Reading in Turbulent Times

By Bill Cayley, MD, MDiv


“Literary experience heals the wound without undermining the privilege of the wound.” —C S Lewis (Goodreads)

In turbulent times, withdrawing to a quiet place with a good book seems more tempting than ever. Escaping to another story, another place, or another time can seem the best refuge from chaos and uncertainty. Yet escaping in reading can also feel like a guilty pleasure when it seems that something should be done. While rest and refuge are important for pacing oneself and avoiding burnout, reading can also provide inspiration as the stories of others give us insight into how they faced turbulence and chaotic change. Perhaps, as we face the current moment, a good book might be just the right thing.

Looking back over recent history, it is hard to think of a more turbulent time than the 1930s and 1940s, when the world learned that the “war to end all wars” (World War I) actually was not. In 1943, Langdon Gilkey was a teacher in China and one of about 2000 expatriates interned at the Weihsien compound for “safety and comfort” during the Japanese occupation of China in World War II. Shantung Compound (HarperCollins) is Gilkey’s story of that experience, as the interned expatriates were essentially left to themselves to organize and run life inside their compound. From dealing with hunger, jealousy, boredom, and fear (and even an exploding egg) to finding ways to make life more civilized and tolerable, the book tells a story of community and humanity in the face of isolation and deprivation. As Gilkey concludes, “Out of apparent evil, new creativity can arise if the meanings and possibilities latent within the new situation are grasped with courage and with faith.”

From World War II also comes the story of Le Chambon, a French village that was the center of a movement which sheltered nearly 5000 people (including more than 3000 Jews) between 1940 and 1944. While many find the stories of Raoul Wallenberg and Oskar Schindler inspiring, most of us are not diplomats or industrial magnates. Lest Innocent Blood Be Shed (HarperCollins) tells the gripping story of how “goodness happened” in Le Chambon as ordinary people daily risked their ordinary lives to overcome an extraordinary evil. As the author concludes his book, he reflects on the way the Chambonnais affected him during his research and writing: “I know now that I want to have a door in the depths of my being, a door that is not locked against the faces of all other human beings. I know that I want to be able to say, from those depths, ‘Naturally, come in, and come in.’”

The biographies of individuals can also motivate us and inform us with the wisdom of others who have trod paths of challenge. In Man’s Search for Meaning (Beacon Press), psychiatrist Viktor Frankl tells his own story of finding meaning in life as he faced the horrors and loss of life in a Nazi concentration camp. Coming to more recent times, the stories of those who fought for civil rights during and since the 1960s provide more than ample inspiration. While nearly all are familiar with Martin Luther King Jr, the name of John Lewis may be less familiar. The great-grandson of an enslaved man, Lewis first aspired to be a preacher, later took part in many central events of the 1960s civil rights movement, and subsequently served 17 terms in the US House of Representatives until his death in 2020. In His Truth Is Marching On (Penguin Random House), Jon Meacham tells the story of Lewis’s decades in public service, shaped by his faith-based belief that one should love one’s neighbor as oneself. Another influential leader shaped by the civil rights movement, family physician David Satcher served as US Surgeon General from 1998 to 2002. My Quest for Health Equity (Johns Hopkins University Press) is Dr Satcher’s autobiographical account of his decades-long work on equity issues through academia and public health.

Finally, at a time when the essence of family medicine seems at risk of being lost amid politics, culture wars, and threats to the integrity of science, stories of others who have walked the path of general (or family) medicine can be grounding. The breadth of medical autobiographies can be overwhelming, but a small sample of noteworthy narratives includes A Fortunate Man (AbeBooks), the story of an English country doctor in the mid–20th century; A Fortunate Woman (AbeBooks), the story of another physician (this time a woman) in the same English rural town; and What Matters in Medicine: Lessons From a Life in Primary Care (University of Michigan Press), Dr David Loxterkamp’s stories from a career in rural Maine.

How to face the current moment? Take a deep breath, take some time for reflection, and consider taking time to find inspiration and wisdom from those who have gone before.

Using While Pregnant

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.

Behind the Curtain: What Really Happens After You Submit a Paper to a Journal

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

Many people express confusion about the process of submitting a paper to a journal, receiving peer reviews, and ultimately getting published. This post attempts to answer your questions. Editors do not want their activity to be opaque. We want everyone to know what really happens when you submit a paper. The team at Family Medicine may do things a little differently than other journals, but the major steps will be the same.

You hit “submit”, then what? Once you submit your paper into the electronic portal (we use ScholarOne) the paper will be evaluated by our editorial assistant. S/he will determine if your paper conforms to our author instructions (please read before submitting) for formatting and whether you have IRB approval, if needed. The assistant will unsubmit your paper if it is too long, has too many references, or if the references are not in the proper format.

First review by the editor in chief: At Family Medicine, I read each submitted paper carefully before assigning it to an associate editor. I will occasionally reject a paper at this stage if it is not in scope for our journal (ie, we do not publish clinical papers) or if I think it is in the wrong category. For example, papers describing educational studies in one residency or one medical school fit in our Brief Report category, but probably not in Original Research. I will send those papers back to the authors if they are submitted in the Original Research category and ask the author(s) to shorten them. Another common mistake I often see is papers submitted as a narrative essay when they are really a commentary or an editorial. Narratives are personal stories about an experience you have with patient care, teaching, or your career.

Assigning papers to the associate editors: We have a team of fabulous associate editors at
Family Medicine. Papers that are both in scope and of interest our readers go on to the next step. I assign these papers to one of our associate editors who carefully reads the paper again, and either advises me they don’t think the paper is appropriate for our journal, or, more commonly, sends the paper for peer review.

Requesting peer reviewers: We have hundreds of peer reviewers who volunteer their time and expertise to help us publish the best papers we can. The associate editors aim to get 2-3 reviewers to evaluate each paper before sending it back to me with a recommendation. The associate editor sends requests to 4-6 people. Sometimes these invited reviewers don’t respond, and sometimes they respond but decline the invitation. It will occasionally require upwards of 10 invitations to find the 2-3 reviewers needed for a thorough review of each paper. We give all peer reviewers 3 weeks to return the review. Sometimes a
paper will be caught in this step for a few months. Family Medicine designates 4 potential
outcomes for a paper after peer review: accept (it’s very unusual to accept after initial peer review),
minor revision, major revision, and reject.

Revisions: The vast majority of authors will be asked to revise their paper. This is a good thing.
It means that the editorial team believes that the paper will be an important addition to the literature when revised. We expect authors to respond to every reviewer comment and explain how they addressed each comment. After the revised manuscript is submitted, I will review it again and then send back to the associate editor. In some cases, if there were many revisions, the associate editor will send the revision back to the reviewers to assure that all comments were addressed. After those reviews come back, the associate editor indicates an outcome. It is not unusual for a paper to be revised a second (and occasionally a third) time. It is important for authors to remember at this point that these further reviews are designed to improve your paper.

Recommendations for publication: Even great papers can be improved, and this is always the goal of peer review. Our peer reviewers and our associate editors provide feedback to authors to help make
their papers better. A minor revision decision signifies that a paper needs only small changes before it is appropriate to publish. A major revision decision signifies that the peer reviewers and the associate editor like the paper and think it has potential to be a meaningful addition to the scholarly literature, but has some weaknesses. We do not ask people to revise a paper if we do not think it will be interesting to our readers and contribute to the literature. Those papers are denied further review.

Acceptance: Once the associate editor believes that the authors have addressed all revision
requests, they send it to me with a recommendation for publication: Yay! Our production
team has worked hard to decrease the time from acceptance to online publication. You may expect your paper to be published online about 6 weeks after you get your acceptance notice. It will be available on the journal’s ‘Recently Published’ page before being assigned to a monthly issue. As you can see, there are a lot of steps in the process! However, they all aim to support authors through optimizing their paper’s impact.