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.

REFERENCES:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7024610/

https://www.indeed.com/career-advice/career-development/advocating-for-patients

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

Sources:

  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.

Human Rights Day, December 10: Access to Medical Care as a Human Right

I was shocked that I had never read the Universal Declaration of Human Rights (UDHR). Surely I must have learned about it at some point? As I scanned my memory back at world history, US history, and government classes, I couldn’t remember studying it in high school or during my years in university. Certainly it was mentioned at some point. But compared to my familiarity with the Declaration of Independence, the U.S. Constitution, and other historic U.S. documents, somehow the UDHR wasn’t on my radar. I believe that we as pediatricians can help change our culture by familiarizing ourselves with the UDHR and referencing it in our conversations with our family members, friends and those with whom we work.

When I discovered and read the UDHR recently, Article 25 in particular stood out to me. “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.” (emphasis added) 

If achieving these rights outlined in the UDHR, namely access to affordable and accessible medical care as a human right, were part of our culture in the United States, how would conversations about child health, public health insurance, and our culture of health in general, change? Where could our actions as a nation collectively, driven by our legislation and system, go with this sort of culture? More can and ought to be done to use this important declaration as a tool to foster a culture and, ultimately, a society that values equal access to healthcare and public health insurance, especially for the most vulnerable children our country. 

The UDHR was drafted by the United Nations Human Rights Commission in 1948 as an important part of an effort to promote peace and prevent further catastrophe that occurred during World War II. In the preamble of the UDHR, it states “Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,… Now, therefore, The General Assembly, Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations…” 

Following its preamble, the Declaration outlines thirty articles that outline what are deemed as universal human rights. In studying these rights, I realized that many of the articles align with concepts familiar to most Americans. To the casual American reader, statements such as “Everyone has the right to life, liberty, and the security of person”, “No one shall be subjected to torture or to cruel, inhuman or degrading treatment of punishment” sound familiar.  Rights such as “the right to freedom of thought, conscience and religion” or “the right to freedom of peaceful assembly and association” have their correlates in the U.S. Constitution. Other rights, such as “the right to marry and found a family” may not be canonized in writing, but are indeed part of our common values as Americans. In short, adopting the principles of the UDHR into our identity, culture and belief system does not require the sacrifice of existing values that we all hold dear. Rather, the UDHR adds to those beliefs some concrete and objective ways by which humans can live life to their fullest potential. Because the Declaration was new to me, I spent some time searching through the medical literature for references to this document. On the AAP website, the UDHR was referenced explicitly in only two articles within its database. On PubMed, searching for “Universal Declaration of Human Rights” yielded 229 results. Common topics of articles that cited the UDHR were articles regarding the rights of underserved, migrant or refugee populations, the rights of persons with speech and communication disorders, and, unsurprisingly, the overlap of  medical ethics and human rights. From this brief search, I concluded that while connections between human rights and access to medical care were being made, it has not been prominent within the culture of medicine or even medical humanities. It reaffirmed to me the need for pediatricians and physicians in general to champion the document and reference it more readily.

One article I found in my search, A Culture of Health and Human Rights, elaborated on the importance of human rights as a framework whereon a national culture of focus towards universal health and well-being could be built. Written in 2016 by two Boston University law professors, the article offers the following model:

 “Human rights offers a sustainable conceptual framework that supports the imperative of improving the social determinants; empowers the public to demand positive change; and offers common ground for initiatives, both public and private, that improve population health. Policies that protect and fulfill basic human rights are policies that address the social determinants of health, well-being, and equity. A culture of health can be most effectively deployed to improve population health when linked to a human rights agenda.” 

In tackling the current culture of health that exists in our country, authors Wendy Mariner and George Annas suggest:

“If a culture of health is intended to mean that Americans should prize health as a national social norm, it will be challenging to realize. In our pluralistic, multicultural country, attitudes about health and its causes vary, especially among different socioeconomic groups. While everyone might agree in principle that health, well-being, and equity are desirable, there is less consensus on where health ranks among life goals and values. Empirical observations of what people actually do—actual norms—suggest that there is no universally accepted—or practiced—culture of health in the United States. Many people might view health not as a primary good or an end in itself but as a means to attain other life goals, such as financial security, personal safety, respect in one’s community, and fulfilling relationships with family and friends. Those who are struggling to raise a family on minimum wages or in a violent neighborhood might be too preoccupied with survival to make health a high priority.”

Mariner and Annas go on to argue that given the plurality of opinions towards health, the best way to improve health culture in our country is to change policy. They astutely note that this endeavor will require decades-long efforts of focused coalitions with unified commitment towards human rights and improving the social determinants of health. 

If culture changes about children’s health can and should start with us as pediatricians, what can we do? More so than ever before, we can amplify our voice on online platforms. Arguably more effective and important are the day-to-day conversations we have with those in our immediate circles. If we individually internalize and embrace those rights that have been declared as universal, we can offer our voice from a place that is grounded in international support and consensus when divisive language about topics like healthcare and immigration arise, or during election seasons. 

Since 1950, December 10th has been dedicated as Human Rights Day and is recognized in many countries. We can use this day, and frankly any other day, to promote access to medical care as a basic human right. Nestled between Thanksgiving and the winter holidays, acknowledging Human Rights Day in our own personal way would lead to conversations about the UDHR.  That will give us opportunities to inform and discuss these principles and how they apply to the children in our communities.

Discussions, especially during the COVID-19 pandemic, have reflected a constant politicization of medical and healthcare issues which need not be political. By addressing the needs of children from a universal human rights framework, we can cast a wider, more inclusive net that catches the attention of those with whom we come in contact. Our efforts can slowly help others, including family, friends and neighbors, embrace health as a part of our culture, and more important, as a human right. As a generation of pediatricians more globally minded than perhaps any generation before, I hope we can help the world embrace the challenge of promoting a “standard of living adequate to the health and well-being” of all children.

David Oleson, MD

References:

Mariner WK, Annas GJ. A Culture Of Health And Human Rights. Health Aff (Millwood). 2016 Nov 1;35(11):1999-2004. doi: 10.1377/hlthaff.2016.0700. PMID: 27834239.

https://www.un.org/en/about-us/universal-declaration-of-human-rights

Promoting healthy smiles: Reviewing preventative guidance for pediatric oral health

With all the changes and challenges we have faced as a society in the past year with the current pandemic, pediatricians should not lose sight of their important role in promoting oral health in children. While it was easy for me to note how the changes in eating habits that came with quarantine affected my clinic patients in terms of weight, I often missed an opportunity to address its potential effect on the development of the most common chronic disease of childhood, dental caries. As many as 24% of children ages 2-4, 53% of children ages 6-8, and 58% of 15-year-olds have had dental caries, and the incidence for the youngest children has only been increasing.1 As pediatricians, we can use recommended preventative strategies in our clinic and telehealth visits.

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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.

Resources:

  • 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

References:

  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

References

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

Introduction

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. 

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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

References:

  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 

References: 

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 

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

https://www.luriechildrens.org/en/blog/social-media-parenting-statistics/

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 

The Importance of Masking in Schools

Bastioned by the AAP’s statement1 in support of school reopenings amidst the ongoing COVID-19 pandemic, school governing bodies everywhere have established a spectrum of different masking requirements for students. Some may argue that masking could be disruptive to learning and development, particularly in young children. However, the caveat in the AAP’s statement must not be forgotten: that the school reopenings are to be driven by science and safety. Arrangements for social distancing at school are frequently changing, with some schools having greater capacity than others to space out students, and some school districts electing to continue the school year entirely online. Parents and guardians are often constrained by work or other life circumstances, including lack of financial or technological resources, giving them little choice but to send their children back to in-person education. Consistent masking practices for as many children as possible at school will greatly help to mitigate the associated risk of students and staff contracting and spreading COVID-19. Pediatricians are uniquely poised to advocate for this low-cost, minimally invasive intervention that may save countless lives of all ages. 

Without clear scientific guidance indicating that children do not contribute significantly to the spread of the pandemic, we are left to answer the question of how to proceed this academic year.

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