Daily Advocacy, A practical guide to advocating for our patients on the wards.

When I think of advocacy, I usually think of a specific cause or interest group working towards a common goal. Usually this type of work occurs outside of the wards. Yet, as a resident, a majority of my life is spent in the hospital. For me, this sparked an important question; what can I be doing on a daily basis to advocate for my patients?

In researching the topic of daily in-hospital advocacy, there was an abundance of articles highlighting what we are doing wrong. Few provided concrete advice on how to change the problems they had discovered. Oddly enough, it wasn’t a peer reviewed article that provided pearls on daily advocacy, but a job search forum, indeed.com (see citation below).

While I had hoped to use a few academic articles to write this post, the sage wisdom indeed.com’s list provided was far too good. Thus for the remainder of this post, I will highlight 3 of the 10 ways to advocate for your patients on a daily basis highlighted in the article.

Communication (specifically language)

It may seem obvious that good communication is the foundation of any relationship. The biblical city of Babel simply crumbled when each member was cursed to speak a different language from the next. So how do we ensure we are effective communicators? Well, I think language is a great starting point.

Its early, you have 12 patients to see, 30 orders, labs to be drawn, and all this must be done before rounds. Your last patient is Spanish-speaking, but the uncle who has been staying there speaks conversational English. You now have a decision to make: you can  discuss the plan with the uncle and hope he relays the message correctly, or you can call an interpreter  which would add 15 minutes to your morning. In a rush you opt for the former. Little did you know that the uncle did not hear you correctly and told your patient that they are being discharged today. When you return for rounds to discuss the plan of keeping him till the end of the week, the patient becomes visible confused and upset. He was told this morning he would be going home, but now he is going to have to stay the whole week. Like that, the trust the patient had for you and the team is ruined.

This is a small example of a very common and potentially dangerous issue. The best practice is to speak in the patient’s native language.  If that isn’t possible for you, don’t allow a family member to translate for you. You can be a great advocate for your patients by communicating in their own language with a certified interpreter.  It may take extra time, this helps ensure that your patients understand their care, diagnosis, and prognosis well enough to be an active participant in their own health.

Providing the highest quality of care

This one will be short, but it was a nice reminder. The fact that we take the time to look up what we don’t know, keep up- to- date on practice changes, re-assess patient daily or hourly,  are great examples of advocacy. These shouldn’t be  taken lightly. For some patients, we are their first interaction with the healthcare system. For others, we could be the first doctor who worked hard to gain their trust. Either way, we are advocates when we give it our A-game, and we should remember that on the tough days.

Communicate the plan

Listen, family centered rounds are not my jam, but what I do enjoy are the moments where I can sit down with a family and discuss medical management. I mean human interaction is the driving force behind why many of us choose medicine. But how does communicating the medical management equate to patient advocacy?

When you inform them about the treatment, they are empowered. You may be the first person to explain asthma or a genetic mutation to them. When they are empowered, they are more likely to speak up for what they need.

For example, I recently learned that getting a nail in the tread of your tire is very different from the outside of the tire. If it is in the tread, the tire can be patched, but if it is on the outer aspect of the tire, then it must be replaced. Prior to this, I assumed that any nail would mean a new tire. I was a sitting duck, and any repair shop could have taken advantage of me and charged me for a new tire. As an informed consumer I am able to go to the  shop knowing the tire only needs a patch.

Now think about an asthmatic. If all they had ever been told was that wheezing=albuterol then that’s all they will would do. But if you decided to advocate for them and explain the new asthma guidelines, along with a continued need for their rescue inhaler at the current rate, they will need a daily controller. Fast forward three months, and that same patient is now in their PCP’s office getting set up for a controller medication to be initiated. This was an appointment that would never have been made if you had not taking the time to educate that patient on their disease process.  Without that patient education, they could have  continued to use albuterol not knowing about another option to create better control with a daily medication.

To me, these interactions that define in-patient advocacy.  And I hope they show you that you can be an advocate every day for your patients.

Zachary W. Blair, M.D.





Climate Change and Health Concerns Regarding Allergies and Asthma

Climate change has been a hot topic lately – it’s a fact that the earth’s temperature is rising, the ice caps are melting, and weather has become more extreme.1 We don’t immediately associate this topic with health and disease. However, global climate change has multiple effects on human health with vulnerable populations such as children disproportionately affected. It is imperative to understand the effect of climate change in relation to health needs of our children and learn how we as pediatricians can help.

Two health conditions that are directly affected by climate change are allergies and asthma. In the United States, 40% of children have nasal allergies and 9% of children have asthma. Climate change has already led to earlier springs and later winters, prolonging pollen season. A study of 60 pollen collecting stations in the U.S. and Canada found that pollen season is now 20 days longer than it was in 1990. Additionally, pollen counts have also increased over the last 20 years, leading to a more intense pollen season. Scientists predict that average pollen counts in 2040 will be double what they were in 2000.2

Increased temperatures with climate change can also aggravate pre-existing respiratory conditions, such as asthma. Children under age 15 with asthma are responsible for 2 million emergency department visits each year. Asthma is also the third leading cause of hospitalization in this population. Increased temperatures cause increase in certain ozone levels, which can cause airway inflammation and damage lung tissue further. Scientists have noted that spikes in these certain ozone levels correspond with increases in ER visits and hospitalizations for those with asthma.

Climate change can also cause an increase in number of extreme weather events.3 Mold growth is related to increased storms, flooding, and humidity and will develop in an indoor area if wet for more than 24-48 hours. Mold is known to decrease air quality in home and school environments and can cause respiratory irritation. It is a common trigger for asthma and allergies.

How can pediatricians protect patients from worsening asthma and allergy symptoms? A great first step is teaching families to reduce exposure. Using online tools like the website pollen.com, pediatricians can show families how to check pollen levels near their home. When pollen levels are high, counsel families to limit outside exposure as much as possible. Another important step is to learn about your patient’s personal asthma triggers and recommend minimizing contact, as avoiding triggers is the best way to prevent asthma episodes. For example, if dust mites are a trigger, recommending measures such as airtight covers around pillows to limit exposure. Finally, help the family create an action plan with each high-risk patient. Prior to allergy and asthma season is the best time, so patients have therapies and resources needed when symptoms begin.

Although climate change can feel overwhelming, talking with families during clinic visits and making small changes can help create long term solutions for our future generations and for this planet.4 We can also take action outside of our clinical settings to reduce the impact of climate change:

  • Plant trees in the community: Adding trees to a community can help improve air quality, especially in urban areas. As an added benefit, they also improve mental health. Certain trees can worsen the spread of pollen, so use this guide from the Academy of Allergy, Asthma, and Immunology to learn which plants are best for people affected by allergies.
  • Reduce energy consumption and waste: Turn the lights off when leaving a room. Use public transportation when it’s a safe option. Donate non-perishable food items to limit the waste in our landfills. Recycle.
  • Invest in efficient and renewable energy: Having homes with solar panels is energy saving and reduces our carbon footprint. We can also reach out to local leaders to support regulations that require new buildings to utilize renewable energy and support energy-saving policies.

Physicians can make a big difference to their patients’ health by addressing issues related to respiratory health. Helping families create an action plan can help reduce the severity of seasonal allergies as well as reduce potentially harmful asthma exacerbations.

Smridhi (Simi) Mahajan, MD


  1. “Climate Change Evidence: How Do We Know?”. Climate Change: Vital Signs Of The Planet, 2021, https://climate.nasa.gov/evidence/.
  2. “Climate Change And Allergies”. C-CHANGE | Harvard T.H. Chan School Of Public Health, 2021, https://www.hsph.harvard.edu/c-change/subtopics/climate-change-and-allergies/.
  3. “Climate Change Indicators: Weather And Climate”. EPA, 2021, https://www.epa.gov/climate-indicators/weather-climate#:~:text=Scientific%20studies%20indicate%20that%20extreme,storms%2C%20floods%2C%20and%20droughts.
  4. “Talking With Children About Climate Change”. Healthychildren.Org, 2021, https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Talking-with-Children-about-Climate-Change.aspx.

Mental Health During the COVID-19 Pandemic

As we come up on a year after initial school closures and nationwide lockdowns due to the COVID-19 pandemic, we can reflect on the psychological and social effects these changes have had on children and adolescents. It has become evident to the pediatricians working in clinics, emergency rooms, and hospitals that our youth have experienced a mental health crisis. We must remain vigilant of the evolving health needs of our patients and adapt our practices to best serve those in our care.

The symptoms of this crisis can vary by age and developmental group. In one review, researchers found that children ages 3-6 are more likely to experience increased clinginess and fear of family members being infected with SARS-CoV-2, the coronavirus that causes COVID-19 disease (Singh 2020). However, children ages 6-10 are more likely to experience inattentiveness (Singh 2020). Certain themes have also been seen across all age groups: increase in disturbed sleep and nightmares, poor appetite, agitation, and separation-related anxiety (Singh 2020). Females of any age specifically saw a three-fold increase in rates of depression during the COVID-19 pandemic (Hawes 2021). Nearly half of female participants experienced elevated generalized anxiety during the pandemic (Hawes 2021). Various studies have found that certain factors predispose a child to have increased mental health challenges regardless of gender (Li 2020). These factors include having the infection, home confinement, concern of their basic needs being met, and prior mental health or behavioral challenges (Li 2020).

What can be done to help our children and adolescents come out of this pandemic as healthy, resilient individuals? A study looking at anxiety and depression prevalence in adolescents found that face-to-face communication and engaging in enjoyable hobbies such as exercise correlated with lower rates of anxiety and depression (Li 2020). Encouraging children to find an activity that brings them joy and partaking in that activity daily or a few times a week can be protective against developing worsening anxiety or depressive symptoms. Examples of activities that my patients have reported to me are learning to play guitar via YouTube videos, regular exercise such as outdoor running or lifting weights in a home gym, and baking.

Another study found that children having discussions with a parent or trusted adult about COVID-19 led to less mental health challenges in children and adolescents (Tang 2021). Parents and trusted adults can have a significant impact on how children and adolescents perceive and adapt to challenging situations. Adults should tailor these conversations to the age and developmental stage of the child to avoid overwhelming them with information that may be difficult to understand or rationalize. The conversations should be open, fact-driven, and conducted in a calm manner.

For teenagers specifically, social media and video games can be both protective and place them at an increased risk for anxiety and depression (Hawes 2021). These online activities allow them to maintain a sense of social connectedness where they otherwise may feel isolated from their peers. It allows for continued formation and exploration of friendships and relationships. However, in excess, social media can foster a negative environment of comparison and a “fear of missing out”. Teenagers may not know how to evaluate information and news that they encounter.

Creating a family media plan with time limits and age-appropriate supervision that all members of the family adhere to is a recommended solution (Hawes 2021). A family media plan should be tailored to each individual family’s situations and include specific time limits on TV, computer and video games, as well as social media sites. These types of plans allow teenagers the freedom to socialize while mitigating the negative effects of too much screen time and social media. To learn more about family media plans, you can follow this link to a separate post:  https://pedsadvocacy.com/2020/11/17/creating-a-family-media-plan/

Finally, keeping a structured routine can be beneficial in protecting against negative mental health consequences from the disruption of the pandemic (Hawes 2021). This is especially important for young children and children who have ADHD or other developmental and learning disabilities. When increased uncertainty exists, younger children can feel that stress even if they do not fully comprehend what is causing it. By maintaining a routine – wake up time, meal times, learning time, play time, bedtime – they are given a sense of stability and safety. Specifically, a structured bedtime routine can mitigate some of the negative effects stress can have on sleep, such as difficulty falling asleep.

As our world begins to move forward and eventually past this pandemic, it is important to continue to have these discussions about mental health with each other and our loved ones. Discussions about our emotions, what we are seeing on the news, and what steps we can take to keep ourselves and our families safe can help stabilize our lives. Furthermore, being available to listen to those are struggling with anxiety, depression, or another mental health concern can help keep our loved ones safe. If a child or teen does come forward with mental health concerns, share resources with their parent and caregivers, such as those listed below.

Hopefully, by implementing these various strategies, we can provide the support our children need to adapt and continue to grow into healthy, resilient adults.


  • HelpWhenYouNeedIt.Org over 350,000 listings for social services, mental health, substance use, legal and financial assistance.
  • Psychology Today offers a national directory of therapists, psychiatrists, therapy groups and treatment facility options
  • The Suicide Prevention Lifeline connects callers to trained crisis counselors (800-273-8255)
  • Mental Health Crisis Line for Dallas County: North Texas Behavioral Health Authority (866) 260-800
  • Crisis Text Line: Text 741741, free service available 24/7


  1. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic [published online ahead of print, 2021 Jan 13]. Psychol Med. 2021;1-9. doi:10.1017/S0033291720005358
  2. Li W, Zhang Y, Wang J, et al. Association of Home Quarantine and Mental Health Among Teenagers in Wuhan, China, During the COVID-19 Pandemic. JAMA Pediatr. 2021;175(3):313–316. doi:10.1001/jamapediatrics.2020.5499
  3. Tang S, Xiang M, Cheung T, Xiang YT. Mental health and its correlates among children and adolescents during COVID-19 school closure: The importance of parent-child discussion. J Affect Disord. 2021;279:353-360. doi:10.1016/j.jad.2020.10.016
  4. Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Res. 2020;293:113429. doi:10.1016/j.psychres.2020.113429

Erin Finnerty, MD

Breaking Down Language Barriers in Healthcare

Working as a pediatric resident in Texas has given me the unique opportunity of serving a diverse patient population. For example, my continuity clinic has a substantial number of patients who only speak Spanish. Unfortunately, I do not speak Spanish, which is not ideal for my patients. As a doctor, I strive to provide the best medical care. So I’ve really reflected upon my experiences with my Spanish speaking population, and how to best navigate the language barrier. Since it’s not feasible to make all practicing physicians learn additional languages, I highly advocate for the next best thing, hiring in-person interpreter services.

Numerous studies have shown that language barriers negatively impact healthcare. A study in New York analyzed an urban, underserved Hispanic population.1 One group could speak English, while the other group could only speak Spanish. The study concluded that English speakers reported a higher satisfaction rate with their healthcare experiences; they were more likely to have medication side effects explained to them, which impacted their compliance. Another study analyzed racial and ethnic differences in access to healthcare.2 The study concluded that the marked disadvantage in Hispanic children’s access to care may be related to a language issue. Primary care is especially important for children because they require a plethora of immunizations and need to be monitored for developmental milestones.

At my clinic, I’ve been in experiences where the phone interpreter service unintentionally worsened the communication issues. The sub-optimal audio quality was exacerbated by the masks that we were wearing due to the COVID-19 pandemic. Sometimes when the interpreter said something, my patients would point at the phone and shake their heads, implying that the interpreter was not interpreting correctly. Other times, even with my limited Spanish knowledge, I realized that the interpreter was miscommunicating information to my patients. When my clinic hired someone to work onsite as our interpreter, the clinic ran so much smoother. The patients felt much more at ease with an in-person interpreter, and I could see them letting their guard down.

A study published by the American Journal of Public Health revealed that providing interpreter services is a financially viable way of enhancing healthcare delivery to people with limited English proficiency.3 The study showed that patients who utilized the interpreter services had significant increases in physician visits and prescription drugs, which suggests that the moderate cost of interpreter services led to the huge benefit of enhancing access to primary and preventive care. People are more inclined to seek healthcare when they understand their health condition, what treatment they need, medication side-effects, and the importance of medication compliance despite the side effects. As physicians, it’s important to break down barriers to healthcare access, and hiring in-person interpreters is one way to do so.

Brina Bui, MD


1. David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. The Mount Sinai Journal of Medicine, New York. 1998 Oct-Nov;65(5-6):393-397.

2. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care. Am J Public Health. 2000;90(11):1771-1774.

3. Jacobs EA, Shepard DS, Suaya JA, et al. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health. 2004;94, 866_869.

“SNAP Chat”: A brief commentary based on my personal experience with the Supplemental Nutrition Assistance Program


For about 5 years, from 2015-2020 while I was completing medical and graduate school in San Antonio, my family which consisted of myself, my wife, and our growing family (first one, then two, then three daughters) received SNAP benefits. While I do not claim to be an expert on the subject, I believe my experience gave me a unique perspective on aspects of SNAP that I had not previously considered thoroughly. After first briefly providing a generalized overview of the program, I hope to touch on a few perceived lingering limitations: 1) barriers to household participation, 2) barriers to ensuring proper nutrition, and 3) barriers to self-sufficiency. These limitations should be considered by pediatricians as they encounter patients and families who have food insecurity, so advice and resources can be helpful to and suitable for the families. 


Guiding patients who look up medical questions online

As pediatricians, we can guide patients and their families to learn how to look up medical questions online properly. Why is it important for people to learn how to do this? There are multiple reasons:

1. We are likely to instantly get a practically infinite number of answers to any question we pose to a search engine. It is not the quantity of answers that is lacking but often the quality. The ‘signal-to-noise’ ratio decreases as we get greater and faster access to more detailed information about the world (1).

2. Our minds are not adapted to handling such large amounts of data especially when we are emotionally invested. Our brains are apt to make quick, safe, somewhat-right judgements based on limited information (2), e.g., deciding if there is a lion in the nearby rustling bushes at night.

3. Few people get advice on how to find and interpret relevant information online. Although, most of it is common sense, patients and families may be emotional and vulnerable to misinformation. Facts obvious to clinicians may not be so to non-medical people and may go undiscussed.

4. The solution is not to ask people to refrain from ‘googling’. Virtually everyone will look up something online: a weird symptom, an unfamiliar disease given as the diagnosis to a close relative, or the side effects of a medication.

5. The internet will always be a source of both true and false information. Our knowledge is fallible, and science needs alternative points of view to move forward (3).

6. In medical ethics we accept that the principle of autonomy supersedes beneficence. This means that we believe that to truly help patients and families is to empower them to be able to make sound medical decisions, not to make the decisions for them.

Recommendations for discussing potential sources of confusion:

  • The problem of anecdotal “evidence”: e.g., “So-and-so tried this alternative treatment for her disease, and it worked for her so it might work for me”. An example can illustrate the difference between anecdotal and scientific evidence to patients. In a randomized controlled trial, a large group of patients is given the novel treatment A and a control group that is similar is given placebo or the standard treatment B. Then, data is collected from both groups and analysed using statistics to find a significant difference. Only then, we can say treatment A works or does not work. This should demonstrate why it is so difficult to draw any conclusions from anecdotes. Even if we assume the anecdote of someone’s success with an alternative treatment was not falsified, many factors could distinguish them from another patient, none of which can be controlled for. Even if all other factors were the same, any positive or negative effect seen from the alternative treatment will likely be due to random chance.
  • About social media posts: Remind patients and families that people do not have any obligation to tell the truth on social media, may have different motivations than expected, or may be unwittingly misleading by leaving out pertinent facts. Even if the social media post is citing seemingly scientific studies, try to verify that a) the studies are real, b) the studies are coming from a peer-reviewed scientific journal, and c) the post is not misrepresenting the study or misinterpreting its conclusions.
  • Why searching a disease could be better than a symptom:  usually a constellation of symptoms and physical exam findings make clinicians suspect one disease or another. A symptom by itself can be remarkably non-specific and lead to excessive worry or delay in seeking help. It’s probably a good idea to suggest sticking to reputable medical websites of institutions such as the American Cancer Society or the CDC for basic information.
  • The distinction between scientific articles published on medical journals and news articles or articles on science blogs: a) Scientific articles are peer-reviewed, b) data is gathered, analyzed, and interpreted by a professional who knows the context of previous studies and standards of practice, and c) any potential conflict of interest must be declared eliminating a potential source of bias. None of these can be guaranteed for non-scientific articles.
  • Documentaries, or videos online as a source: Even if they seem to have a high production cost, these usually conflate anecdotal evidence with real scientific evidence, embellish facts for dramatic effect, and do not have to meet any scientific standards.

Today’s families are surrounded by differing sources of knowledge. Thus, part of the doctor-patient relationship should more than ever be helping families sift through the information and make the right decisions for themselves and their children.

Can Ozlu, MD


  1. Taleb NN. Fooled by Randomness. New York: Random House; 2016.
  2. Kahneman D. Thinking, Fast and Slow. Penguin Books; 2012.
  3. Popper KR. The Open Society and Its Enemies. Princeton, NJ: Princeton University Press; 2011.

Creating a Family Media Plan

In these times of social distancing, I have found myself spending an increased amount of time on media. This includes social media, news websites, streaming platforms, online shopping; I am guilty of all of them. From my conversations with others and in further research, I have learned I am not alone in this. Many of my family, friends, and patients all endorse a similar increase. Between March and June of 2020, Lurie Children’s in Chicago polled 2,909 American parents of teenagers, and 63% reported their teenager was using social media more. Technology and media do have benefits and have especially helped in these times by allowing us to stay connected with loved ones, continue education, and even buy groceries from home. But they can also have negative consequences when not used in a responsible manner. I encourage all pediatricians to address media use with their patients and families. One way this can be done is by introducing the idea of a family media plan.  

In today’s era of COVID-19, virtual media is one of the easiest ways to stay connected with others. However, just because it is convenient does not mean it is benign. Facebook is still the most widely used social media website. A study from France used experience-sampling to see that rather than enhancing well-being, use of Facebook had the opposite result. The study indicated that Facebook use leads to decline in the two areas defined as cognitive and subjective well-being.  Cognitive wellbeing was how satisfied people are with their lives, and subjective well-being was how people feel moment to moment. In contrast to the use of Facebook, direct social interaction showed no change in cognitive well-being and an increase in subjective well-being.  

What about the effects of other types of media? For example, children watching television? Research shows higher media use in young children is associated with higher BMI, decreased sleep, and cognitive, language, and social/emotional delays. As far as delays, most of these are thought to be due to a decrease in a child’s interactions with their parent/caregiver. Watching television should not take the place of a child interacting with real people in their real environment, replace exercise, or decrease the amount of sleep a child gets.  

What does responsible media use look like in my own life, and how can I counsel my patients and their families? Not all use of media is bad, but it should be used judiciously. In looking for the answer to this question, I found the website www.healthychildren.org, which has information dedicated to creating a family media plan. It allows a family to create a comprehensive plan, which can be individualized for every member. It addresses screen free zones and times, device curfews, media manners and safety, healthy sleep and exercise, and more. You can find the information at https://www.healthychildren.org/English/media/Pages/default.aspx  

As a reference when creating your family media plan, the American Academy of Pediatrics recommends: 

  • For children younger than 18 months, avoid use of screen media other than video-chatting. Parents of children 18 to 24 months of age who want to introduce digital media should choose high-quality programming, and watch it with their children to help them understand what they’re seeing. 
  • For children ages 2 to 5 years, limit screen use to 1 hour per day of high-quality programs. Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them. 
  • For children ages 6 and older, place consistent limits on the time spent using media, and the types of media, and make sure media does not take the place of adequate sleep, physical activity and other behaviors essential to health. 
  • Designate media-free times together, such as dinner or driving, as well as media-free locations at home, such as bedrooms. 
  • Have ongoing communication about online citizenship and safety, including treating others with respect online and offline. 

While geared towards children and adolescents, I plan to make a media use plan for myself – and I encourage other adults to do so as well! 

Jenny Riepma, MD 


Cespedes EM, Gillman MW, Kleinman K, Rifas-Shiman SL, Redline S, Taveras EM. Television viewing, bedroom television, and sleep duration from infancy to mid-childhood. Pediatrics. 2014;133(5). Available at: www.pediatrics.org/cgi/content/full/133/5/e1163pmid:24733878 

Chiong C, Shuler C; The Joan Ganz Cooney Center at Sesame Workshop. Learning: Is there an app for that? Investigations of young children’s usage of learning with mobile devices and apps. Available at: http://dmlcentral.net/wp-content/uploads/files/learningapps_final_110410.pdf 

Cox R, Skouteris H, Rutherford L, Fuller-Tyszkiewicz M, Dell’ Aquila D, Hardy LL. Television viewing, television content, food intake, physical activity and body mass index: a cross-sectional study of preschool children aged 2-6 years. Health Promot J Austr. 2012;23(1):58–62pmid:22730942 



Kross E, Verduyn P, Demiralp E, et al. Facebook use predicts declines in subjective well-being in young adults. PLoS One. 2013;8(8):e69841pmid:23967061 

Children’s Hospitals Need More COVID-19 Emergency Relief Funding

Since the start of the COVID-19 pandemic, the financial losses of businesses and employees in the service, retail, and entertainment industries have been the subject of a large amount of media attention. What many Americans would not expect is that health systems are also under major financial strain during this difficult time.  Pediatricians can act now by writing their U.S. Representative or Senator to express the need for additional emergency funding for children’s health systems.


Two to Tango: Shared Decision Making

Often patients or their parents can place an expectation on our shoulders to always have a plan and answers as their physician. The shaking truth of the medical field is that this is not always possible. While the expectation is seen as a privilege by most physicians, it can also lead to significant stress and pressure. When asked specific questions that are either unanswerable or unknown at that time, a physician may find it difficult. Shared decision making is fundamental for patient care as an effective tool for a physician to use when addressing such situations with patients and their parents.

The idea of shared decision making is more recent in the field, compared to the centuries of the practice of medicine (Veatch). It is a hallmark in patient-centered care because it relies heavily on patient and/or parental input into treatment decisions. Glyn Ewlyn, et al. described a practical way to implement shared decision making using:

  • Choices: making sure that patients/parents know different, reasonable options are available to them,
  • Options: providing detailed information about all options, and
  • Decision talk: supporting and allowing for time for the patients/parents to deliberate over the available options.

While shared decision making is an important part of patient care, its use can be limited in some situations, such as in emergencies that require immediate action or conditions that require extensive use of medical knowledge to make a decision. Other limitations to shared decision making include inadequate health literacy and cultural differences in autonomy (Glyn Ewlyn et al). Even in these situations, using shared decision making as much as possible at the patient/parent’s level of understanding can help. It can be employed as a tool to help move forward in difficult situations, or even to create an open dialogue and invite parents to share their input. 

Even in pediatrics, we can involve our patients in shared decision making to empower them to actively participate in their own health. One small example includes asking them the form of medication they like (e.g.pill, liquid, or chewable) (Furman). Although we are not asking them what treatment plan they want, offering even a small choice can help empower them in their own healthcare. 

While shared decision making can be used in a positive way to forge a bond between parents and pediatricians, a one-sided relationship, whether on the parent or physician side, can be detrimental to this balance. With the advent of the internet, parents have numerous different resources to use as they deliberate their options. This should be supported and encouraged within reasonable limits by pediatricians. The balance lies within the decision talk portion of shared decision making. Pediatricians should listen to parent’s wishes and informed decisions, and parents should work with the pediatricians and trust them to make decisions for their child’s well-being. With unbalanced power on either side, friction and erosion of patients’ care can occur.

Many questions still exist as to how to best integrate and implement shared decision making from both the parent’s and the pediatrician’s role in a child’s medical care. By implementing these three steps into each patient encounter, both with a patient and their parents, pediatricians can create an optimal balance in unknown or difficult situations. 

Chelsea Burroughs, M.D.


Elwyn, Glyn et al. “Shared decision making: a model for clinical practice.” Journal of general internal medicine vol. 27,10 (2012): 1361-7. doi:10.1007/s11606-012-2077-6

Furman, Lydia. “Shared Decision Making – Harnessing Trainee Enthusiasm.” American Academy of Pediatrics (2017). 

Veatch, Robert. “Models for Ethical Medicine in a Revolutionary Age.” The Hastings Center Report vol. 2, 3 (1972): pp 5-7. 

Barriers to successful HPV vaccination in US adolescents

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States with a peak prevalence in adolescents and young adults. It is a viral infection that can persist in the body and lead to a significant risk of developing various types of cancer later in life. HPV infection is preventable thanks to the advent of vaccination. The current 9-valent HPV vaccine is proven to be safe, effective and successfully prevents morbidity and mortality associated with HPV-related diseases. Pediatricians, in particular, play a key role as providers of vaccination but also need to become leaders in HPV-vaccination education for children, adolescents and their parents.
Current guidelines from the Centers for Disease Control and Prevention (CDC) US Advisory Committee on Immunization Practices (UCIP) and the American Academy of Pediatrics (AAP) recommend initiating the 9-valent vaccine with 2-dose schedule at ages 11-12 (although can be started as early as age 9) and 3-dose schedule for those starting at ages 13-26. [2]
However, the HPV vaccination rate in the U.S. is still very low, particularly among adolescents, with less than two-thirds of adolescents ages 13-17 receiving at least one dose of the HPV vaccine. In Texas, low vaccination rates are even more prevalent in rural areas and border towns with higher Hispanic/Latino populations. Thus, Hispanic women in areas such as the Rio Grande Valley are at significantly higher risks for cervical cancer incidence and mortality than Hispanic women generally in the U.S. [1-3]
Under current Texas health law, adolescents can obtain health information on safe sexual practices, self-request pregnancy tests, contraception and STI tests confidentially with medical providers. HPV vaccination, however, is under immunization/vaccine law and thus requires parental consent for a teen to be vaccinated. Studies have shown that there is misinformation in the community regarding HPV vaccination, and that leads to parents declining HPV vaccination for their children. That in in turn leads to lower vaccination rates. Some barriers to vaccination cited include concerns about vaccine’s effect on sexual behavior, low perceived risk of HPV infection, social influence, irregular preventive care and concern for out-of-pocket costs. Interestingly, parents also cited healthcare professionals’ recommendations as one of the most important factors in their decision to vaccinate. [1]
Misinformation appears to be the key driving force behind suboptimal vaccination rates. This is in line with studies that have shown that parent/adolescent education and vaccination availability are key to addressing the issue. As an example, a single onsite school-based active vaccination program coupled with physician-led education on HPV and HPV vaccines for parents/guardians, school nurses and pediatric/family providers in a rural community in south Texas led to almost double HPV initiation and completion rates. [1,3]
Parents can find it complicated to navigate around all the misinformation around vaccinations, especially in a climate of a generalized sense of distrust geared toward the medical/pharmacological enterprise. Pediatricians and family medicine providers should clearly inform patients and their parents about the distinct benefits and safety regarding HPV vaccination, and the drastic, positive impact the vaccine provides in preventing HPV-associated cancer.
Cost should be less of a barrier, because the Patient Protection and Affordable Care Act requires insurance companies to cover ACIP-recommended vaccines without copays, and federal programs provide vaccines to Medicaid eligible children without cost. Finally, pediatricians should also establish strategic partnerships with schools and local health providers to develop active education programs and on-site vaccination programs. These steps can improve successful HPV vaccination rates and reduce risks for HPV-associated cancers.
1. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to Human Papillomavirus Vaccination Among US Adolescents: A Systematic Review of the Literature. JAMA Pediatr. 2014 Jan; 168(1): 76–82.
2. Yang DY, Bracken K. Update on the new 9-valent vaccine for human papillomavirus prevention. Can Fam Physician. 2016 May; 62(5): 399–402.
3. Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019 Dec;8:100189.