Uncategorized

Watching our Words

We have all heard the Latin phrase primum non nocere, meaning first do no harm. While many of us may think of this phrase in terms of how we select the optimal treatments and make the best management decisions for our patients, this phrase should guide physicians in all interactions with patients. Most of the time, our first interactions with patients are verbal – taking the history. And if we are not as thoughtful about the way we speak to our patients from the beginning as we are when it comes to developing our plans, we may do them harm from our very first interactions. As physicians, we have devoted our lives to keeping ourselves up-to-date on the latest medical knowledge; we ought to embrace the same expectation when it comes to the way we speak to and about patients. I will provide three examples of language use that will demonstrate sensitivity toward patients, with the corresponding pitfalls which may actually cause harm.

First, the use of person-first language should be the default way that physicians address and discuss their patients. The American Psychological Association first began emphasizing person-first language in 1992 as a way to communicate information about individuals that limits that information’s ability to cause initial bias. For example, this means rather than referring to a patient as a “bronchiolitic” he/she should instead be referred to as “the patient with bronchiolitis.” It is also a way to prevent patients who have the same disease from being lumped together (i.e., “people with chronic pain” rather than “chronic pain patients.”) In general, medical trainees are taught to use this kind of language, but in practice, it is not always our habit. Similarly, while most of us would likely not refer to a patient as “the sickler in room 5” to their face, we may be tempted to use this disease-first language when discussing with colleagues. When we fail to use person first language when describing patients, we ignore their immediate personhood, choosing instead to focus on their disease condition as their identity.

However, the astute physician must be aware that there are exceptions to person-first language. One notable counter-example is the Deaf community. In general, the Deaf community prefers the use of the word Deaf (“deaf people” rather than “person with deafness”) because the overall opinion by the community is that deafness is a medical condition, not an impairment and that their identity as Deaf is not something of which to be ashamed. This serves as an example of the fact that physicians must become aware of the particular values of the communities they serve rather than attempting to learn oversimplified rules about language. Just as we pour ourselves over the details of scientific journal articles, looking for subtleties in disease manifestations and treatments, we must pay similar attention to detail when it comes to the preferred way to speak about and to our patients.

Finally, not only should we as physicians learn the ways patients would like to be addressed, we must also be those innovating change in language. One current medical frontier is the way we think about and treat mental illness. As we continue to remove the stigma of mental illness, we must deliberately change the words we use to speak of it. For example, it may not seem harmful to use the phrase “commit suicide.” On the contrary, while this phrase has been the customary way to speak, it actually does harm. The word “commit” places moral blame on the person who died, seeing as the word’s synonym include “perpetrate” and “violate.” Using the phrase “commit suicide,” rather than the more neutral phrase “die by suicide,” places unnecessary burden and judgment on surviving family members and friends who are already experiencing complex grief.  They often report feeling that they must obtain permission prior to grieving their loved one who died by suicide. Removing the stigma on mental illness includes removing judgmental phrases from our professional and personal lexicons.

Just as medical knowledge is constantly evolving, one need only look at the branching and twisted tree branches that map the progression of modern languages. We interact with our patients through language first and foremost and thus need to ensure that the words we use reflect our mission to serve.

Katie Dolak, MD

References

“Community and Culture – Frequently Asked Questions.” NAD. National Association of the Deaf, 2019, https://www.nad.org/resources/american-sign-language/community-and-culture-frequently-asked-questions/​ . Accessed 25 Nov. 2019.

Crocker, Amy F and Susan N Smith. “Person-First Language, Are We Practicing What We Preach?” Journal of Multidisciplinary Healthcare​, vol. 12, 2019, pp. 125-129.​

Shields, Chris, Michele Kavanaugh, and Kate Russo. “A Qualitative Systematic of the Bereavement Process Following Suicide.” Journal of Death and Dying, vol. 74, no. 4, 2017, pp. 426 – 454.

The Milky Way: A Pediatrician’s Role in Promoting Breastfeeding

It is well established that exclusive breastfeeding for the first six months of life and then breastfeeding combined with complementary solid foods for at least the first year of life is the ideal infant diet. As pediatricians, we need to promote breastfeeding and understand how to do this effectively.

Breastfed infants have a decreased risk of a multitude of diseases including asthma, obesity, type 1 and 2 diabetes, severe lower respiratory disease, acute otitis media, sudden infant death syndrome, gastrointestinal infections, bacteremia, urinary tract infection, lymphoma, leukemia, Hodgkins disease, and necrotizing enterocolitis (1,2). Interestingly, the breastfeeding mother also has many benefits including decreased postpartum bleeding, more rapid uterine involution, decreased menstrual blood loss, increased child spacing, earlier return to pregnancy weight, and decreased risk of breast and ovarian cancers (2). And on top of that, it is free! So why are only 1 in 3 infants getting breastfed at 12 months (3) and what can we do about it?

Over 80% of moms start off breastfeeding their infants. However, by three months of age, less than 50% are still exclusively breastfeeding. Barriers to breastfeeding include lack of knowledge, social norms, poor family and social support, embarrassment, lactation problems, employment and child care, and barriers related to health services (4). We need to understand these barriers and how we can help to alleviate at least some of them at our clinic visits.

Increasing rates of breastfeeding starts with proper education about the benefits of breastfeeding. Unfortunately, a national survey clearly demonstrated lack of understanding about the benefits of breastfeeding. It found that only a quarter of the US public believed that formula feeding could increase the risk of an infant getting sick (4). While it may be time consuming, we need to take the initiative to help moms understand the long list of benefits both them and their babies will receive from breastfeeding. Moms of lower socioeconomic status, and particularly less education, are less likely to breastfeed their children (5). Educating about this topic is our responsibility, especially for more vulnerable populations. We also need to educate our mothers about the laws that protect them including the ones that allow them to breastfeed in public or private locations and workplace laws that require employers to provide mothers with reasonable break time and a private, non-bathroom space to express breast milk (1). Breastfeeding while working is intimidating, and knowing the laws is vital.

Additionally, although breastfeeding is amazing, it is not always easy. We need to give realistic expectations about what the process looks likes. Unrealistic expectations lead to mothers believing that breastfeeding is not going well for them specifically and that they should stop. If there are issues occurring, lactation consultants are invaluable resources in helping a mother overcome these. We need to educate ourselves about the proper way to breastfeed so that we ourselves can also be a resource to our mothers. Finally, we need to promote breastfeeding by guiding our mothers to resources like free breast pumps from WIC instead of free formula.

As pediatricians, we want what is best for our patients. Too often, we ask what an infant is being fed, but we don’t help guide that decision. We are in a uniquely special position to help our patients’ mothers navigate this vital time in their child’s life. Together, we can increase rates of breastfeeding and improve infant health.

Kelly Lawson, MD

1) “Frequently Asked Questions (FAQs).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 4 Nov. 2019, https://www.cdc.gov/breastfeeding/faq/index.htm.

2) “Benefits of Breastfeeding.” AAP.org, https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx.

3) “CDC Releases 2018 Breastfeeding Report Card.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Aug. 2018, https://www.cdc.gov/media/releases/2018/p0820-breastfeeding-report-card.html.

4) Office of the Surgeon General (US). “Barriers to Breastfeeding in the United States.” The Surgeon General’s Call to Action to Support Breastfeeding., U.S. National Library of Medicine, 1 Jan. 1970, https://www.ncbi.nlm.nih.gov/books/NBK52688/.

5) Heck, Katherine E, et al. “Socioeconomic Status and Breastfeeding Initiation among California Mothers.” Public Health Reports (Washington, D.C. : 1974), Association of Schools of Public Health, 2006, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497787/.

How Should We Approach Language Barriers in Healthcare?

Over 60 million people in the United States speak a language other than English at home, and greater than 25 million people have limited English proficiency (speak English “less than very well”) according to the American Community Survey [1]. It is inevitable that healthcare providers will work with patients whose primary language is not English at some point in their training or careers. Physicians should understand how language barriers can affect the health of their patients in order to provide better care for this population.

Studies have shown that language barriers can affect multiple components of healthcare including healthcare access, overall health status, satisfaction of care and patient safety [2, 3]. However, with over 100 different languages spoken in the United States, finding and working with appropriate interpreters can be challenging. As pediatricians, there can be an additional challenge of finding an appropriate balance while working between parents with limited English proficiency and their children who may be more fluent in English. Many pediatricians, including myself, can find language barriers to be an especially frustrating part of our work given the added time in visits and sometimes the uncertainty of whether your intended message was properly relayed to families. It may be helpful to look at why we should have some extra patience and attentiveness in these encounters.

A study looking at errors in medical interpretation and their consequences in pediatric care showed that medical interpretation errors are common. An average of 31 errors are made per clinical encounter. These errors can be categorized as errors of:

  • Omission (lack of interpretation of a word or phrase from parent or clinician)
  • Addition (addition of a word or phrase not mentioned in the interaction)
  • Substitution (different word or phrase was used)
  • Editorialization (addition of interpreter’s own views to interaction)
  • False fluency (incorrect word or phrase used)

Of all the errors, 63% (~19 errors per encounter) were found to have potential clinical consequences including: alterations of the history, omitting drug dosing/frequency/duration information and instructions, omission of previous workup/interventions, poor understanding of the child’s illness or treatment by parents and lack of clarity on plans for follow-up or referrals. Use of ad hoc interpreters (non-professional including staff, family, untrained individuals) were found to have an increased likelihood of committing errors that have potential clinical consequences compared to trained hospital interpreters (77% vs. 53%) [2]. Pediatricians should especially avoid having children interpret for parents given their limited understanding and unfamiliarity with medical terminology and added burden of responsibility.

The results of the study supported the use of trained interpreter services for all patients/families with limited English proficiency. Title VI of the Civil Rights Act requires recipients of federal financial assistance to provide interpreter services for patients with limited English proficiency. Many large institutions and universities have readily accessible professional interpreters, but smaller clinics and offices may not. Different services are available including various telephone interpreting lines and video interpreting services for American sign language communication. Studies have shown that use of telephone interpreting services is not inferior to having a bilingual health care professional. Interpreters may also be a resource to bridge the gap in cultural differences or misunderstandings [3].

Here are some tips to most effectively use medical interpreters [3]:

  • Meet with the interpreter before the interview to give some background information and set goals
  • Speak directly to the patient and not the interpreter
  • Use first-person statements and avoid saying things like “he said” or “tell her”
  • Speak in short sentences
  • Do not use idioms, acronyms, jargon or humor
  • Insist on sentence-by-sentence interpretation to avoid tangential conversations
  • Use the “teach back” method to ensure patient comprehension

Language barriers can have a significant impact on health. Although it may be difficult to work through language barriers, it is important for pediatricians to approach this challenge with patience and humility. Pediatricians should be equipped with the appropriate resources and understand that a little patience can go a long way in providing better care for this population.

Gina Lee, MD

References

  1. U.S. Census Bureau. American community survey. https://www.census.gov/content/census/en/data/tables/2013/demo/2009-2013-lang-tables.html. Accessed October 30, 2019.
  2. Flores G, Laws MB, Mayo SJ, et at. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14
  3. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476–80.

Impact of Social Media on Well-Being

What do you do when there is a pause in conversation or have a small break? Do you nap, stretch, pick up a book, or scroll through social media. I can safely say a majority of the world chooses the last option. Previous surveys suggest that 22% of teenagers log on to their favorite social media site more than 10 times per day (Schurgin 801). Thanks to smart phones access to social media is omnipresent. There is probably a good chance you are even reading this from your phone because it was shared on your timeline. Both parents and pediatricians need to understand social media can have a negative impact on their children and patients especially teenagers, and be able to provide guidance to them.

Since I have your attention, I want you to try a thought experiment. Think about the last time you were on Instagram, Snapchat, or Facebook. Your friends are sending pictures of their amazing vacation to Greece, Japan, or Mexico. They are modeling their delicious food and cultural experiences. Now, how do you feel at this moment? How do you feel while sitting in your cubicle or lying on your couch after your hard day at work? How do you think your children feel when they see the same photos?

When we see these photos and experiences its natural to compare our experiences. However, it is very easy to look at our lives “unfiltered” and feel a sense of loss. As a media user, I have felt this feeling. I have felt the fear of missing out and I am not alone.

            Let’s talk about usage. How do you or does your child use social media? Are you actively posting or casually browsing others’ posts? Research performed at UT Dallas shows passive browsing to be more harmful to mental health. Adolescents were at increased risk of depression and anxiety. In 2016, a Scottish study evaluated social media’s impact on sleep and self-esteem in adolescence. They found adolescence with increased social media use, at night and overall, had lower self-esteem and higher rates of depression and anxiety.

Social media skews our perception of experiences by representing only positive experiences. We are catching a glimpse of the best moments in people’s days. That glimpse is enough to prompt you to compare your life to theirs. Picture centric media platforms like Instagram are more likely to promote appearance and life comparisons with others. As a result, adolescents and adults may feel more negatively about their self-image.

Researchers have proposed a phenomenon called “Facebook depression” (Schurgin 802). Social media exposure can be a trigger for depression in some adolescents. Although Facebook has seen a decrease in usage, the premise is still relevant. Teenagers are at a critical point in their lives when acceptance by peers is crucial.

Social media has benefits as well as drawbacks. Social media provides children and teenagers the opportunity to collaborate within their community. They can stay in touch with friends and share ideas. They learn from podcasts, videos, and even blogs like this one. Social media can be used to develop social skills. A great example is the ability for students to work collaboratively on class projects together with ease. There is a myriad of benefits for our children.

Unfortunately, those benefits come with risks. Social media can contribute to anxiety and depression, but it’s only one of the many contributing factors in most cases. We can start to understand the impact of social media on well-being by understanding what makes social media so fun. Parents need to understand what their teenagers are talking about. When social media is used right it can be enjoyable and safe. Parents need to understand the technology that adolescents are using and also be able to openly discuss how their kids are using it. Social media is prevalent throughout our entire lives so we must treat it as part of our daily routine.

Pediatricians should encourage parents to create an online plan for themselves and their children. The plan can include discussing online issues and checking privacy settings. The goal is to encourage well-being and safe practices on the internet. Social media is omnipresent; however, it does not have to be omnipotent. We are in control of how we use it and how it makes us feel.

Matthew Hibbs, M.D.

References

Okeeffe, G. S., & Clarke-Pearson, K. (2011). The Impact of Social Media on Children, Adolescents, and Families. Pediatrics127(4), 800–804. doi: 10.1542/peds.2011-0054

Psychologists Examine Mental Toll of Passive Social Media Use. (2019, September 26). Retrieved October 2, 2019, from https://utdallas.edu/news/research/social-media-fear-missing-out-2019/.

Woods, H. C., & Scott, H. (2016). #Sleepyteens: Social media use in adolescence is associated with poor sleep quality, anxiety, depression and low self-esteem. Journal of Adolescence51, 41–49. doi: 10.1016/j.adolescence.2016.05.008

The “Social Visit”

We have all been there… your last patient of the day is 20 minutes late to their appointment. All you can think about is how much more time do you give them, before telling the front desk to reschedule the appointment. With all those notes backed up, it would be nice to focus on finishing up, so you can get home before you miss another dinner. However, even after giving them an additional 15 minutes, they do not show up. During those times is not uncommon to hear or think things like, “they better have a good excuse”, “why can they not get here early like everyone else”, or “they have had no-shown 3 appointments, let’s fire them from the clinic.”

But in those moments, it is vital that we start to move away from the thought process of how this missed appointment affects us, to the thought of how does this missed appointment affect the patient and why could they not make it in today? Not only do missed appointments have negative effects on the patient, they can also impact the healthcare system as a whole [1,2]. While evidence suggests the majority of appointments are missed because of forgetfulness, other factors have been reported by families to affect their ability to attending clinic visits, such as: [2]

  • Issues with transportation
  • Schedule conflict (work, school, other appointments)
  • Feeling appointments were unnecessary
  • Child’s health improved
  • Not feeling well
  • Time commitment 
  • Insurance issues

Typical responses to a high volume of missed appointments in a clinic usually involve efforts to improve communication with families via reminder calls/text, open access scheduling to improve appointment wait times, and extended clinic hours to provide more flexible assess to care [2-4]. But none of these fully address issues with transportation, financial short falls, lack of insurance, or any of the countless other hardships families face while navigating a complex medical system. Each no-showed appointment is a unique problem that requires a unique solution, because the underlying factors can vary from day to day and patient to patient.

This is a perfect place to have the “social visit”: think of it as the well-child visit par excellence. These visits would be tailored to identify factors that act as barriers to receiving timely medical and preventive care. During these visits, referrals can be made to community resources, education can be provided on how preventative care is essential for maintaining health, and time can be dedicated for family-provider interactions to establish a robust therapeutic alliance. 

In a perfect world, this would be done in the clinic so providers and families can personally come together and tackle their unique situation as a united team. However, if you cannot get patients into the clinic for regular visits, how effective is the “social visit” going to be if they do not show up for that either? Thankfully, it could also be completed by phone, which would allow for greater flexibility for families and hopefully lead to improved relationships and clinic attendance.

As pediatricians, we have the responsibility to make the effort to start changing the thought process and culture around missed appointments. These are perfect opportunities to reach out to families and provide assistance that they might not otherwise be willing to ask for. Additionally, we must advocate for our patients to make sure they have access to the “social visit”, regardless of billing/productivity constraints. We should push for protected time to make this happens, with the ultimate goal of changing the perspective, so we start to look at the causes of health disparities as medical diagnoses.

Aaron Pope, MD

1.         Cameron E., et al. “Health care professional’s views of paediatric outpatient non-attendance; implications for general practice.” Fam Pract. 2014 Feb; 31(1): 111–117. Published online 2013 Nov 15. doi: 10.1093/fampra/cmt063

2.         Samuels RC., et al. “Missed appointments: Factors Contributing to High No-Show Rates in an Urban Pediatrics Primary Care Clinic.” Clin Pediatr (Phila). 2015 Sep;54(10):976-82. doi: 10.1177/0009922815570613. Epub 2015 Feb 12.

3.         O’Connor M., et al. “Effects of Open Access Scheduling on Missed Appointments, Immunizations, and Continuity of Care for infant Well-Child Care Visits.” Arch Pediatr Adolesc Med. 2006;160(9):889-893. doi:10.1001/archpedi.160.9.889

4.         Aral L., et al. “‘Did not attends’ in children 0-10: a scoping review” Child Care Health Dev. 2014 Nov;40(6):797-805. doi: 10.1111/cch.12111. Epub 2013 Oct 18.

Autism is diagnosed starting at age 2. But what can we do before then?

In recent years, autism has been at the forefront of many discussions in pediatrics. Its prevalence has increased from 1 in 150 children to 1 in 59 over the last 20 years according to the CDC[i]and this is likely due in large part to our ever-growing knowledge of the condition and efforts promoting early diagnosis. Research thus far has shown that early diagnosis and intervention have been instrumental in generating positive outcomes. But how early can we start “therapy” for autism when it can’t even be diagnosed until 24 months of age? We now have research to show that pediatricians should be encouraging parents to consistently talk to their young children even if they aren’t getting any responses back.[ii]

A recent study published in the journal Autism Research delved a bit deeper into the concept of early intervention.[iii]Dr. Meghan Swanson conducted a study looking at 96 infants, 60 of whom had an older sibling with autism. Such a design was necessary given the age restriction on diagnosis and that younger siblings of children with autism have a 20% chance of having autism as well. This statistic was proven true as 14 of those 60 subjects were later diagnosed with autism at 24 months (23%). Dr. Swanson’s method was to monitor 2 full days of audio in the child’s home via LENA audio software- one day when the child was 9 months old and again at 15 months. The LENA software counts number of words as well as “conversation turns,” meaning when one person speaks and another responds. The content of what is said is not evaluated. The subjects’ language skills were then later assessed at 24 months. 

As mentioned, 14 of the subjects were ultimately diagnosed with autism and were placed in the “high-familial-risk who have ASD” group. The remaining subjects were divided into 2 groups: 1) those with older siblings affected by autism but who did not have autism themselves (high-familial-risk who did not have ASD, n=46) and 2) low-familial-risk who exhibited typical development (n=36). The conclusions of the study were two-fold. First and most important, a richer home language environment with higher numbers of adult words and conversational turns correlated to better language development for ALL study groups. Second, higher parent education levels corresponded to richer home language environment. 

As these results show, the benefit from caregiver interaction particularly in the realm of reciprocal spoken language is not restricted to typically developing children. Pediatricians should advise parents to enhance their child’s development from birth by speaking to them regardless of whether they are able to respond appropriately or at all. To be clear, autism is not a diagnosis that is caused by parenting style. The diagnosis will be present or not regardless of parental intervention. However, this study shows that frequent and early communication from birth can improve language development even in children with autism. Additionally, there are centers available that can provide more directed therapies for children struggling with language, social skills, and other developmental milestones. Life Skills Autism Academy is opening its flagship location in Plano, Texas where children 18 months to 5 years can receive personalized one-on-one therapy and assistance in developing an appropriate Individualized Education Plan (IEP) and advocating for the child in the school system.[iv]

Pediatricians can share this knowledge to help all their infant patients improve language development and kickstart their learning with the goal of success in school and beyond. 

Rachel Tonnis, MD


[i]https://www.cdc.gov/ncbddd/autism/data.html 

[ii]https://utdallas.edu/news/research/autism-language-skills-study-2019/

[iii]Swanson, Meghan R. “Early language exposure supports later language skills in infants with and without autism.” Wiley Online Library. Dallas, TX. 1 Sep. 2019. https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2163.

[iv]https://www.dallasnews.com/business/health-care/2019/08/29/life-skills-autism-academy-opening-in-plano-plans-to-provide-one-on-one-therapy/

New “Public Charge” Rule: How does it affect our patients’ families?

Texas is home to approximately 4.7 million immigrants (an estimated 17% of the state population), including approximately 317,000 immigrant children1. Of these immigrants, approximately 1.7 million are naturalized US citizens, nearly 1 million are eligible to become naturalized US citizens, and nearly 2 million are undocumented immigrants1,2. The number of US-born children in Texas who live with an undocumented family member is reported to be approximately 1 million, with approximately 500,000 children with an undocumented parent1,3. Obtaining permanent residency status is a lengthy process and a source of anxiety for many immigrants. Recent changes to the US Department of Homeland Security (DHS) rules regarding which public benefits count negatively towards obtaining permanent residency may impact these families and children. Pediatric healthcare providers should be prepared to help immigrant families understand how the use of public benefits could impact changing their immigration status.

(more…)

Why is Healthcare Expensive?

The United States has the most expensive health care system in the world [1]. This has led to extensive discussions and debates on how best to finance it and what kind of insurance system will be preferred to ensure access to everyone. While healthcare financing is an important aspect of this discussion, the root cause of why healthcare is expensive and whether we should address this root cause are usually not at the forefront of national or public discussion. While insurance billing and administration costs are a large contributing factor, pediatricians should educate themselves on other root causes of why healthcare is expensive and advocate for broader discussions about the  salaries of healthcare professionals and the cost of pharmaceuticals and medical devices. 

The reason why healthcare is expensive is complicated, but it mainly comes down to the fixed cost that is charged for each service provided. When it comes to basic human needs such as food and clothing, people usually have a wide range of options in terms of what they can pay for a given item. Expensive food types and  famous brands of clothing are not a necessity for everyone, and there are options for cheaper alternatives. With healthcare, there are no options. Hospitals, clinics, pharmaceutical and medical device companies set the prices for the service and the therapeutics provided, which are mostly standard across the board. The only thing that comes close to a cheaper alternative in medicine is the availability of generic drugs. While the prices for generic drugs decline, the average price for  brand-name prescription drugs increased 164% between 2008 and 2016 [2]. 

Salaries are another component of the expense of U.S. healthcare. On average, European physicians get paid much less than physicians in the United States: in Germany they make about one-third less [3]. The salary of healthcare professionals is one of the least discussed contributors to the healthcare cost in the United States. While most physicians, including pediatricians, are strong advocates for increased access to healthcare, most of their focus has been on changing healthcare financing [4]. Salaries of physicians, particularly for some specialties and for those in private practice, play a significant role in increasing the healthcare cost. The high student loan debt for medical education  fuels the need for medical graduates to factor in the salary when choosing their future career. While salary is not the only factor, generally the lesser paying specialties attract less interest from medical graduates while the higher paying specialties are the most competitive. Because asking physicians not to worry about their salaries in the face of the large amount of student loans they carry would be unreasonable, addressing the cost of medical education could be one step to begin tackling one of the root causes of the increasing healthcare costs. 

Rising prices for pharmaceuticals and medical devices is another complicated aspect of healthcare cost. While research and advances in new technologies continue to lead to novel diagnostic and treatment methods, they have  come with significantly higher cost [3]. The prices of these new therapeutics and devices are solely set by the industry. Patients usually have no alternative options, particularly when it comes to the most advanced treatments that are protected with patents with no generic alternatives. While many of the governments in Europe have mechanisms in place to negotiate drug prices with pharmaceutical companies, there is no such current practice in the U.S.[3]. Moreover, diagnostic tools such as CT scans or MRIs do not have generic forms that patients can choose from. Unless we find a way to reduce the continued escalation in price that comes with advances in technology,  healthcare costs will not stop increasing. 

Pediatricians should  lead discussions about ways to address the root causes of increasing healthcare cost. We are  caring for children who deserve options to access the best diagnostics and treatments available. Advocating for public health insurance such as Medicaid and CHIP  is necessary, but the sustainability and further expansion of such or new programs will require reducing the direct cost of healthcare. Pediatricians should engage in broader discussions on these topics to generate sustainable solutions at the local and national level. 

Tewodros (Teddy) Mamo, M.D.,Ph.D.

References:

[1]: Landrigan CP, “Cutting Children’s Health Care Costs.” Pediatrics. 2018 Aug;142(2). https://pediatrics.aappublications.org/content/142/2/e20181549#ref-1 

[2]: Galea S., “The Cost of Pharmaceuticals, the Role of Public Health”, Dean’s note, ethics & human rights, health law, pharmaceuticals, Jun, 2016.  http://www.bu.edu/sph/2016/06/05/the-cost-of-pharmaceuticals-the-role-of-public-health/ 

[3]: DPE Fact Sheet, “The U.S. Health Care System: An International Perspective” 2016. https://dpeaflcio.org/programs-publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/ 

[4]: “Understanding the Economics of the Healthcare Environment – Financing and Utilization”, AAP article on Practice Transformation, accessed on 8/18/2019.https://www.aap.org/en-us/professional-resources/practice-transformation/economics/Pages/Financing-and-Utilization.aspx

Children’s Social Media Consumption and Eating Behavior

With the advancements in technology and the introduction of high-speed internet, our societies have been facing a whole new set of issues and concerns especially when it comes to the role and impact of social media on the development and health of our children.  Pediatricians should educate parents about the influence of social media on their children’s eating habits and share resources to counteract the effects of unhealthy foods digital marketing.

A decade ago I never thought I would have to include restricted social media use and modified Facebook or YouTube home content as part of my diet plan. Nowadays, our exposure to social media influencers significantly impacts our subconscious decisions even when it comes to snack choices. This is also true for our young children and adolescents.

Is it true that our children are following social media influencers when it comes to food consumption.? And is social media contributing to the obesity epidemic?

A randomized trial study published in Pediatrics by Anna E. Coates et al. included 176 children between 9 and 11 years old.  The children were assigned to view mock Instagram profiles of two popular YouTube vloggers and influencers promoting healthy or unhealthy snacks or nonfood products.  The results of this study indicated that children who viewed unhealthy snacks content had a statistically significant increase in food intake compared to those who viewed the influencers promoting healthy snacks. Thus, the study concluded that marketing of unhealthy foods through social media influencers increased children’s food intake of 26% more kilocalories compared to children who viewed healthy food behavior.

With childhood obesity remaining a major health epidemic, it is crucial for pediatricians to recognize the impact of digital marketing on the health and eating behavior of children exposed to thousands and thousands of social media influencers on a daily basis. Methods for restricting social media food marketing content should be implemented to protect the health of the new generation of children and adolescents.

Parents can be advised to have a family media use framework to control the content of social media that their children view. Parents should start the conversation early about social media influence with their children, explaining the risks of the promoted unhealthy foods on their children’s health.

Sonia Allouch, MD

References:

  • AAP COUNCIL ON COMMUNICATIONS AND MEDIA.  Media and Young Minds. Pediatrics. 2016;138(5):e20162591

https://pediatrics.aappublications.org/content/138/5/e20162591

  • Coates AE, Hardman CA, Halford JCG, et al. Social Media Influencer Marketing and Children’s Food Intake: A Randomized Trial. Pediatrics. 2019;143(4):e20182554

https://pediatrics.aappublications.org/content/pediatrics/143/4/e20182554.full.pdf

  • Coyne S, Radesky J, Collier KM, Gentile DA, Ruh Linder J, Nathanson AI, Rasmussen EE, Reich SM, Rogers J.  Parenting and Digital Media. Pediatrics 2017;140;S112

https://pediatrics.aappublications.org/content/140/Supplement_2/S112

  • Robinson TN, Banda JA, Hale L, Shirong Lu A, Fleming-Milici F, Calvert SL, Wartella E.

Screen Media Exposure and Obesity in Children and Adolescents. Pediatrics 2017;140;S97

https://pediatrics.aappublications.org/content/140/Supplement_2/S97

Be Kind to the Brain

“I could not leave the team behind. I needed to get back in. They told me I had to keep going and move.” These harrowing words send chills down my spine. Why all the upset? These statements represent the sentiment often carried by those who subsequently suffer from a concussion. During one of my hospital shifts, I met a young man who arrived in agony from a severe headache. He was hit in the head several times throughout the week during football practice. He was hit not 2, not 3, but 4 times before he sought help. Each impact led to worsening headache, blurry vision, and dizziness, but it was ignored.

Concussion is a group of symptoms representing a type of traumatic brain injury that results in chemical damage to the brain. Brain damage can result from a direct blow to the head or an indirect hit to the body that results in the head and brain shaking. This type of damage is frequent in children who participate in sports, especially football and soccer [1]. It, however, can occur several other ways. The CDC estimates that as many as 3.8 million suffer from a concussion annually, with females suffering more frequently.

It is imperative that parents, coaches, teachers and medical professionals recognize the signs. These can include: headache, vomiting, light sensitivity, sound sensitivity, slurred speech, emotional changes, memory issues, and problems with sleep. Loss of consciousness may or may not occur. There are several scoring systems that can help aid in a child or adolescent that you suspect experienced a concussion [2]. When in doubt, set them out! The CDC offers wonderful information and training online to become familiar with the condition [2].

As the pediatrician or concussion specialist, you can work to structure a schedule that will allow the patient to get better. This will involve a graduated program that increases their activity level as the individual improves [3]. The school should provide the student with the necessary accommodations to ensure full recovery. Rest is a crucial component of this process. Without it, the child or young adult may risk developing long term memory problems, behavior issues, and significant depression [4]. Most patients recover after two weeks but some take months to regain their baseline health. You are encouraged to follow the child or adolescent and perform the necessary exams to assess progress.

My patient spent several days in pain, unable to move from his hospital bed. He explained with great detail that he was not his normal self. He felt angrier, sadder, and unable to cope with daily activities. I have seen worse outcomes; thus, I end with a message to pass to all those who seek your care. It is okay to step out of a game when you are hurt. It takes courage to tell someone you need help. We are proud that you recognize it. You are a rock star and the game is not worth gambling your life. Also, missing one game, does not mean missing an entire season. Allow the brain the time to heal; it will love you for it!

References

1. Meehan III, W. P., & O’ Brien, M. J. (2018, November 14). Concussion in children and adolescents: Clinical manifestations and diagnosis. Retrieved from UptoDate: https://www.uptodate.com/contents/concussion-in-children-and-adolescents-clinical-manifestations-and-diagnosis?source=history_widget

2. US Department of Health and Human Services. (2017, June 22). Heads Up. Retrieved from The Centers for Disease Control and Prevention: https://www.cdc.gov/headsup/index.html

3. Centers for Disease Control and Prevention. (n.d.). Cole’s Story: Coach Saves a Wrestler’s Life by Knowing Concussion Signs and Symptoms. Retrieved from https://www.cdc.gov/headsup/pdfs/stories/coles_story_one_pager-a.pdf

4. Forgrave, R. (2017, January 10). The Concussion Diaries: One High School Football Player’s Secret Struggle with CTE. Retrieved from GQ Magazine: https://www.gq.com/story/the-concussion-diaries-high-school-football-cte

Abdelrahim Abdel, MD