Mohamadou Preveiw

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 139 FINDING AN OB/GYN YOU TRUST A gynecologist is a doctor who specializes in women’s reproductive health. Obstetricians care for women during their pregnancy and just after the baby is born. They also deliver babies. Your ob-gyn will deal with some of the most important health issues in your life including birth control, childbirth, and menopause. An ob-gyn can also screen for cancer, treat infections, and perform surgery for pelvic organ or urinary tract problems. Because ob-gyns deal with such personal and sensitive health issues, the thought of seeing one, especially for the first time may be troubling for some women. You might be nervous or embarrassed at having a doctor see the most private parts of your body. Or you may be somewhat reluctant to discuss your most intimate issues with an ob-gyn. You wouldn’t want to trust just anyone with the most sensitive parts of your body. That’s why you need to think carefully about your choice of an ob-gyn. Don’t just randomly select a doctor’s name from your health insur- ance list. Get a referral from a friend, a family member, or your primary care doctor. Consider if you would prefer a male or female gynecologist. Some women are more comfortable going to a woman because they will have to undress completely during the exam. Meet with the ob-gyn before making a decision. Ask about his or her medical experience, certification, and attitude about important reproduc- tive issues like birth control. Your questions might include: • Do you accept my health insurance? • At which hospital do you have admitting privileges? • What are your office hours? • If you are not available when I need to see you, who will cover for you? Make sure you are completely comfortable before becoming a patient.

140 MOHAMADOU M. DIENE WHAT TO EXPECT DURING YOUR OB-GYN VISITS? The American Congress of Obstetrics and Gynecologists (ACOG) recom- mends that girls have their first ob-gyn visit when they are 13 to 15 years old or when they become sexually active. The first visit for teens may just include a talk with the doctor and no exam. Try to avoid having sex or douching within 24 hours of your appoint- ment. Sexual activity could irritate the tissue of the vagina and affect your Pap test results. Your appointment will usually start with a general health check. The nurse will weigh you and take your pulse and blood pressure, your temperature. You may have blood and urine tests done too. Then it’s time for the physical exam. Your ob-gyn will start by asking you some general questions about your personal and family health history. A nurse or another health profes- sional might stay in the room with you and the ob-gyn for the pelvic exam. The doctor will first examine the outside of your vagina which includes the vulva area and vaginal opening for abnormalities. The doctor will then examine your reproductive organs from the inside. While your knees are bent and your feet are in stirrups to keep them apart, the gynecologist will use a speculum—a device that holds the vagina open—to view the inside of your vagina and cervix (the opening to your uterus). You might feel some pressure during the exam, but it shouldn’t be painful. Your ob-gyn will also examine the walls of the vagina and cervix. A Pap test is often done during the pelvic exam. Your ob-gyn will remove a sample of cells from your cervix using a small brush. Those cells will be sent to a lab and checked for cervical cancer or other abnormalities. If you are sexually active the doctor might also test you for sexually trans- mitted diseases (STDs) like gonorrhea, chlamydia, syphilis, and HIV. To screen for STDs, the ob-gyn will take a swab of tissue during the pelvic exam and/or do blood tests. Then the ob-gyn will perform an internal bimanual exam by placing one or two gloved fingers in your vagina and the other hand on top of the lower

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 141 part of your abdomen to feel your cervix, uterus, fallopian tubes, and ovaries from outside your body. Your doctor may also if needed, do a recto-vaginal exam which involves placing a gloved finger in your rectum. Your ob-gyn should also do a breast exam to check for any lumps or other abnormalities. TALKING TO YOUR OB-GYN Use your annual ob-gyn appointment as an opportunity to ask questions even if they seem intimate or embarrassing. Chances are that your doctor has heard them before. It’s okay to ask about your periods, sex, or whatever you want to know about your reproductive health. Your ob-gyn should also ask you a lot of questions. These questions might get very personal, but your doctor needs to know the answers in order to care for you properly. Questions can deal with: • Your period and any problems with it such as missed or heavy periods • Vaginal discharge • Whether you are sexually active and how active you are • The number of sexual partners that you have now and have had in the past • Sexual issues or problems • Any sexually transmitted diseases you have had or think you might have • Birth control methods • Vaccine history Remember that your ob-gyn is your partner in reproductive health. Carry on that partnership by making and keeping your annual appointments. In between visits let your doctor know if you have any new problems.

CHAPTER 22 GET THE MOST FROM YOUR PRENATAL CARE VISITS Make sure you have the right doctor. Having a solid doctor-patient relationship is an important step in getting the medical care you need. During pregnancy it’s especially crucial to be partnered with a doctor you feel is competent and compassionate. You should be able to trust your doctor, and your doctor should be able to trust you. If you feel uncomfortable in the doctor’s office, it’s time to consider finding a new doctor, midwife, or healthcare provider. Once you find someone you click with, you’ll want to build a strong relationship. Unfortunately because of current legal issues, a lot of doctors are retiring from obstetrics, limiting their practices to gynecology or moving to less re- strictive states. That means there are fewer obstetricians to go around and your time with your doctor is even more precious.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 143 To make the most of it use the following advice. Ask questions (within reason). You’re bound to have questions—especially if this is your first preg- nancy—and you should feel free to ask them. Just try to be reasonable about the number of questions and amount of time you spend asking them. Ask- ing 45 minutes’ worth of questions when you’re two weeks pregnant can be a bit much. Instead, prioritize so that you are sure to get your doctor’s re- sponse to your most pressing queries. Write down your questions—and the answers. It can be hard to remember what you wanted to ask your doctor, so jot down your questions in advance of your appointment. And if you’re con- cerned you’ll forget what the doctor said once you leave the office, be sure to jot down notes during your visit. Tell your doctor at the start of your appointment that you have questions. Doctors have different preferences when it comes to the timing of ques- tions. Some like to save all of the questions until the end of the visit whereas others like to hear them right off the bat. If the doctor knows a patient’s questions from the start, he or she may look for certain things during the exam. Either way giving your doctor a heads-up can help him or her organ- ize the appointment and budget time for some questions and answers. Save late-night calls for emergencies. Doctors are only humans and pag- ing or calling them in the middle of the night to ask a non-urgent question can really alienate them. If it’s not an emergency, save your questions for office visits or call the doctor’s office during business hours. Talk to the nurse. If you have a question between appointments, call the doctor’s office and ask to speak with a nurse. She may be able to answer your questions immediately (as opposed to the doctor who will probably have to call you back) or, if she isn’t able to answer your question, she can arrange for the doctor to call you. Don’t come spouting facts from the internet. There is a lot of good in- formation on the internet but also plenty of bad stuff in the mix. It’s totally fine to say, “Doctor, I read x,y,z on the internet. Is that true?” However,

144 MOHAMADOU M. DIENE avoid making statements like “according to the internet, I should have a C- section,” which can put your doctor on the defensive. Show that you’re invested in your pregnancy. For example, if you’re a smoker who kicks the habit when you learn you’re pregnant, that shows your doctor that you really care about your pregnancy and your baby. She or he knows you’re putting in 150 percent and is likely to do the same for you. WHO PROVIDES MY PRENATAL CARE? Depending on what is available in your community and covered by your provincial health system, most women can choose the kind of prenatal care they have – either seeing their family doctor, an obstetrician, or a midwife. In some areas, you can opt to be under the sole care of midwives who can only handle low-risk pregnancies. If you have an obstetric history that is in any way out of the ordinary, you will likely want to be under the care of an obstetrician. WHERE DO I GO FOR PRENATAL CHECK-UPS? Most women have their check-ups at their doctor’s office or midwifery clinic. In many areas, you’ll only have to visit the hospital for your ultra- sounds and special tests. Will I see the same caregivers all the way through my pregnancy and delivery? It depends. Some midwifery practices operate a system where you see the same midwife or her back- up at each visit. You’ll at least get to know the faces of the other midwives. Even though you’ll likely see the same doctor throughout your care, he or she might not be ‘on call’ when you deliver, so a different doctor could be present. When you first meet with your doctor or midwife, it’s a good idea to ask how their practice works and what happens if they are not on call when you deliver.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 145 If your family doctor is providing your prenatal care you may be with him or her until you deliver. Some family doctors provide prenatal care un- til the third trimester and then you switch to an ob-gyn for the final weeks and delivery. WHAT HAPPENS AT MY FIRST PRENATAL CHECK? The timing of your first prenatal appointment will vary according to where you live. Usually you will see your family doctor as soon as you suspect you are pregnant. Your family doctor will book your first prenatal appointment there at that office, or refer you to a midwife practice or an obstetrician. It’s a good idea to ask around for names of midwife clinics or ob-gyn before you go to this initial appointment with your family doctor. That way you can request a referral to a specific midwife clinic or doctor. Most women used to have their first appointment at around 12 weeks of pregnancy. However, most doctors and midwives now like to see you for the initial visit as early as 8 weeks after your last menstrual period. One of the reasons for this is that the dating ultrasound which is carried out at, or shortly after the initial visit is more accurate if you are between 8 and 11 weeks pregnant. Be prepared for lots of questions (and form filling), as your doctor or midwife needs to establish an accurate picture of your health, your partner’s health and both of your families’ medical history. Here are some of the things he or she may ask you: Date of last period. Knowing the date of your last menstrual period or LMP allows your doctor to calculate your due date. You might also be offered a dating ultrasound to get a more accurate idea of how pregnant you are and to see if you are expecting more than one baby. Previous miscarriages, abortions and births. your ‘obstetric history’ is im- portant and could have a bearing on how well you cope with pregnancy this

146 MOHAMADOU M. DIENE time around, plus it can affect how your labor is managed. Family history of disease/genetic conditions. Screening is now available for known genetic conditions such as cystic fibrosis, so if you have a family history, your doctor can explain and organize tests. Depending on your eth- nic background, your doctor may also offer you a blood test to screen for conditions such as sickle cell disease which is more common in women of African and West Indian descent. Also having a family history of allergies, heart disease or certain other major medical conditions could all have a bear- ing on your pregnancy, so go prepared with any relevant information about your (and your partner’s) medical history. Your lifestyle. your doctor or midwife will ask a few questions about how much alcohol you drink and whether you smoke. As both can affect your baby’s health your doctor or midwife will likely offer advice or organizations that can help you quit smoking plus dietary and other advice if needed. Where to have your baby. although it’s early, your doctor or midwife may explain your giving birth options so you’ve got plenty of time to think about it and discuss with your partner. These will vary depending on your prov- ince and community and in some places, you’ll even have the option of a home birth. In addition, at your first visit, your doctor will take your blood pressure and might measure and weigh you so that he or she can work out your body mass index (BMI). Your urine will also be checked for protein which could indicate the pregnancy-related condition pre-eclampsia. HOW OFTEN WILL I HAVE PRENATAL APPOINTMENTS? When you’re expecting, you’ll welcome a new routine into your life: regular prenatal visits. As many moms can tell you, there is an air of excitement to these visits. You’ll learn your estimated due date and hear your baby’s heart- beat for the first time. Your doctor will also monitor your health and your

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 147 baby’s health, provide nutrition and activity guidelines, explain what to ex- pect during labor and delivery, and offer tips on how to care for and feed your new baby. RECOMMENDED SCHEDULE FOR A HEALTHY PREGNANCY For a healthy pregnancy your doctor will probably want to see you on the following recommended schedule of prenatal visits: • Weeks 4 to 28: 1 prenatal visit a month • Weeks 28 to 36: 1 prenatal visit every 2 weeks • Weeks 36 to 40: 1 prenatal visit every week Be sure to stick to the schedule that your doctor suggests even if life gets hectic. Prenatal care is important for both your health and your baby’s health. In fact, when a mother doesn’t get prenatal care, her baby is three times more likely to have a low birth weight. When your doctor checks you regularly, he or she can spot problems early and treat them so that you can have the healthiest pregnancy possible. RISK FACTORS THAT MAY REQUIRE MORE VISITS The recommended schedule isn’t set in stone. Your doctor will decide how often to see you based on your individual health picture. Your doctor will want to see you more often if you had any health problems before you be- came pregnant or if problems develop during your pregnancy. You also may need additional tests to ensure that you and your baby stay healthy. If you have any of these risk factors, your doctor may increase the number of your prenatal visits: • Being age 35 and older, because you have an increased chance of having a baby born with a birth defect. You also have a higher risk

148 MOHAMADOU M. DIENE for complications during pregnancy. • Pre-existing health problems. If you have a history of diabetes or high blood pressure, your doctor will probably want to see you more often. Your doctor will work with you to closely manage these health conditions so they don’t affect your pregnancy or your baby’s health. Other health problems such as asthma, lupus, anemia, or obesity may also require more visits. • Medical problems that develop during pregnancy. During prena- tal visits, your doctor will look for complications that can occur af- ter you’ve become pregnant. These include preeclampsia, or preg- nancy-related high blood pressure, and gestational diabetes, a type of diabetes that occurs during pregnancy. If you develop any of these health conditions, you may need to come in more often so your doctor can keep close tabs on your health. • Risk of preterm labor. If you have a history of preterm labor or of premature birth, or if you start showing signs of preterm labor, your doctor will want to monitor you more closely. Seeing your doctor for regular prenatal care can help put your mind at ease. You’ll know that you’re doing all you can to have a healthy baby and safe pregnancy. WHAT IF I’M WORRIED ABOUT SOMETHING BETWEEN PRENATAL VISITS? If you’re concerned about something, don’t wait until your next prenatal check-up is due: either make an earlier appointment, call or visit your mid- wife or doctor. WHAT IF YOU’VE GOTTEN SPECIAL PROBLEMS? If you’ve gotten special problems such as a pre-existing medical condition

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 149 or if you develop a problem during your pregnancy, you’ll probably be transferred to the care of an obstetrician, if you’re not already under an ob- stetrician’s care. You’ll then see a doctor at most of your prenatal visits and may need to go for more regular check-ups than other mothers-to-be. If you have a problem in late pregnancy – particularly a rise in blood pressure, or a concern that your baby isn’t moving around a lot – you may be referred to a hospital for tests and closer examination. WHAT IS LABOR AND DELIVERY? At the end of the third trimester of pregnancy your body will begin to show signs that it is time for your baby to be born. The process that leads to the birth of your baby is called labor and delivery. Every labor and delivery in- cludes certain stages, but each birth is unique. Even if you have had a baby before, the next time will be different. Giving birth to a baby is hard work. It can also be scary, thrilling, and unpredictable. Learning all you can ahead of time will help you be ready when your time comes. WHAT ARE THE STAGES OF LABOR? There are three stages of labor. The first stage includes early labor and active labor. The second stage lasts through the birth with the baby traveling down and out of the birth canal. The third stage is after the birth when the pla- centa is delivered. During stage one the muscles of the uterus start to tighten (contract) and then relax. These contractions help to thin and dilate the cervix so the baby can pass though the birth canal. Stage one has three phases: • Early. Early contractions are usually irregular, and they usually last less than a minute. The early phase of labor can be uncomfortable

150 MOHAMADOU M. DIENE and may last from a few hours to days. • Active. Contractions become strong and regular and last about a minute. This is the time to go to the hospital or birthing center. The pain of contractions may be moderate or intense. • Transition. The cervix will open completely. If there are no prob- lems, the baby should be in position to be born. HOW CAN YOU MANAGE PAIN? Having a support person, trying different positions, or using breathing ex- ercises may help you cope with labor pain. You also can listen to music or use imagery to distract you and help you relax. Many women ask for pain medicine such as an epidural injection which partially or fully numbs the lower body. Even if you plan to not use pain medicine (natural childbirth), it can be comforting to know that you can get pain relief if you want it. HOW CAN YOU PREPARE FOR LABOR AND DELIVERY? Getting regular exercise during pregnancy will help you handle the physical demands of labor and delivery. You need exercises that strengthen your pel- vic floor muscles. This helps prevent a long period of pushing during labor. In your sixth or seventh month of pregnancy, consider taking a childbirth education class with your partner or support person. It can teach you ways to relax and the best ways for your support person to help you. Watching a video on childbirth also helps. There are many decisions to make about labor and delivery. Before your last weeks of pregnancy, be sure to talk to your doctor or nurse-midwife about your birthing options and what you prefer. You can write down all of your preferences as a birth plan. This gives you a chance to state how you would most like things to be handled. Just keep in mind that it is not pos- sible to predict exactly what will happen during labor and delivery.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 151 WHAT CAN YOU EXPECT RIGHT AFTER CHILDBIRTH? Now you get to hold and look at your baby for the first time. You may feel excited, tired, and amazed all at the same time. If you plan to breast-feed, you may start soon after birth. Don’t be surprised if you have some trouble at first. Breast-feeding is something you and your baby have to learn to- gether. You will get better with practice. If you need help getting started, ask a nurse or breast-feeding specialist (lactation consultant). In the hours after delivery, you may feel sore and need help going to the bathroom. You may have sharp, painful contractions for several days as your uterus shrinks in size.

CHAPTER 23 GETTING THE MOST OUT OF YOUR CHILD’S CHECKUP Pediatricians now agree that the number one ally in making the most of any well child visit is you. Checkups are the cornerstone of good health, and in your baby’s first couple of years she’ll have plenty of them as the American Academy of Pediatrics recommends at least nine from birth to 18 months. Checkups are the best way to ensure a child is growing and developing as she should. But they’re more than that: routine visits to the pediatrician give parents the opportunity to learn how to keep their chil- dren healthy and safe and to have all their medical questions answered. The following tips will help you ensure a successful visit to the pediatrician.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 153 1. Time it right Don’t make an appointment that will coincide with your child’s naps or meals, and avoid periods when he tends to get fussy. Feed him beforehand or pack snacks. Find out when the office is least likely to be busy, and if possible, schedule checkups during these off-peak times so you don’t have to wait long. 2. If you need extra time, say so A problem like poor eating habits or developmental delays may require a little more attention, so be sure to alert the office staff when you’re making an appointment that you have an important issue to discuss. 3. Dress your baby for success Avoid multilayered outfits or clothes with lots of snaps and buttons. Many toddlers don’t like having their shoes taken off, so opt for slip-ons and re- move them yourself before the exam. 4. Be your child’s advocate If you know your toddler is spooked by the scale, ask the nurse to hold off weighing her until the end of the physical. If she hates to have her clothes removed, see if the doctor can perform most of the exam while she’s still dressed and in your arms or lap. 5. Bring photos or videos Snap a photo with your smartphone to show the doctor just how bad the rash was two days ago. Or use a flip video camera to record your baby’s col- icky cries. These tools are highly useful in diagnosing and treating patients. 6. Write it down Bring a list of questions so you don’t forget anything important you want to discuss. You may also find it useful to bring a pad and pen to help you remember the doctor’s answers and instructions after you leave.

154 MOHAMADOU M. DIENE Questions you may want to ask your baby’s doctor include: • Is my child growing as expected? • Are his immunizations up to date? • What changes should I see during his next stage of development? 7. Speak freely There’s no such thing as a silly question. If you want to know whether something is normal or whether your child should have a new test or vaccine you have read about, just ask. Part of the purpose of these well-baby check- ups is to get information and reassurance from your doctor. 8. Prepare to report Be ready to answer questions on general topics, such as how your child is sleeping, what and how much he is eating and whether his health or behav- ior has changed since his last visit. You’ll also be asked age-specific questions about milestones like walking and talking. 9. Be honest If your child isn’t sleeping enough or is eating too much junk food, fess up; your doctor can make accurate judgments only if you tell him or her the truth. 10. Don’t worry, be happy Mothers mirror “the exam anxiety.” Instead of being anxious yourself, quickly engage the doctor with “happy to be here” greetings and facial ges- tures. When your baby senses that the doctor is a mom-approved person, she’ll be more cooperative. If both parents have questions, both of them should try to go to the phys- ical. Many doctors like meeting both parents. And you’ll all get more out of the visit together.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 155 Bring records of any visits with other doctors, emergency departments, and urgent care centers. If your child has been prescribed medications from other doctors, bring those too. Use this as an opportunity to make sure all of the records are straight and all in one place. Bring questions. A typed list, scribbled notes on a receipt, or a few words typed in a phone app. Any kind of list is a good idea. You won’t get answers if you don’t remember your questions. Put your questions in order, starting with the ones you’re most concerned about. If possible, don’t bring other children, especially young, distracting sib- lings. It’s not always practical, but if you can possibly set up a time for just the child, parents, and doctor to be in a room together, you can best focus on the star of the show. If you do have to bring siblings—and I understand, sometimes you just have to bring the whole family—try to bring something for them to do like crayons, iPads, whatever you’ve got. If for some reason you can’t make it on time, reschedule the visit. You’ll get more out of a rescheduled well check than a rushed well check. If you have to cancel, please call ahead of time—doctors always have a waiting list of people hoping to grab a cancelled slot. Do someone else a favor and call ahead of time if you can’t make it to your appointment. Talk with your child in advance about what to expect. The doctor is go- ing to check “down there,” which is okay for the doctor to do as long as mom or dad is in the room—when children get older, doctors sometimes ask mom and dad to leave—expect that by the teenage years. They just want to make sure everything is okay, and that means everything. There may be some things you don’t want to talk about in front of the child. Maybe school problems, or bullying, or maybe there are marital prob- lems that are stressing your child out. These are all good questions and sometimes it can be awkward to bring them up. If it’s a quick question, slip the nurse a note that you need a moment alone with the doctor. If you think you need more private time with the physician, call ahead and ask how your doctor’s office likes to handle that. It’s unfair to leave a child alone in the room for a long time while you talk secretly with the doctor—and it makes

156 MOHAMADOU M. DIENE children very, very nervous. It might be best to set up a separate time for parents to come in. For visits with school-aged or older children, be prepared to let your child talk. I know you’ve got questions too and you’ll get to those—but first make sure your child knows this is his visit. He gets to talk first. That drives some parents crazy, but that’s the way it works best. A yearly checkup with your child’s doctor is a chance to catch up and make sure someone is looking at “the big picture.” Parents and doctors both want to make sure that these checkups are valuable for the children and families. Be prepared and you’ll get the most out of the visit. You are an important member of your child’s health care team. The following sugges- tions will help you get the most from your appointment. Before your appointment: (1) Write down your questions and concerns (2) If your child has had previous evaluations or sees a specialist, sign a release form so his current doctor may have evaluations or reports available Come to the appointment with: • A list of your child’s medications • A list of your child’s previous/ current providers • Your insurance card • Your child’s immunization history • Your child’s comfort item like a favorite soft toy or book At the appointment: • Relax, ask questions, take notes. Tell the doctor if something is not clear

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 157 • Be sure you are clear about your child’s treatment plan • Ask when you should schedule your child’s next appointment After the appointment: (1) Take a moment to just be with your child and let him know what a great job he did–give yourself a pat on the back too. (2) Put your child’s medical information and the date for the next ap- pointment in one place, ready for next time.

CHAPTER 24 PREPARING FOR YOUR PSYCHIATRIC APPOINTMENT Mental illness can impact people of any age, race, religion or in- come. It is estimated that one in five Americans experience men- tal illness each year. Mental health is not only the absence of mental illness, but also includes emotional, psychological, and social well- being. Mental health issues are treatable and there is help out there. Though people often worry about their physical health, they tend to often not pay attention to their mental health. We also need to break down the stigma surrounding mental health issues. We all need to have a wholesome and healthy mind as well as body. Seek a psychiatrist if you suffer from anxiety, depression, substance abuse or other emotional disorders. Psychiatrists can assist with diagnosing and treating mental disorders and help shed light on

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 159 illnesses. Psychiatric treatment involves a mental and physical health evalu- ation and an individualized treatment plan which may include talk therapy or medication. Treatment for mental illnesses is effective in 70 to 90 percent of people and results in patients experiencing significant reduction of symp- toms and improved quality of life. Take steps to prepare for your appointment whether you schedule an appointment with your primary care provider to talk about mental health concerns or you’re referred to a mental health provider such as a psychiatrist or psychologist. FINDING A PSYCHIATRIST • Talk to your primary physician about your feelings and ask for a reference. Get at least two to three names of psychiatrists. • Speak with your insurance provider to see if there are psychiatrists in your network. You may need to get a pre-approval or a referral from your doctor. • Check with your local medical or psychiatric society, community health center or hospital for referrals to a psychiatrist. • Search the phone book or the internet for a psychiatrist in your area. Verify that doctors have the proper credentials from an accredited school. • Speak with family and friends to see if they have recommendations for a psychiatrist. MAKING THE APPOINTMENT • Write down the name and address of the psychiatrist you want to see. There may be more than one doctor working at an office, so be specific. • Call the office and ask the receptionist if your chosen psychiatrist

160 MOHAMADOU M. DIENE is accepting new patients. If no new patients are being accepted, the receptionist may refer you to another psychiatrist. • Ask to schedule an appointment. Be prepared to provide back- ground information and an explanation why you are seeking an appointment. If you do not have insurance ask the receptionist about the costs and payment options. • Record the time, date and location of your appointment. Make note of any additional information you may need to bring such as a list of current medications or your insurance information. Whenever possible take a family member or a friend along. Someone who has known you for a long time may be able to share important information with your health care provider with your permission. Before your appointment make a list of: • Any symptoms you or people close to you have noticed, and for how long. • Key personal information, including traumatic events in your past and any current major stressors. • Your medical information, including other physical or mental health conditions. • Any medications, vitamins, herbal products or other supplements you take and their doses. • Questions to ask your doctor or mental health provider. Questions to ask include: • What type of mental illness might I have? • Why can’t I get over mental illness on my own? • How do you treat my type of mental illness? • Will talk therapy help? • Are there medications that might help?

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 161 • How long will it take for the medications to start working? • How long will treatment take? • What can I do to help myself? • Do you have any brochures or other printed material that I can have? • What websites do you recommend? Don’t hesitate to ask any other questions. WHAT TO EXPECT FROM YOUR DOCTOR? During your appointment, your doctor or mental health provider is likely to ask you several questions about your mood, thoughts and behavior, such as: • When did you first notice symptoms? • How is your daily life affected by your symptoms? • What treatment, if any, have you had for mental illness? • What have you tried on your own to feel better or control your symptoms? • What things make you feel worse? • Have family members or friends commented on your mood or be- havior? • Do you have a family history of mental illness, meaning blood rel- atives with mental illness? • What do you hope to gain from treatment? What are your goals and expectations? • What medications or over-the-counter herbs and supplements do you take? • Do you drink alcohol or use any recreational drugs?

162 MOHAMADOU M. DIENE TESTS AND DIAGNOSIS To determine a diagnosis and check for related complications, you may have: • A physical exam. Your doctor will try to rule out physical prob- lems that could cause your symptoms. • Lab tests. These may include, for example, a check of your thyroid function or a screening for alcohol and drugs. • A psychological evaluation. A doctor or mental health provider talks to you about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help an- swer these questions. DETERMINING WHICH MENTAL ILLNESS YOU HAVE Sometimes it is difficult to find out which mental illness may be causing your symptoms. But taking the time and effort to get an accurate diagnosis will help determine the appropriate treatment. The defining symptoms for each mental illness are detailed in the Diag- nostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to re- imburse for treatment. Effective October 1, 2015, HIPAA-covered entities must use ICD-10 codes. Classes of mental illness There are several classes of mental illness like: • Neurodevelopmental disorders. Examples include autism spec- trum disorder, attention-deficit/hyperactivity disorder (ADHD) and learning disorders.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 163 • Schizophrenia spectrum and other psychotic disorders. Psychotic disorders cause detachment from reality — such as delusions, hal- lucinations, and disorganized thinking and speech. The most no- table example is schizophrenia, although other classes of disorders can be associated with detachment from reality at times. • Bipolar and related disorders. This class includes disorders with al- ternating episodes of mania — periods of excessive activity, energy and excitement — and depression. • Depressive disorders. These include disorders that affect how you feel emotionally, such as the level of sadness and happiness, and they can disrupt your ability to function. Examples include major depressive disorder and premenstrual dysphoric disorder. • Anxiety disorders. Anxiety is an emotion characterized by the an- ticipation of future danger or misfortune along with excessive wor- rying. It can include behavior aimed at avoiding situations that cause anxiety. This class includes generalized anxiety disorder, panic disorder and phobias. • Obsessive-compulsive and related disorders. These disorders in- volve preoccupations or obsessions and repetitive thoughts and ac- tions. Examples include obsessive-compulsive disorder, hoarding disorder and hair-pulling disorder (trichotillomania). • Trauma- and stressor-related disorders. These are adjustment dis- orders in which a person has trouble coping during or after a stressful life event. Examples include post-traumatic stress disorder (PTSD) and acute stress disorder. • Feeding and eating disorders. These disorders include disturbances related to eating such as anorexia nervosa and binge-eating disorder. • Substance-related and addictive disorders. These include problems associated with the excessive use of alcohol, caffeine, tobacco and drugs. This class also includes gambling disorder. • Other mental disorders. This class includes mental disorders that are due to other medical conditions or that do not meet the full

164 MOHAMADOU M. DIENE criteria for one of the above disorders. TREATMENTS AND DRUGS Your treatment depends on the type of mental illness you have, its severity and what works best for you. In many cases a combination of treatments works best. If you have a mild mental illness with well-controlled symptoms, treat- ment from one health care provider may be sufficient. However, often a team approach is appropriate to make sure all your psychiatric, medical and social needs are met. This is especially important for severe mental illnesses such as schizophrenia. YOUR TREATMENT TEAM Your treatment team may include you and your: • Family or primary care doctor. • Nurse practitioner. • Physician assistant. • Psychiatrist, a medical doctor who diagnoses and treats mental illnesses. • Psychotherapist, such as a psychologist or a licensed counselor. • Pharmacist. • Social worker. • Family members. However, always remember that the most important person in you healthcare team is you. Again, the healthcare providers are experts in the medical field, but you are expert in you. MEDICATIONS Although psychiatric medications don’t cure mental illness, they can often

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 165 significantly improve symptoms. Psychiatric medications can also help make other treatments such as psychotherapy more effective. The best med- ications for you will depend on your particular situation and how your body responds to the medication. Some of the most commonly used classes of prescription psychiatric med- ications include: • Antidepressants. Antidepressants are used to treat depression, anxi- ety and sometimes other conditions. They can help improve symptoms such as sadness, hopelessness, lack of energy, difficulty concentrating and lack of interest in activities. Antidepressants are not addictive and do not cause dependency. • Anti-anxiety medications. These drugs are used to treat anxiety disorders, such as generalized anxiety disorder or panic disorder. They may also help reduce agitation and insomnia. Long-term anti-anxiety drugs typically are antidepressants that also work for anxiety. Fast-acting anti-anxiety drugs help with short-term relief, and they also have the potential to cause dependency, so ideally they’d be used in short term. • Mood-stabilizing medications. Mood stabilizers are most com- monly used to treat bipolar disorders which involves alternating episodes of mania and depression. Sometimes mood stabilizers are used with antidepressants to treat depression. • Antipsychotic medications. Antipsychotic drugs are typically used to treat psychotic disorders such as schizophrenia. Antipsychotic medications may also be used to treat bipolar disorders or used with antidepressants to treat depression. PSYCHOTHERAPY Psychotherapy, also called talk therapy, involves talking about your condi- tion and related issues with a mental health provider. During psychotherapy

166 MOHAMADOU M. DIENE you learn about your condition and your moods, feelings, thoughts and be- havior. With the insights and knowledge you gain you can learn coping and stress management skills. There are many types of psychotherapy, each with its own approach to improving your mental well-being. Psychotherapy often can be successfully completed in a few months, but in some cases, long-term treatment may be needed. It can take place one-on-one, in a group or with family members. When choosing a therapist, you should feel comfortable and be confident that he or she is capable of listening and hearing what you have to say. Also it is important that your therapist understands the life journey that has helped shape who you are and how you live in the world. BRAIN-STIMULATION TREATMENTS Brain-stimulation treatments are sometimes used for depression and other mental health disorders. They are generally reserved for situations in which medications and psychotherapy haven’t worked. They include electrocon- vulsive therapy, transcranial magnetic stimulation, an experimental treat- ment called deep brain stimulation and vagus nerve stimulation. Make sure you understand all the risks and benefits of any recommended treatment. HOSPITAL AND RESIDENTIAL TREATMENT PROGRAMS Sometimes mental illness becomes so severe that you need care in a psychi- atric hospital. This is generally recommended when you cannot care for yourself properly or when you are in immediate danger of harming yourself or someone else. Options include 24-hour inpatient care, partial or day hospitalization, or residential treatment which offers a temporary supportive place to live. An- other option may be intensive outpatient treatment.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 167 Substance abuse treatment Substance abuse commonly occurs along with mental illness. Often it in- terferes with treatment and worsens mental illness. If you cannot stop using drugs or alcohol on your own, you need treatment. Talk to your doctor about treatment options. Participating in your own care Working together, you and your health care provider can decide which treatment may be best depending on your symptoms and their severity, your personal preferences, medication side effects, and other factors. In some cases, a mental illness may be so severe that a doctor or a loved one may need to guide your care until you are well enough to participate in decision-making. LIFESTYLE AND HOME REMEDIES In most cases a mental illness won’t get better if you try to treat it on your own without professional care. But you can do some things for yourself that will build on your treatment plan: • Stick to your treatment plan. Don’t skip therapy sessions. Even if you are feeling better, don’t skip your medications. If you stop, symptoms may come back. And you could have withdrawal-like symptoms if you stop a medication too suddenly. If you have bothersome drug side effects or other problems with treatment, talk to your doctor before making changes. • Avoid alcohol and drug use. Using alcohol or recreational drugs can make it difficult to treat a mental illness. If you are addicted, quitting can be a real challenge. If you can’t quit on your own, see your doctor or find a support group to help you. • Stay active. Exercise can help you manage symptoms of depres- sion, stress and anxiety. Physical activity can also counteract the

168 MOHAMADOU M. DIENE effects of some psychiatric medications that may cause weight gain. Consider walking, swimming, gardening or any form of physical activity that you enjoy. Even light physical activity can make a difference. • Don’t make important decisions when your symptoms are severe. Avoid decision-making when you are in the depth of mental ill- ness symptoms since you may not be thinking clearly. • Determine priorities. You may reduce the impact of your mental illness by managing time and energy. Cut back on obligations when necessary and set reasonable goals. Give yourself permission to do less when symptoms are worse. You may find it helpful to make a list of daily tasks or use a planner to structure your time and stay organized. • Learn to adopt a positive attitude. Focusing on the positive things in your life can make your life better and may even improve your health. Try to accept changes when they occur and keep problems in perspective. Stress management techniques, including relaxa- tion methods may help. COPING AND SUPPORT Coping with a mental illness can be challenging. Talk to your doctor or therapist about improving your coping skills, and consider these tips: • Learn as much as you can about your mental illness. Your doctor or therapist can provide you with information or may recommend classes, books or websites. Include your family too — this can help the people who care about you better understand what you are go- ing through and learn how they can help. • Join a support group. Connecting with other individuals facing similar challenges may help you cope better with your mental ill-

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 169 ness. Support groups for mental illness are available in many com- munities and online. One good place to start is the National Alli- ance on Mental Illness. • Maintain links and stay connected with friends and family. Try to participate in social activities, and get together with family or friends regularly. Ask for help when you need it, and be upfront with your loved ones about how you are doing. • Keep a personal journal. Keeping track of your personal life can help you and your mental health provider identify what triggers or improves your symptoms. It is also a healthy way to explore and express pain, anger, fear and other emotions. PREVENTION There is no real method to prevent mental illness. However, if you have a mental illness, taking steps to control stress, to increase your resilience and to boost low self-esteem may help keep your symptoms under control. Fol- low these steps: • Pay close attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs. • Get routine medical care. Don’t neglect checkups or skip visits to your health care provider, especially if you aren’t feeling well. You may have a new health problem that needs to be treated, or you may be experiencing side effects of medication. • Get help early when you need it. Mental health conditions can be harder to treat if you wait until symptoms get worse. Long-term maintenance treatment also may help prevent a relapse of symptoms.

170 MOHAMADOU M. DIENE • Take good care of yourself. Sufficient sleep, healthy eating and regular physical activity are important. Try to maintain a regular schedule. Talk to your health care provider if you have trouble sleeping or if you have questions about diet and physical activity. EMERGENCY MENTAL HEALTH CARE What is a mental health emergency? You have an emergency if the patient: • Is at immediate risk of serious harm to self or others as a result of mental disorder. • Needs immediate continuous skilled observation at the acute level of care (based on a psychiatric evaluation). When you have a mental health emergency: • Call 911 or go to the nearest emergency room. • You don’t need prior authorization. • If admitted, call your regional contractor within 24 hours or the next business day. • Admissions must be reported within 72 hours. Non-Emergency Mental Health Care • Follow your plan’s rules for getting non-emergency mental health care. TYPES OF MENTAL HEALTH PROFESSIONALS There are many types of mental health professionals. Finding the right one for you requires some research. Below is a listing of types of mental health

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 171 treatment professionals to help you understand the differences between the services they provide. The following mental health professionals can provide psychological as- sessments and therapy; however, they cannot prescribe medications (alt- hough some states may allow it): • Clinical Psychologist– a Psychologist with a doctoral degree in psy- chology from an accredited/designated program in psychology. Psy- chologist are trained to make diagnoses and provide individual and group therapy. • School Psychologist– A psychologist with an advanced degree in psychology from an accredited/designated program in School Psy- chology. School Psychologists are trained to make diagnoses, pro- vide individual and group therapy, and work with school staff to maximize efficiency in the school setting. The following mental health professionals can provide counseling: how- ever, they cannot prescribe medication: • Clinical Social Worker– A counselor with a master’s degree in so- cial work from an accredited graduate program. Trained to make diagnoses, provide individual and group counseling, and provide case management and advocacy services; usually found in the hos- pital setting. • Licensed Professional Counselor– A counselor with a master’s de- gree in psychology, counseling or related field. Trained to diag- nose and provide individual and group counseling. • Mental Health Counselor– A counselor with master’s degree and several years of supervised clinical work experience. Trained to di- agnose and provide individual and group counseling. • Certified Alcohol and Drug Abuse Counselor– A counselor with

172 MOHAMADOU M. DIENE specific clinical training in alcohol and drug abuse. Trained to di- agnose and provide individual and group counseling. • Nurse Psychotherapist– a registered nurse who is trained in the practice of psychiatric and mental health nursing. Trained to diag- nose and provide individual and group counseling. • Marital and Family Therapist– A counselor with a master’s degree with special education and training in marital and family therapy. Trained to diagnose and provide individual and group counseling. • Pastoral Counselor– A clergy with training in clinical pastoral edu- cation. Trained to diagnose and provide individual and group counseling. • Peer Specialist– A counselor with lived experience with mental health or substance use conditions. Assists clients with recovery by identifying and developing strengths, and setting goals. Many peer support programs require several hours of training. • Other therapists– therapists with an advanced degree trained in specialized forms of therapy. Examples include art therapy, music, dance therapy. The following mental health professionals can prescribe medication; however, they may provide therapy: • Psychiatrist– A medical doctor with special training in the diagno- sis and treatment of mental and emotional illnesses. A psychiatrist can prescribe medication, but they often counsel patients. • Child/Adolescent Psychiatrist– A medical doctor with special training in the diagnosis and treatment of emotional behavioral problems in children. Child and Adolescent psychiatrists can also prescribe medication; however they may not provide psychotherapy. • Psychiatric or Mental Health Nurse Practitioner– A registered nurse practitioner with a graduate degree and specialized training in the diagnosis and treatment of mental and emotional illness.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 173 Additionally, your Primary Care Physician, Physician’s Assistant or Nurse Practitioner (depending on your state) are often qualified to prescribe medication. HOW TO BE HEARD BY YOUR PSYCHIATRIST How do I get my concerns heard about the direction of my treatment? On the surface, it seems easy. Just tell your psychiatrist what you want him or her to pay attention to. On the other hand, there are many reasons why this not so simple. • Many psychiatrists diagnose a patient’s illness after a 45-50 mi- nute interview without doing any tests to rule out potential medi- cal causes of psychiatric symptoms and without obtaining history from corroborating sources, as recommended by diagnostic ex- perts. • They see patients in follow up for 15 minutes or less. • In general, patients who take still unfortunately difficult step of seeing a psychiatrist want to believe that they are getting better even when they are not. • For a patient, telling a psychiatrist they are not feeling heard might feel too risky – the patient may think that the psychiatrist might get upset at him or her and might not like him or her as a patient anymore. • You could just change psychiatrists. But it’s not easy. You have to reveal the workings of your mind to yet another stranger. To be honest, the best way to be heard is to build a routine from the very first appointment. The key components of the “Getting Heard Routine” are as follows.

174 MOHAMADOU M. DIENE First appointment. Go to your first appointment with a notebook. Be hon- est in your responses to the psychiatrist. Before you leave ask her or him what is the formal diagnosis she or he is giving you and why. Ask questions about the medications being prescribed. At the end of the appointment, in your notebook, write down a summary of the discussion with the psychia- trist, treatment changes and your honest, gut-level rating of that psychiatrist on the qualities that make a good, competent psychiatrist. Between appointments. Note any particular changes in your own or loved ones’ emotions or behavior that indicate to you change for better or worse in your psychiatric symptoms. Especially note how you are sleeping and how you are feeling about work and about interacting with others. Note side-effects of medications. One day before your next appointment. Take 15 minutes to think about how you are doing overall since the last appointment, and jot down in your notebook all the questions and concerns you want to discuss in your ap- pointment with your psychiatrist. At a follow up appointment. Do not reflexively answer “fine” when the psychiatrists asks “How are you doing?” Instead say “I took some notes and want to share my observations and questions with you” as you open your notebook and begin sharing and asking. At the end of the appointment note down if you felt satisfied with the psychiatrist’s response. This becomes a concern to discuss in the next appointment. Note any change in your gut- level impression of this psychiatrist. At occasional appointments. Take a loved one to the appointment to make it easy for the psychiatrist to get corroborating history and corroborate your own impressions of that psychiatrist. If none of this works, unfortunately there is not much you can do other than voting with your feet, assuming there are no constraints to you choosing another psychiatrist.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 175 Do you ever feel too overwhelmed to deal with your problems? If so, you are not alone. According to the National Institute of Mental Health, more than a quarter of American adults experience depression, anxiety or another mental disorder in any given year. Others need help coping with a serious illness, lose weight or stop smoking. Still others struggle to cope with rela- tionship troubles, job loss, the death of a loved one, stress, substance abuse or other issues. And these problems can often become debilitating. WHAT IS PSYCHOTHERAPY? A psychologist can help you work through such problems. Through psy- chotherapy, psychologists help people of all ages live happier, healthier and more productive lives. In psychotherapy, psychologists apply scientifically validated procedures to help people develop healthier, more effective habits. There are several approaches to psychotherapy—including cognitive- behavioral, interper- sonal and other kinds of talk therapy—that help individuals work through their problems. Psychotherapy is a collaborative treatment based on the relationship be- tween an individual and a psychologist. Grounded in dialogue, it provides a supportive environment that allows you to talk openly with someone who is objective, neutral and nonjudgmental. You and your psychologist will work together to identify and change the thought and behavior patterns that are keeping you from feeling your best. By the time you are done, you will not only have solved the problem that brought you in, but you will have learned new skills so you can better cope with whatever challenges arise in the future. WHEN SHOULD YOU CONSIDER PSYCHOTHERAPY? Because of the many misconceptions about psychotherapy, you may be re- luctant to try it out. Even if you know the realities instead of the myths, you may feel nervous about trying it yourself.

176 MOHAMADOU M. DIENE Overcoming that nervousness is worth it. That’s because anytime your quality of life isn’t what you want it to be, psychotherapy can help. Some people seek psychotherapy because they have felt depressed, anx- ious or angry for a long time. Others may want help for a chronic illness that is interfering with their emotional or physical well-being. Still others may have short-term problems they need help navigating. They may be go- ing through a divorce, facing an empty nest, feeling overwhelmed by a new job or grieving a family member’s death for example. Signs that you could benefit from therapy include: • You feel an overwhelming, prolonged sense of helplessness and sadness. • Your problems don’t seem to get better despite your efforts and help from family and friends. • You find it difficult to concentrate on work assignments or to carry out other everyday activities. • You worry excessively, expect the worst or are constantly on edge. • Your actions, such as drinking too much alcohol, using drugs or being aggressive, are harming you or others. WHAT ARE THE DIFFERENT KINDS OF PSYCHOTHERAPY? There are many different approaches to psychotherapy. Psychologists gen- erally draw on one or more of these. Each theoretical perspective acts as a roadmap to help the psychologist understand their clients and their prob- lems and develop solutions. The kind of treatment you receive will depend on a variety of factors: current psychological research, your psychologist’s theoretical orientation and what works best for your situation. Your psychologist’s theoretical perspective will affect what goes on in his

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 177 or her office. Psychologists who use cognitive-behavioral therapy, for exam- ple have a practical approach to treatment. Your psychologist might ask you to tackle certain tasks designed to help you develop more effective coping skills. This approach often involves homework assignments. Your psycholo- gist might ask you to gather more information, such as logging your reac- tions to a particular situation as they occur. Or your psychologist might want you to practice new skills between sessions, such as asking someone with an elevator phobia to practice pushing elevator buttons. You might also have reading assignments so you can learn more about a particular topic. In contrast, psychoanalytic and humanistic approaches typically focus more on talking than doing. You might spend your sessions discussing your early experiences to help you and your psychologist better understand the root causes of your current problems. Your psychologist may combine elements from several styles of psycho- therapy. In fact, most therapists don’t tie themselves to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each client’s needs. The main thing to know is whether your psychologist has expertise in the area you need help with and whether your psychologist feels he or she can help you.

CHAPTER 25 MAKING SURE YOUR HIV CARE IS THE BEST IT CAN BE HIV stands for human immunodeficiency virus. It weakens a per- son’s immune system by destroying important cells that fight dis- eases and infections. No effective cure exists for HIV. But with proper medical care HIV can be controlled. Some groups of people in the United States are more likely to get HIV than others because of many fac- tors including their sex partners, their risk behaviors, and where they live. This section will give you basic information about HIV, such as how it is transmitted, how you can prevent it, and how to get tested for HIV. TRANSMISSION Only certain body fluids—blood, semen (cum), pre-seminal fluid (pre-cum),

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 179 rectal fluids, vaginal fluids, and breast milk—from a person who has HIV— can transmit HIV. These fluids must come in contact with a mucous mem- brane or damaged tissue or be directly injected into the bloodstream (from a needle or syringe) for transmission to occur. Mucous membranes are found inside the rectum, vagina, penis, and mouth. In the United States HIV is spread mainly by: • Having anal or vaginal sex with someone who has HIV without using a condom or taking medicines to prevent or treat HIV. o Anal sex is the highest-risk sexual behavior. For the HIV- negative partner, receptive anal sex (bottoming) is riskier than insertive anal sex (topping). o Vaginal sex is the second highest-risk sexual behavior. • Sharing needles or syringes, rinse water, or other equipment – works- used to prepare drugs for injection with someone who has HIV. HIV can live in a used needle up to 42 days depending on temperature and other factors. Less commonly, HIV may be spread: • From mother to child during pregnancy, birth, or breastfeeding. Although the risk can be high if a mother is living with HIV and not taking medicine, recommendations to test all pregnant women for HIV and start HIV treatment immediately have low- ered the number of babies who are born with HIV. • By being stuck with an HIV-contaminated needle or other sharp object. This is a risk mainly for health care workers. Testing The only way to know for sure whether you have HIV is to get tested. Knowing your status is important because it helps you make healthy deci- sions to prevent getting or transmitting HIV.

180 MOHAMADOU M. DIENE Some people may experience a flu-like illness within 2 to 4 weeks after infection (Stage 1 HIV infection). But some people may not feel sick during this stage. Flu-like symptoms include fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, or mouth ulcers. These symptoms can last anywhere from a few days to several weeks. During this time, HIV infection may not show up on an HIV test, but people who have it are highly infectious and can spread the infection to others. If you have these symptoms, that doesn’t mean you have HIV. Each of these symptoms can be caused by other illnesses. But if you have these symptoms after a potential exposure to HIV, see a health care provider and tell him or her about your risk. The only way to determine whether you are infected is to be tested for HIV infection. To find places near you that offer confidential HIV testing: • Visit gettested.cdc.gov, • Text your ZIP code to KNOW IT (566948), or • Call 1-800-CDC-INFO (1-800-232-4636). You can also use a home testing kit, available for purchase in most phar- macies and online. After you get tested, it is important to find out the result of your test so you can talk to your health care provider about treatment options if you’re HIV-positive or learn ways to prevent getting HIV if you’re HIV-negative. IS THERE A CURE FOR HIV? No effective cure currently exists for HIV. But with proper medical care HIV can be controlled. Treatment for HIV is called antiretroviral therapy or ART. If taken the right way every day, ART can dramatically prolong the lives of many people infected with HIV, keep them healthy, and greatly lower their chance of infecting others. Before the introduction of ART in the mid-1990s, people with HIV could progress to AIDS (the last stage of HIV infection) in a few years. Today, someone diagnosed with HIV and

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 181 treated before the disease is far advanced can live nearly as long as someone who does not have HIV. Prevention Today more tools than ever are available to prevent HIV. In addition to abstinence, limiting your number of sexual partners, never sharing needles, and using condoms the right way every time you have sex, you may be able to take advantage of newer medicines such as in pre-exposure prophylaxis (PrEP), and in post-exposure prophylaxis (PEP). PrEP Pre-exposure prophylaxis (or PrEP) is when people at very high risk for HIV take HIV medicines daily to lower their chances of getting infected. A com- bination of two HIV medicines (tenofovir and emtricitabine), sold under the name Truvada is approved for daily use as PrEP to help prevent an HIV- negative person from getting HIV from a sexual or injection-drug-using partner who is HIV- positive. Studies have shown that PrEP is highly effec- tive for preventing HIV if it is used as prescribed along with other preven- tion options such as condoms. PrEP is much less effective when it is not taken consistently. Talk to your doctor to find out if PrEP is right for you. PEP PEP (post-exposure prophylaxis) means taking antiretroviral medicines (ART) after being potentially exposed to HIV to prevent becoming in- fected. PEP should be used only in emergency situations and must be started within 72 hours after a recent possible exposure to HIV. If you think you’ve recently been exposed to HIV during sex or through sharing needles and works to prepare drugs or if you’ve been sexually assaulted, talk to your health care provider or an emergency room doctor about PEP right away. The National HIV/AIDS Strategy is a five-year plan that details princi- ples, priorities, and actions to guide our collective national response to the HIV epidemic. First released by President Obama on July 13, 2010, the

182 MOHAMADOU M. DIENE Strategy identified a set of priorities and strategic action steps tied to meas- urable outcomes for moving the nation forward in addressing the domestic HIV epidemic. In July 2015, the White House released the National HIV/AIDS Strategy for the United States: Updated to 2020. This Update reflects the work accomplished and the new scientific developments since 2010 and charts a course for collective actions across the federal government and all sectors of society to move us close to the Strategy’s vision. STRATEGY VISION The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/eth- nicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination. Strategy goals: 1. Reduce new infections 2. Increase access to care and improve health outcomes for people living with HIV 3. Reduce HIV-related health disparities and health inequities 4. Achieve a more coordinated national response to the HIV epi- demic. You have a right to the highest quality HIV care possible. You play an important part in improving the quality of HIV care at your clinic. What you need and what you think about your care matters. If you speak, people will listen. Factors that contribute to the quality of your care include: • The relationships you have with your doctor and the other clinic staff. • The location of the facilities and services provided at your clinic.

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 183 • How well your personal needs are met. • How well your medical care is handled (are the right tests and treatments provided when they should be?). • When you are not satisfied with your care, someone is there to help you make improvements. • How well you can communicate with your doctor and other health care providers. Some important indicators of the quality of the medical care you receive are: 1. HIV viral load tests are done at least every 4 months and the re- sults are discussed with you. 2. You have a TB test (PPD, or Quantiferon test) every year. 3. If you are a woman, you have a pelvic exam every year. 4. If you are pregnant, you are offered antiretroviral medication to help prevent HIV infection to your newborn child. On June 29,2014, Governor Andrew M. Cuomo announced a three- point plan to bend the curve and decrease new HIV infections to the point where the number of people living with HIV in New York State is reduced for the first time. The end of the AIDS epidemic in New York will occur when the total number of new HIV infections has fallen below the number of HIV-related deaths. The bending the curve three-point program includes: 1. Identifying persons with HIV who remain undiagnosed and link- ing them to health care; 2. Linking and retaining persons diagnosed with HIV to health care and getting them on anti-HIV therapy to maximize HIV viral suppression so they remain healthy and prevent further transmis- sion; and

184 MOHAMADOU M. DIENE 3. Providing access to Pre-Exposure Prophylaxis (PrEP) for high-risk persons to keep them HIV negative.

CHAPTER 26 ORAL HEALTH Oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans. However, not all Americans are achieving the same degree of oral health. In spite of the safe and effective means of maintaining oral health that have benefited the majority of Americans over the past half century, many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the qual- ity of life and burden American society. What amounts to “a silent epidemic” of oral diseases is affecting our most vulnerable citizens—poor children, the elderly, and many members of racial and ethnic minority groups. Oral health means much more than healthy teeth. It means being free of chronic oral-facial pain conditions, oral and pharyngeal (throat) cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues, collectively known as the craniofacial complex. These are tissues

186 MOHAMADOU M. DIENE whose functions we often take for granted, yet they represent the very es- sence of our humanity. They allow us to speak and smile, sigh and kiss, smell, taste, chew, and swallow, cry out in pain, and convey a world of feel- ings and emotions through facial expressions. They also provide protection against microbial infections and environmental insults. A thorough oral examination can detect signs of nutritional deficiencies as well as a number of systemic diseases including microbial infections, im- mune disorders, injuries, and some cancers. Indeed, the phrase the mouth is a mirror has been used to illustrate the wealth of information that can be derived from examining oral tissues. New research is pointing to associations between chronic oral infections and heart and lung diseases, stroke, and low-birth-weight, premature births. Associations between periodontal disease and diabetes have long been noted. The broadened meaning of oral health parallels the broadened mean- ing of health which is “a complete state of physical, mental, and social well- being, and not just the absence of infirmity.” It follows that oral health must also include well-being. Just as we now understand that nature and nurture are inextricably linked, and mind and body are both expressions of our hu- man biology, so too we must recognize that oral health and general health are inseparable. You cannot be healthy without oral health. Oral health and general health should not be interpreted as separate entities. Oral health is a critical component of health and must be included in the provision of health care and the design of community programs. The wider meanings of oral health in no way diminish the relevance and importance of the two leading dental diseases, caries and the periodontal diseases. They remain common and widespread, affecting nearly everyone at some point in the life span. What has changed is what we can do about them. Researchers in the 1930s discovered that people living in communities with naturally fluoridated water supplies had less dental caries than people drinking un-fluoridated water. But not until the end of World War II were the investigators able to design and implement the community clinical trials

MAKING THE MOST OF YOUR DOCTOR’S APPOINTMENT 187 that confirmed their observations and launched a better approach to the problem of dental caries: prevention. Soon after, adjusting the fluoride con- tent of community water supplies was pursued as an important public health measure to prevent dental caries. THE BURDEN OF ORAL DISEASES AND DISORDERS Oral diseases are progressive and cumulative and become more complex over time. They can affect our ability to eat the foods we choose, how we look, and the way we communicate. These diseases can affect economic productivity and compromise our ability to work at home, at school, or on the job. Health disparities exist across population groups at all ages. Over one third of the US population (100 million people) has no access to com- munity water fluoridation. Over 108 million children and adults lack dental insurance, which is over 2.5 times the number who lack medical insurance. The theme of prevention gained momentum as pioneering investigators and practitioners in the 1950s and 1960s showed that not only dental caries but also periodontal diseases are bacterial infections. The researchers demonstrated that the infections could be prevented by increasing host re- sistance to disease and reducing or eliminating the suspected microbial pathogens in the oral cavity. The applications of research discoveries have resulted in continuing improvements in the oral health of Americans, new approaches to the prevention and treatment of dental diseases, and the growth of the science. The significant role that scientists, dentists, dental hygienists, and other health professionals have played in the prevention of oral disease and disa- bility leads to the conclusion that safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease. These measures include daily oral hygiene procedures and other lifestyle behaviors, community programs such as community water fluori- dation or tobacco cessation programs, and provider-based interventions such as the placement of dental sealants and examinations for common oral

188 MOHAMADOU M. DIENE and pharyngeal cancers. At the same time more needs to be done to ensure that messages of health promotion and disease prevention are brought home to all Americans. General health risk factors, such as tobacco use and poor dietary practices, also affect oral and craniofacial health. All the health professions can play a role in reducing the burden of disease in America by calling attention to these and other risk factors and suggesting appropriate actions. Clearly, promoting health and preventing disease are concepts the Amer- ican people have taken to heart. For the third decade the nation has devel- oped a plan for the prevention of disease and the promotion of health, em- bodied in the US Department of Health and Human Services (2000) doc- ument, Healthy People 2010. As a nation, we hope to eliminate disparities in health and eradicate cancer, birth defects, AIDS and other devastating infections, mental illness and suicide, and the chronic diseases of aging. To live well into old age free of pain and infirmity, and with a high quality of life, is the American dream. Scientists today take that dream seriously in researching the intricacies of the craniofacial complex. They are using an ever-growing array of sophisti- cated analytic tools and imaging systems to study normal function and di- agnose disease. They are completing the mapping and sequencing of hu- man, animal, microbial, and plant genomes to better understand the com- plexities of human development, aging, and pathological processes. They are growing cell lines, synthesizing molecules, and using a new generation of biomaterials to revolutionize tissue repair and regeneration. More than ever before they are working in multidisciplinary teams to bring new knowledge and expertise to the goal of understanding complex human dis- eases and disorders. THE CHALLENGE Racial and ethnic inequities and disparities exist when it comes to oral health as well, and they affect those least able to mobilize the resources to