Category: Expert Opinions

A friend and colleague recently told me that he can feel anxious about going to see his doctor for follow-up care if he has not accomplished the health goals discussed at his last visit.

When I asked why, he said he worried that he would be labeled “nonadherent” or scolded for being unprepared. He did not want to waste his doctor’s time.

I was surprised, since many of my own patients come in for visits without completing every goal we set out. I may not have communicated the plan clearly, and sometimes, as the saying goes, life gets in the way.

Then I began to wonder about patients who cancel appointments, miss follow-up visits, or never schedule them at all. Could some be avoiding care because they fear being judged for not meeting expectations?

As physicians, we often emphasize treatment plans and health goals. Less often do we consider whether patients feel safe admitting when they have struggled to follow them.

I would never scold a patient if they did not complete everything on the to-do list. At the same time, I don’t think I have ever directly said that I want to be sure they come back for follow-up regardless. I realized that I could address this with phrasing like:

I trust you will try your best to follow our plan. But whether you are able to get these things done or not, I still want to see you back in a few months.

Astute problem-solving, empathy, compassion, and clear communication are qualities clinicians aspire to in our professional roles. Equally important, though less emphasized, is creating a psychologically safe environment. This means ensuring patients can speak honestly without feeling at risk of being judged.

Psychological safety was originally studied in workplace teams, based on the work of Harvard researcher Amy Edmondson. To reach high performance, Edmondson found team members need to feel comfortable taking risks, admitting mistakes without fear of shaming or reprisal.

The principles of psychological safety apply to many settings. Planet Fitness, for example, posts signs on the walls and equipment declaring “Judgement Free Zone” and “No Gymtimidation” in an effort to make members feel welcome regardless of their level of fitness.

In medicine, a psychologically safe office or exam room may help patients feel more comfortable being vulnerable and discussing more emotionally sensitive concerns. It may also improve the likelihood of scheduled follow-up.

So what did I tell my friend-colleague? I suggested that he think about the source of his follow up worries. Some of this may require self-exploration, but there may also be areas where his own medical practice could do a better job at creating a psychologically safe, nonjudgmental environment that encourages follow-up.

Patients should know that a missed goal is not a failed appointment. In health, as in life, progress is rarely linear. In fact, the times when things have not gone according to plan are often the times when medical follow-up matters most. Clinicians should make that message clear.

Jeffrey Millstein is an internist and regional medical director for Penn Primary and Specialty Care.

As a pediatrician, I recommend children get approximately 30 injections between birth and 18 years of age, following the American Academy of Pediatrics vaccination schedule — and that’s not including their annual influenza vaccine.

While these vaccines keep children healthy from vaccine-preventable illnesses, I recognize that pain related to these shots can worry children and their parents. Unfortunately, myths surrounding vaccine pain — including that pain is something that needs to be endured without help, or that the pain is too much for a small child to handle — can lead families to delay vaccination.

This is risky at a time of rising vaccine hesitancy. Pennsylvania is currently experiencing the nation’s third-largest outbreak of measles, a vaccine-preventable disease, with more than 500 cases reported statewide so far this year.

Most parents want to do everything they can to protect their children. That can feel hard when protection comes with a painful experience. Many parents tell me and my colleagues they “can’t look” when their child receives a shot. Some may be drawing on their own fear of needles; others simply find it difficult to watch their child cry or experience pain.

As children grow older and begin to voice their own concerns about shots, these fears can become even more difficult to navigate. “I hate shots,” kids say to me all the time. And while I often quip that “no one likes getting shots,” that’s not entirely true.

The experience of vaccine pain varies by child — age, developmental stage, prior experiences with pain, and temperament can all impact their pain perception. It takes time to assess how best to address a patient’s pain, because there is no one-size-fits-all approach.

Historically, healthcare providers viewed vaccine pain as a normal part of a pediatric medical visit. We expected patients to bear it without any support. In a survey of nurses and medical assistants at Children’s Hospital of Philadelphia in 2022 regarding vaccine pain, one nurse said, “better to get it done and move on.” While well-intentioned, that mindset overlooks what we know about children’s experiences with pain.

Pain is complex and deeply personal. Children’s memories of past procedures and their fears can shape how they respond to future vaccinations and medical visits. Anticipation and anxiety can become as important as the procedure itself.

For some children, fear of pain can become a barrier to healthcare, affecting not only a single visit but their willingness to return for future care. By addressing pain proactively, pediatric practices can reduce distress, strengthen trust, and help children feel safer engaging with healthcare throughout their lives.

That’s why CHOP created the Guided by Comfort program, enabling patients in our primary care locations to choose from a menu of comfort measures to address needle-related pain.

Using evidence-based guidelines on the best way to manage needle pain, patients can be positioned for comfort and offered distractions. We also offer additional options for the appropriate ages, such as breastfeeding, sweetened water, vibration with ice, a plastic disc, and cooling spray. The comfort menu includes photos and descriptions of each item, much like the menu at a restaurant.

In the 16 months since we introduced the Guided by Comfort program in all primary care offices, we have reached nearly 200,000 patients, with 82.5% electing to use a menu offering. One parent reported that her child “felt understood and in control of her own health.” These comfort menu options are helping parents and children to build trust and partnership with their healthcare team.

This program offers a solution to a common concern identified through Pediatric Health Chat, a CHOP initiative tracking common myths and rumors in pediatric healthcare. CHOP teams have also created informational videos that empower parents and their children with practical strategies to make vaccinations more comfortable and help prevent pain from becoming a barrier to vaccination.

We have proven that offering comfort measures to patients and families can make getting vaccines on schedule less stressful. Comfort isn’t an extra; we are treating it as part of the vaccination experience.

The views expressed in this article are those of the authors and not necessarily those of CHOP. This information is not intended to provide medical advice, diagnosis, or treatment. Always consult a qualified healthcare professional regarding any health or medical concerns.

Katie Lockwood is a primary care pediatrician at Children’s Hospital of Philadelphia and cofounder of Pediatric Health Chat, an online initiative providing resources for families looking for good information on the latest myths and misconceptions about children’s health.

The nationwide cyclospora outbreak is very likely a result of sewage contamination in the food supply, according to scientific researchers and public health officials.

The parasite’s spread can become a self-perpetuating cycle. Cyclospora is found only in humans, where it replicates in the intestinal tract, causing severe diarrhea. The organism reproduces by releasing oocysts, which are excreted in those human feces. In the U.S., feces usually end up in sewage systems.

In many states, sewage water is treated — though not always in ways that remove or kill the oocysts — and then released into waterways and can be used to irrigate crops. The oocysts mature in the environment with warm temperatures in about a week. Then a human comes along and eats the irrigated food or drinks the water and gets sick, releasing more oocysts into sewage systems.

I am a public health water microbiologist who collects sewage water and tests it for evidence of harmful pathogens, such as cyclospora. The first time I studied cyclospora was in the first outbreak ever documented in the U.S., a small, 45-case outbreak in Florida in 1995.

The cause was initially suspected to be strawberries grown in California, but later it was determined it was more likely due to imported contaminated raspberries from Guatemala. That country’s raspberries were also associated with much larger outbreaks in 1996 and 1997. At the time, little was known about this single-celled protozoan pathogen.

More than 30 years later, the largest outbreak ever recorded in the U.S. has sickened more than 22,000 people, and contributed to the deaths of two in Michigan, where I live and work. Using treated sewage to irrigate crops is common in many places, especially where groundwater and surface water are in short supply.

What’s in wastewater

There are two reasons researchers like me collect sewage and monitor what’s in it.

The first is to evaluate levels of disease in a community. Measuring viruses such as SARS-CoV-2 in untreated sewage helped paint a picture of the spread of COVID-19 and the emergence of variants as the pandemic continued.

The second reason is to determine whether and how sewage treatment removes, inactivates, or kills pathogens.

It is not easy to measure cyclospora oocysts in sewage, contaminated water, or food. Even modern laboratory methods have trouble reliably detecting low levels of oocysts, which can still cause disease.

Cyclospora oocysts have been found in sewage around the world. A range of studies across the world shows that they can be detected in up to 25% of sewage samples — but not all studies report how high or low the concentrations of the oocysts were. So it can be hard to say exactly how widespread it is.

A person who is infected with cyclospora excretes somewhere between 100 and 10,000 oocysts per gram of feces for as long as 60 days. Based on what is known about other fecal pathogen excretions from patients, related to the concentrations of those pathogens in sewage, I estimate that there could be anywhere from 1 to 100 oocysts per liter in sewage.

Our laboratory at Michigan State University is developing a method to more accurately detect this parasite even at lower levels in sewage. This type of wastewater surveillance may help determine when an outbreak is beginning to subside and where larger numbers of people are still affected. In addition, this information could allow sewage treatment plant managers to regularly monitor their discharges.

What happens during sewage treatment?

There isn’t clear data on how well standard sewage treatment processes reduce the numbers of cyclospora oocysts. But there is information on two other similar protozoa that also cause significant diarrhea in humans: Cryptosporidium produces an oocyst about half the size of cyclospora, and giardia produces a cyst that is similar in size to cyclospora.

From 2001 to 2003, my laboratory studied the occurrence of those protozoa at six sewage treatment plants — one each in Arizona and California and four in Florida. All had been approved by their respective state regulators for nonpotable reuse, including irrigation of landscapes and, in some cases, crops.

In that study, we found these protozoa in all the untreated sewage we tested, indicating there is some portion of the population that is infected and excreting their cysts or oocysts.

The five treatment plants whose processes included disinfection with chlorine were able to get rid of a high percentage — but not all — of the protozoa in their discharged wastewater. Some cysts and oocysts remained intact, with the potential to cause disease, even in water that had gone through the entire treatment process, as it is known that wastewater chlorination does not kill these protozoa.

From that data, it seems reasonable to assume that at least some small proportion of cyclospora oocysts also survive sewage treatment processes and are released back into the environment, where they can survive for months.

What about reuse?

Across the U.S., 200 billion gallons of treated sewage wastewater are used for irrigation of agricultural lands each year.

Some of that wastewater undergoes additional filtration and disinfection for reuse before being spread directly on landscapes or crops. The volumes, however, are not readily known. And other treated sewage, which undergoes only standard secondary treatment, is discharged into rivers, streams, and reservoirs that could provide irrigation water.

But few states regulate efforts to remove or monitor protozoa such as cyclospora in treated sewage. Filtration can remove protozoa but must be designed and operated correctly. Chlorination is not effective, but ultraviolet light does inactivate cryptosporidium and eimeria, a chicken protozoan highly related to and used as a surrogate in studies testing methods of killing cyclospora by the food safety industry.

What is needed for better risk assessment and management?

As floods and droughts occur routinely across the U.S. and around the world, sewage may overflow into bodies of water or be used directly on crops. That increases the risk that diseases, including protozoa such as cyclospora, which are transmitted through ingestion of fecal matter, may spread through food and water supplies.

And because cyclospora oocysts mature in outdoor heat, it is possible that increasing temperatures, such as heat domes, could speed up their maturation, exposing more people to the infectious form of the parasite.

Modern technology and techniques are capable of monitoring water quality, detecting harmful pathogens and eliminating them. Expanding monitoring of wastewater for protozoan diseases and other dangers can help prevent outbreaks and slow the spread of disease from sewage-contaminated water in the future.

Joan Rose is a professor of water research and director of the Water Alliance at Michigan State University.

Reprinted from The Conversation.