regular check-ups of exams |
69% |
68% |
73% |
|
Skipped or
postponed dental check-ups of exams |
70% |
68% |
72% |
|
Preventative
screenings such as mammograms, colonoscopies, or other screenings |
38% |
36% |
42% |
|
Doctor visits
for chronic conditions such as diabetes and high blood conditions* |
28% |
34% |
17% |
|
Doctor visits
for symptoms you were experiencing |
39% |
43% |
33% |
|
Reproductive
health care visits |
20% |
18% |
25% |
|
Immunizations
for your child or other child wellness visits |
30% |
31% |
29% |
|
Mental health
care |
19% |
17% |
23% |
|
Physical
therapy or rehabilitation care |
17% |
19% |
14% |
|
Surgery |
17% |
18% |
16% |
|
Cancer
treatments |
4% |
6% |
2% |
