Author Archives: stfmguestblogger

Using While Pregnant

Posted on June 5, 2025 | Leave a comment

A Life-Changing Knock


By Meheret Mekonnen, MS

The fear of having a newborn taken away—this is a reality for many women who test positive for substances on a urine drug screen during pregnancy. The stigma and complications of substance use disorders are associated with insufficient prenatal care, inadequate nutrition, chronic medical conditions, and domestic violence.¹

Prenatal substance use and neonatal substance exposure have become pressing public health concerns. It is estimated that more than 4.4% of pregnant women in the United States use 1 or more substances during pregnancy.² Opioid use among pregnant women and cases of neonatal abstinence syndrome have risen alarmingly, with a 131% increase in opioid-related diagnoses during delivery hospitalizations from 2010 to 2017.² Each year, approximately 800,000 of the 4.3 million neonates born in the United States are exposed to illicit substances in utero.³ These statistics, along with countless patient testimonials, highlight the critical need for health care professionals to implement screening, brief intervention, and referral to treatment as part of routine care.

One of the many challenges clinicians and institutions face is how to effectively screen pregnant patients. Many facilities still rely on unstandardized substance use screening, often in the form of urine toxicology testing. However, urine drug screens have demonstrated poor positive predictive value and reveal significant disparities in outcomes.⁴ Historically, unstandardized screening and disclosure practices have been shaped by provider bias, particularly against single women with poor psychological, financial, or social functioning; women with delivery complications; Black women; and those receiving care in public health settings.⁵

Leading organizations—including the World Health Organization (WHO), the US Preventive Services Task Force (USPSTF), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the American College of Obstetricians and Gynecologists (ACOG)—strongly recommend standardizing substance use screening as part of comprehensive obstetric care.⁶ Validated screening tools such as the 5Ps (Parents, Peers, Partner, Pregnancy, Past) offer a structured approach to assessing alcohol and substance use during pregnancy.⁷

Critics of universal verbal screening cite concerns about patient honesty, staff burden, and time constraints. Yet, successful models demonstrate that integration into existing clinic workflows, engagement of multidisciplinary stakeholders, and support from institutional leadership can facilitate adoption and acceptance.⁸

More work is needed to address disparities in substance use screening and the broader public health challenge of prenatal substance exposure. However, universal verbal screening is a meaningful step toward building patient trust, mitigating provider bias, and promoting equity in prenatal care.⁹

References

1. Wendell AD. Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol. 2013;56(1):91–96. Available from: https://journals.lww.com/clinicalobgyn/FullText/2013/03000/Overview_and_Epidemiology_of_Substance_Abuse_in.15.aspx

2. Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010–2017. JAMA. 2021;325(2):146–147.

3. Joseph R, Brady E, Hudson ME, Moran MM. Perinatal substance exposure and long-term outcomes in children: a literature review. 2020.

4. Chin JM, Chen E, Wright T, Bravo RM, Nakashima E, Kiyokawa M, et al. Urine drug screening on labor and delivery. Am J Obstet Gynecol MFM. 2022;4(6):100733. doi:10.1016/j.ajogmf.2022.100733

5. Madora M, Wetzler S, Jose A, Bernstein PS. Pregnant and postpartum people with substance use disorders: understanding the obstetrical care provider’s roles and responsibilities. Matern Child Health J. 2022;26(7):1409–1414.

6. Whittaker A. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. By World Health Organization. Geneva, Switzerland: WHO Press; 2014. Drug Alcohol Rev. 2015;34(3):340–341.

7. Hostage JC, Brock J, Craig W, Sepulveda D. Integrating screening, brief intervention and referral to treatment for substance abuse into prenatal care [3L]. Obstet Gynecol. 2018;131:129S–130S.

8. Chasnoff IJ, Wells AM, McGourty RF, Bailey LK. Validation of the 4P’s Plus© screen for substance use in pregnancy. J Perinatol. 2007;27(12):744–748.

9. Ulrich M, Memmo EP, Cruz A, Heinz A, Iverson RE. Implementation of a universal screening process for substance use in pregnancy. Obstet Gynecol. 2021;137(4):695–701.

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Getting Started With Your Writing: Finding Your Voice

Posted on October 25, 2024 | Leave a comment
By Sarina Schrager, MD, MS, 
Family Medicine editor-in-chief

I will often talk to groups of junior faculty, fellows, residents, and students about writing. When I say enthusiastically, that writing is fun, I am faced with a sea of skeptical faces.  Is writing fun?  Well, for most people the answer is no. Why not?  Because it is hard and for many of us no one has taught us how to do it. One of my favorite quotes about writing is by Ernest Hemingway. He said, “We are all apprentices in a craft where no one ever becomes a master.”  Well, that’s frustrating you may say. If I can’t become a master, why bother?  My answer is that seeing your work in print is worth the effort. The process of writing and editing and developing a strong final product is very satisfying. You have something to say and writing is an excellent way to share your ideas with a broader public. So, how do we get started?  

  1. Just start writing.  No one is born a great writer and the only way to get better is to practice.  Think about what you want to write and start writing. You can practice when writing for work (craft well worded e-mails for example) or in your every-day life.
  2. Try writing short academic pieces like case reports or book reviews or letters to the editor. These forms of writing are less intimidating because they are short and very structured.  Family Medicine has a new article type called Family Medicine Focus. This infographic is less than 500 words and covers a narrow, specific topic on education or professional development. (Family Medicine (stfm.org))
  3. Think about how you want to structure your work. People have different techniques for planning out a writing project.  Many people use outlines. Some people will use bulleted lists of headings or topics to cover.  Some people start writing at the end and then go back and craft the beginning of their writing. Others will start with the section that is easiest for them—just to get something down on paper.
  4. Give up perfectionism. This may sound simple, but it is hard to be a good writer if you get lost in trying to find the perfect words.  Start off by just writing. If you want to dictate and then transcribe, that can help you put your ideas down on paper. Then, you can edit, craft your argument, and look for clear ways of communicating. Pulling out the thesaurus does not come until you are a couple of revisions into the process.
  5. Ask for help. Yikes, this is a hard thing to do.  But, asking a friend, colleague or family member to read your work before sending it into a journal can get you honest feedback that will improve your writing. It may be painful, but better to address weaknesses in your writing first rather than getting rejected from a journal.
  6. Find your voice. Writing takes a lot of time and can be frustrating if you are not writing about a topic that you care about. Look around you and explore writing about your teaching, your patient care, your work experiences, or your research. You have a story to tell!
  7. Finding a time to write.  For many of us, clinical duties, teaching responsibilities, and administrative tasks take precedence and writing and scholarship quickly fall down the “to do” list. The most prolific writers have one thing in common and that is that they designate time to write. It may not be daily, or even weekly, but if you talk to someone who writes a lot, they will tell you that they block off their calendar to write. Evaluate how, where, and when you work best and take advantage of that. I often recommend a 2009 article in the Emergency Medicine literature entitled, “Tuesdays to Write”.   The author talks about designating Tuesdays for academic time and blocking off the entire day to write.  Obviously, that is not possible for many of us, but the concept is alluring. Look ahead at your calendar. Are there mornings or afternoons that you can block off to write?  
  8. Keep practicing. Maya Angelou said, “Do the best you can until you know better. Then when you know better, do better.”  Start writing for yourself and as you get better at it, share it with your colleagues and the broader family medicine community.  

Reference:

  1. Lowenstein SR. Tuesdays to write … A guide to time management in academic emergency medicine. Acad Emerg Med. 2009 Feb;16(2):165-7. doi: 10.1111/j.1553-2712.2008.00337.x. Epub 2008 Dec 30.

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Responding to Reviewer Suggestions…

Posted on June 4, 2024 | 1 comment

By Sarina Schrager, MD, MS, Family Medicine editor-in-chief

It is exceedingly uncommon for a paper to get accepted when first submitted to a journal. The vast majority of papers are sent back to authors for revision. As editors, we depend on peer reviewers to provide feedback designed to make each paper better. We ask that you view the feedback that you receive from reviewers as a constructive way to improve your paper. As an author, you are asked to respond to every comment made by every reviewer, which can feel like a herculean task. The following suggestions from the editorial team are geared to help you organize and structure your responses whereby improving your chances of having your paper accepted the second time around.

  1. Don’t take it personally—remember that the reviewers are giving feedback on your paper, not on who you are as a person. Remember, by requesting a revision of your paper, the editors and the reviewers think it has potential. Creating space between yourself and the revision requests will help you move forward toward successful publication. Some people will put the revisions aside for a day or two before rereading them.
  2. Always, always respond respectfully to reviewer comments—there is nothing an editor dislikes more than an author being obstinate and dismissive about reviewer comments. The editors rely on peer reviewers volunteering their time. As such, we want to protect peer reviewers from abusive language coming from authors. It is actually common practice to thank the reviewers for their feedback (however unwelcome it may be). This is an important publishing convention because while you don’t know who the reviewers are, they see author names and they likely review for several publications.
  3. It’s okay to disagree—it is okay to disagree respectfully with a reviewer comment.  However, we recommend that you prioritize the comments you disagree with and only include a few (2-3 at maximum) in your responses. Include a detailed explanation of why you disagree and include references if available. The editors will weigh your comments and decide if they still want you to make changes.
  4. Make it easy for the editors—editors and reviewers are busy people who are often volunteering their time to help you improve your paper. So, it is up to you to do everything you can to make that task easier. We recommend that you structure your response letter in table form or use different fonts or underlines so that it is easy for the editor to see that you addressed every single comment. Also, it is good practice to specifically state how you addressed the comment. Instead of just saying “this was changed”, provide details about how you changed the paper or even cut and paste the new sentence into your table of reviewer responses.
  5. What if reviewers give me conflicting feedback?—it is challenging when reviewers have differing opinions about your paper. Most of the time, the associate editor will provide guidance about which reviewer’s comments to follow. If you don’t think that you are getting clear guidance, feel free to e-mail the editorial team for help.  It is perfectly appropriate to ask the associate editor what they think you should do.

Even if your revision does not get accepted, by following reviewer suggestions you have improved the quality of your work and are optimally positioned to submit the paper to a different journal. Happy writing and please consider signing up to be a reviewer to help make Family Medicine the best journal it can be.

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