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Language development is the canary in the coal mine
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].
Your son and football?
Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”
Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?
Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.
Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.
I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.
Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.
I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.
Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.
The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” To comment, e-mail him at [email protected].
Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”
Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?
Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.
Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.
I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.
Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.
I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.
Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.
The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” To comment, e-mail him at [email protected].
Imagine that you have finished dinner and have just sat down to watch the last half of the nightly news. Your 9-year-old son whom you have watched play soccer since he was 5 years old hands you a crumpled sheet of paper extracted from his backpack and asks, “Dad, can you sign this permission slip so I can play football?” Will you respond, “Sure, when is the first practice?”
Or will this be the jumping-off point for a dissertation on why you think football is a bad idea? Will you tell him that you are concerned that he will sustain a concussion, or two or three? Will you ask him why he would want a play a sport whose top level players are steroid pumped, inarticulate wife beaters? Or, will you tell him that the football culture tolerates the evils of hazing and fosters aggressive behavior?
Before we go any further, I must offer the disclaimer that I played high school football wearing a leather helmet. And that I played college football for 2 years until the handwriting on the locker room wall said, “Your skill level makes it very unlikely that you will ever get off the bench; maybe you should focus on lacrosse.” Which I did.
Although I had a few “stingers,” I never sustained any serious injuries other than a torn hamstring that still plagues me. My two concussions were unrelated to contact sports. As a team doctor for the local high school, I’m sure I sent several concussed players back onto the field. But in retrospect, I and most other physicians back then were working with a definition of concussion that was far too narrow. The most serious injuries I encountered as a game physician occurred during soccer matches.
I read the same headlines you do about what appear to be late effects in professional athletes of repeated blows to the head. I am repulsed by the off-field behavior of both collegiate and professional football players, and I continue to search unsuccessfully for admirable role models in the ranks of high-profile athletes.
Despite all the unseemly publicity, television revenues from professional football continue to surge unabated. However, I hear an undercurrent of discomfort with football from parents and some pediatricians: “Why would I allow my child to play a dangerous sport with despicable role models?” That’s a good question, and is the same one I asked you in the first line of this letter. I wouldn’t be surprised if some time in the not-too-distant future, the level of discomfort reaches a point that groups such as the American Academy of Pediatrics suggest that parents be strongly discouraged from allowing their children to play football.
I hope that this point is never reached because from my personal and professional experience, football can offer enough positives to make its risks acceptable – risks that are on a par with most activities that involve getting off the couch and physically interacting with peers and the environment. Football helped me to learn initiative (some might confuse this with aggression). It allowed me to enjoy the benefits of succeeding and failing as a member of a team. It exposed me to the value of careful preparation and meticulous attention to detail. One could argue that I could have acquired those insights and skills by participating in other activities, athletic or not. But for me it happened to be football. Were there downsides? Yes, because football was the only fall sport at my high school, it had the feel of an exclusive fraternity, a feeling that I have grown to dislike.
Would I sign my son’s permission slip to play football? Yes. Would I worry about him getting hurt? No more than I would when he played soccer and hockey. Because despite his dreams, we live in a town that isn’t football obsessed, and he isn’t going to have a 10-year career in professional sports. The risks of cumulative traumatic brain injury are too small to consider.
The bigger risk is that he might encounter a coach with a win-at-any-cost attitude and the moral character of a doorknob. But that can happen in any sport. Together he and I will continue to search for good role models in other avenues of life.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” To comment, e-mail him at [email protected].
Commentary: The importance of bias in education
Prestigious medical journals continue to publish one-sided editorial pieces extolling the evils of commercial interests and their relationship and effect on medical education (N. Engl. J. Med. 2012;366:1069-71; Circulation 2010;121:2228-34; JAMA 2010;304:729-31; JAMA 2014;312:697-8). A comprehensive review was written regarding industry-academic relationships in four high-impact medical journals published between the 1980s and 2008 (Nature Biotechnology 2012;30:320-2). Of the 108 articles that met the reviewers’ strict criteria, only 12 (11%) were published that were either neutral or emphasized some benefit. Of these 12, all addressed the opposing points of view, and 50% critically emphasized and attempted to refute the alternative points of view.
On the other hand, 16 research articles (15%) emphasized the risks of a relationship with industry, and none critically analyzed and attempted to refute the alternative points of view. The majority, 80 (74%) of the articles published were commentary articles that emphasized the risks of a relationship with industry, and only 7 (6%) articles critically analyzed and attempted to refute the opposing points of view.
The authors conclude that a major anti-industry publication bias exists and that a conformity cascade – where policy does not emerge from objective weighing of evidence but from social pressure – may be a factor for this major bias from medical journals that are influential in affecting policy.
Amazingly, a profession that prides itself on using scientific studies to reach conclusions has used little science and relies predominantly on emotion and scare tactics, to conclude that an industry-provider relationship is bad for health care outcomes.
Anti-industry authors mainly focus on “studies” directed at the effect of marketing. Marketing does increase the likelihood that a product will be used. However, data on how this translates into health care outcomes, the important issue, are lacking. Common sense would suggest that using newer, frequently better, products and vaccines is more, not less, likely to improve these outcomes. Further reductions in the relationship between industry and education will certainly lead to fewer, not more, potentially educational interactions. On the other hand, genuine collaboration could lead to opportunities to improve education beyond what CME [continuing medical education] alone offers.
The “Sunshine Act,” renamed the Open Payments Act, may be particularly harmful. Many of the few remaining academics that still have a relationship with industry will sever this relationship for fear of being a “target.” Restrictions imposed on faculty by many academic institutions, reducing the faculty members’ exposure and interactions with pharmaceutical scientists and other faculty, also are not helpful. Past speaker and advisory sessions were attended by an eclectic group of specialists and generalists, and were filled with fertile discussions and debates regarding disease and treatment perspectives. There are no winners when these bright educators are kept away from potential learning and teaching situations.
More than 22 years of chairing the CME Committee of an extremely active American Academy of Pediatrics (AAP) Chapter and cochairing the CME Committee of an AAP District has given me the privilege of intimate interactions with hundreds of nationally recognized speakers, some with and some without industry affiliation. Myths, frequently perpetuated by those with little or no real-world contact with these programs or by people with anti-industry bias and peppered with words like “perceived” and “potential conflict,” need to be corrected.
Myth:Faculty with a pharmaceutical relationship are inferior to faculty without this relationship. They are privy to much more data, have frequently been involved in the product research, often freely duel with industry scientists and others about the data generated and how the information needs to be disseminated, interact with others researching the topic, and present newer, not-yet-published information (and disclose this) to attendees.
Myth:Education is better off without the pharmaceutical industry. At a time when medical knowledge is rapidly expanding, and it is becoming increasingly more complicated, and greater dissemination of the latest, best information is desperately needed, pharmaceutical financial support can help. Pharmaceutical support allows us to invite – free of charge – all University of California, Irvine-Children’s Hospital of Orange County pediatric residents and U.C. Irvine medical students to every CME program. Industry restrictions already in place are sufficient to promote more educational opportunities and less-expensive attendee costs. No new restrictions are needed.
Myth:Only faculty without industry relationships are unbiased and should be allowed to influence policy regarding education. This nasty, modern-day expression of “McCarthyism” attacks those with industry relationships, dismissing their contributions, intelligence, and sincerity with the “of course they support so-and-so; they are being paid by industry.” A 5-year evaluation of CME programs sponsored by California Chapter 4 AAP from 2009 to 2013 reveals the following data: 23 CME programs, 24 of 55 speakers listed a potential conflict of interest (44%). There were 1,995 attendees and 1,370 returned a response on whether or not a commercial bias was in the presentation; 1,342 responded “No” (98%) and 28 responded “Yes” (2%). Although almost half of the faculty had a potential conflict, only 2% of attendees felt their presentation suggested a commercial conflict. Interestingly, some of the “yes” responses were for faculty with no conflict to disclose.
I received the following comment recently from one of our meeting faculty members, whose name is withheld for fear of being a “target.”
“During my training, we were basically told to avoid interacting with pharma reps, and our interaction with them was highly restricted or, in many cases, forbidden.
“It is only now in my role at the state and doing my Centers for Disease Control and Prevention work that I am realizing how much we need industry to move science and public health forward, and industry needs us for dissemination/implementation and the shaping of the research agenda. I think of how we are down to one class of antibiotics to treat gonorrhea, and we are not going to get a lot of new therapies without industry (certainly not from academia or public health).
“I just returned from the big (company name withheld) meeting and decided to take a different tactic – instead of avoiding (company name withheld) physician advisers, I decided to sit down and actually have a conversation with some of them – and I learned a ton. Different type of inside perspective that one cannot gain from just sitting in sessions.”
Those of us interested in education need to keep an eye on the prize – educating providers so that health care is optimized. This is best done by broadening the dialogue about how to improve and better disseminate both the quality and quantity of health care information being generated. Besides, the industry that has given us medications and vaccines that have improved the quality of life for so many needs to be treated with less contempt and more respect. It is time to build bridges, not walls, and broaden the collaboration needed to better disseminate the vast amount of new information being generated. Improving practitioner education will need fresh ideas, an open mind, validating studies, a gentler dialogue, and the respect, inclusion, and collaboration of all stakeholders.
Dr. Pellman is clinical professor of pediatrics at the University of California, Irvine. Dr. Pellman disclosed he is on the speakers bureau for Medimmune vaccine division. To comment, e-mail him at [email protected].
Prestigious medical journals continue to publish one-sided editorial pieces extolling the evils of commercial interests and their relationship and effect on medical education (N. Engl. J. Med. 2012;366:1069-71; Circulation 2010;121:2228-34; JAMA 2010;304:729-31; JAMA 2014;312:697-8). A comprehensive review was written regarding industry-academic relationships in four high-impact medical journals published between the 1980s and 2008 (Nature Biotechnology 2012;30:320-2). Of the 108 articles that met the reviewers’ strict criteria, only 12 (11%) were published that were either neutral or emphasized some benefit. Of these 12, all addressed the opposing points of view, and 50% critically emphasized and attempted to refute the alternative points of view.
On the other hand, 16 research articles (15%) emphasized the risks of a relationship with industry, and none critically analyzed and attempted to refute the alternative points of view. The majority, 80 (74%) of the articles published were commentary articles that emphasized the risks of a relationship with industry, and only 7 (6%) articles critically analyzed and attempted to refute the opposing points of view.
The authors conclude that a major anti-industry publication bias exists and that a conformity cascade – where policy does not emerge from objective weighing of evidence but from social pressure – may be a factor for this major bias from medical journals that are influential in affecting policy.
Amazingly, a profession that prides itself on using scientific studies to reach conclusions has used little science and relies predominantly on emotion and scare tactics, to conclude that an industry-provider relationship is bad for health care outcomes.
Anti-industry authors mainly focus on “studies” directed at the effect of marketing. Marketing does increase the likelihood that a product will be used. However, data on how this translates into health care outcomes, the important issue, are lacking. Common sense would suggest that using newer, frequently better, products and vaccines is more, not less, likely to improve these outcomes. Further reductions in the relationship between industry and education will certainly lead to fewer, not more, potentially educational interactions. On the other hand, genuine collaboration could lead to opportunities to improve education beyond what CME [continuing medical education] alone offers.
The “Sunshine Act,” renamed the Open Payments Act, may be particularly harmful. Many of the few remaining academics that still have a relationship with industry will sever this relationship for fear of being a “target.” Restrictions imposed on faculty by many academic institutions, reducing the faculty members’ exposure and interactions with pharmaceutical scientists and other faculty, also are not helpful. Past speaker and advisory sessions were attended by an eclectic group of specialists and generalists, and were filled with fertile discussions and debates regarding disease and treatment perspectives. There are no winners when these bright educators are kept away from potential learning and teaching situations.
More than 22 years of chairing the CME Committee of an extremely active American Academy of Pediatrics (AAP) Chapter and cochairing the CME Committee of an AAP District has given me the privilege of intimate interactions with hundreds of nationally recognized speakers, some with and some without industry affiliation. Myths, frequently perpetuated by those with little or no real-world contact with these programs or by people with anti-industry bias and peppered with words like “perceived” and “potential conflict,” need to be corrected.
Myth:Faculty with a pharmaceutical relationship are inferior to faculty without this relationship. They are privy to much more data, have frequently been involved in the product research, often freely duel with industry scientists and others about the data generated and how the information needs to be disseminated, interact with others researching the topic, and present newer, not-yet-published information (and disclose this) to attendees.
Myth:Education is better off without the pharmaceutical industry. At a time when medical knowledge is rapidly expanding, and it is becoming increasingly more complicated, and greater dissemination of the latest, best information is desperately needed, pharmaceutical financial support can help. Pharmaceutical support allows us to invite – free of charge – all University of California, Irvine-Children’s Hospital of Orange County pediatric residents and U.C. Irvine medical students to every CME program. Industry restrictions already in place are sufficient to promote more educational opportunities and less-expensive attendee costs. No new restrictions are needed.
Myth:Only faculty without industry relationships are unbiased and should be allowed to influence policy regarding education. This nasty, modern-day expression of “McCarthyism” attacks those with industry relationships, dismissing their contributions, intelligence, and sincerity with the “of course they support so-and-so; they are being paid by industry.” A 5-year evaluation of CME programs sponsored by California Chapter 4 AAP from 2009 to 2013 reveals the following data: 23 CME programs, 24 of 55 speakers listed a potential conflict of interest (44%). There were 1,995 attendees and 1,370 returned a response on whether or not a commercial bias was in the presentation; 1,342 responded “No” (98%) and 28 responded “Yes” (2%). Although almost half of the faculty had a potential conflict, only 2% of attendees felt their presentation suggested a commercial conflict. Interestingly, some of the “yes” responses were for faculty with no conflict to disclose.
I received the following comment recently from one of our meeting faculty members, whose name is withheld for fear of being a “target.”
“During my training, we were basically told to avoid interacting with pharma reps, and our interaction with them was highly restricted or, in many cases, forbidden.
“It is only now in my role at the state and doing my Centers for Disease Control and Prevention work that I am realizing how much we need industry to move science and public health forward, and industry needs us for dissemination/implementation and the shaping of the research agenda. I think of how we are down to one class of antibiotics to treat gonorrhea, and we are not going to get a lot of new therapies without industry (certainly not from academia or public health).
“I just returned from the big (company name withheld) meeting and decided to take a different tactic – instead of avoiding (company name withheld) physician advisers, I decided to sit down and actually have a conversation with some of them – and I learned a ton. Different type of inside perspective that one cannot gain from just sitting in sessions.”
Those of us interested in education need to keep an eye on the prize – educating providers so that health care is optimized. This is best done by broadening the dialogue about how to improve and better disseminate both the quality and quantity of health care information being generated. Besides, the industry that has given us medications and vaccines that have improved the quality of life for so many needs to be treated with less contempt and more respect. It is time to build bridges, not walls, and broaden the collaboration needed to better disseminate the vast amount of new information being generated. Improving practitioner education will need fresh ideas, an open mind, validating studies, a gentler dialogue, and the respect, inclusion, and collaboration of all stakeholders.
Dr. Pellman is clinical professor of pediatrics at the University of California, Irvine. Dr. Pellman disclosed he is on the speakers bureau for Medimmune vaccine division. To comment, e-mail him at [email protected].
Prestigious medical journals continue to publish one-sided editorial pieces extolling the evils of commercial interests and their relationship and effect on medical education (N. Engl. J. Med. 2012;366:1069-71; Circulation 2010;121:2228-34; JAMA 2010;304:729-31; JAMA 2014;312:697-8). A comprehensive review was written regarding industry-academic relationships in four high-impact medical journals published between the 1980s and 2008 (Nature Biotechnology 2012;30:320-2). Of the 108 articles that met the reviewers’ strict criteria, only 12 (11%) were published that were either neutral or emphasized some benefit. Of these 12, all addressed the opposing points of view, and 50% critically emphasized and attempted to refute the alternative points of view.
On the other hand, 16 research articles (15%) emphasized the risks of a relationship with industry, and none critically analyzed and attempted to refute the alternative points of view. The majority, 80 (74%) of the articles published were commentary articles that emphasized the risks of a relationship with industry, and only 7 (6%) articles critically analyzed and attempted to refute the opposing points of view.
The authors conclude that a major anti-industry publication bias exists and that a conformity cascade – where policy does not emerge from objective weighing of evidence but from social pressure – may be a factor for this major bias from medical journals that are influential in affecting policy.
Amazingly, a profession that prides itself on using scientific studies to reach conclusions has used little science and relies predominantly on emotion and scare tactics, to conclude that an industry-provider relationship is bad for health care outcomes.
Anti-industry authors mainly focus on “studies” directed at the effect of marketing. Marketing does increase the likelihood that a product will be used. However, data on how this translates into health care outcomes, the important issue, are lacking. Common sense would suggest that using newer, frequently better, products and vaccines is more, not less, likely to improve these outcomes. Further reductions in the relationship between industry and education will certainly lead to fewer, not more, potentially educational interactions. On the other hand, genuine collaboration could lead to opportunities to improve education beyond what CME [continuing medical education] alone offers.
The “Sunshine Act,” renamed the Open Payments Act, may be particularly harmful. Many of the few remaining academics that still have a relationship with industry will sever this relationship for fear of being a “target.” Restrictions imposed on faculty by many academic institutions, reducing the faculty members’ exposure and interactions with pharmaceutical scientists and other faculty, also are not helpful. Past speaker and advisory sessions were attended by an eclectic group of specialists and generalists, and were filled with fertile discussions and debates regarding disease and treatment perspectives. There are no winners when these bright educators are kept away from potential learning and teaching situations.
More than 22 years of chairing the CME Committee of an extremely active American Academy of Pediatrics (AAP) Chapter and cochairing the CME Committee of an AAP District has given me the privilege of intimate interactions with hundreds of nationally recognized speakers, some with and some without industry affiliation. Myths, frequently perpetuated by those with little or no real-world contact with these programs or by people with anti-industry bias and peppered with words like “perceived” and “potential conflict,” need to be corrected.
Myth:Faculty with a pharmaceutical relationship are inferior to faculty without this relationship. They are privy to much more data, have frequently been involved in the product research, often freely duel with industry scientists and others about the data generated and how the information needs to be disseminated, interact with others researching the topic, and present newer, not-yet-published information (and disclose this) to attendees.
Myth:Education is better off without the pharmaceutical industry. At a time when medical knowledge is rapidly expanding, and it is becoming increasingly more complicated, and greater dissemination of the latest, best information is desperately needed, pharmaceutical financial support can help. Pharmaceutical support allows us to invite – free of charge – all University of California, Irvine-Children’s Hospital of Orange County pediatric residents and U.C. Irvine medical students to every CME program. Industry restrictions already in place are sufficient to promote more educational opportunities and less-expensive attendee costs. No new restrictions are needed.
Myth:Only faculty without industry relationships are unbiased and should be allowed to influence policy regarding education. This nasty, modern-day expression of “McCarthyism” attacks those with industry relationships, dismissing their contributions, intelligence, and sincerity with the “of course they support so-and-so; they are being paid by industry.” A 5-year evaluation of CME programs sponsored by California Chapter 4 AAP from 2009 to 2013 reveals the following data: 23 CME programs, 24 of 55 speakers listed a potential conflict of interest (44%). There were 1,995 attendees and 1,370 returned a response on whether or not a commercial bias was in the presentation; 1,342 responded “No” (98%) and 28 responded “Yes” (2%). Although almost half of the faculty had a potential conflict, only 2% of attendees felt their presentation suggested a commercial conflict. Interestingly, some of the “yes” responses were for faculty with no conflict to disclose.
I received the following comment recently from one of our meeting faculty members, whose name is withheld for fear of being a “target.”
“During my training, we were basically told to avoid interacting with pharma reps, and our interaction with them was highly restricted or, in many cases, forbidden.
“It is only now in my role at the state and doing my Centers for Disease Control and Prevention work that I am realizing how much we need industry to move science and public health forward, and industry needs us for dissemination/implementation and the shaping of the research agenda. I think of how we are down to one class of antibiotics to treat gonorrhea, and we are not going to get a lot of new therapies without industry (certainly not from academia or public health).
“I just returned from the big (company name withheld) meeting and decided to take a different tactic – instead of avoiding (company name withheld) physician advisers, I decided to sit down and actually have a conversation with some of them – and I learned a ton. Different type of inside perspective that one cannot gain from just sitting in sessions.”
Those of us interested in education need to keep an eye on the prize – educating providers so that health care is optimized. This is best done by broadening the dialogue about how to improve and better disseminate both the quality and quantity of health care information being generated. Besides, the industry that has given us medications and vaccines that have improved the quality of life for so many needs to be treated with less contempt and more respect. It is time to build bridges, not walls, and broaden the collaboration needed to better disseminate the vast amount of new information being generated. Improving practitioner education will need fresh ideas, an open mind, validating studies, a gentler dialogue, and the respect, inclusion, and collaboration of all stakeholders.
Dr. Pellman is clinical professor of pediatrics at the University of California, Irvine. Dr. Pellman disclosed he is on the speakers bureau for Medimmune vaccine division. To comment, e-mail him at [email protected].
Blognosis: Participatory surveillance needs you!
One of the biggest lessons so far from the West African Ebola outbreak is the importance of early identification of infectious disease outbreaks. That’s the best way to get a quick response, and a quick response can mean the difference between an outbreak’s control or spread.
As reported from the International Meeting on Emerging Diseases and Surveillance (IMED) in early November, the Ebola experience in Africa this past year has been marked by slow responses in Liberia and Sierra Leone, followed by unprecedented Ebola spread – and quick responses in Nigeria and the Democratic Republic of the Congo, followed by declarations by the World Health Organization that Nigeria and then DRC had become Ebola-free.
Many factors play into early identification of infection outbreaks, but a new approach may be one of the best, especially once it fully catches on. It’s called participatory surveillance, and it means that everyone – or at least as many as can be persuaded – commits to regularly updating (usually weekly) a public health database on their health status.
While participatory surveillance is not being used in Africa, it’s being used elsewhere, including in the United States as the Flu Near You program. As also reported out of the same IMED meeting, Flu Near You is the best U.S. example of participatory surveillance, with a current database of about 100,000 U.S. enrollees. Ideally, the participants reply each week to a short survey that asks if they had any of 10 symptoms that can flag influenza, such as fever, headache, cough, sore throat, or fatigue.
When we first reported on Flu Near You nearly 2 years ago, it was an interesting concept just starting to roll out. Returning to Flu Near You for a second look a few weeks ago revealed that it had become a useful if still immature tool that had caught the notice of the Centers for Disease Control and Prevention (CDC).
Now it’s poised for the next step, which is where you come in: Sign up, and be active by responding to the weekly survey.
A CDC staffer in Atlanta told us that the agency already sees Flu Near You as a valuable adjunct to the flu surveillance it traditionally conducts. If the database is helpful for tracking national influenza trends with 100,000 Americans registered, imagine how much more informative it would be with 1 million, 10 million, or even more participants. The only way participatory surveillance succeeds is if people buy in and become part of the process. If enough people did that, the public health insights would soar.
Numbers are what’s holding Flu Near You back right now. Each of us has the ability to change that a little.
On Twitter @mitchelzoler
One of the biggest lessons so far from the West African Ebola outbreak is the importance of early identification of infectious disease outbreaks. That’s the best way to get a quick response, and a quick response can mean the difference between an outbreak’s control or spread.
As reported from the International Meeting on Emerging Diseases and Surveillance (IMED) in early November, the Ebola experience in Africa this past year has been marked by slow responses in Liberia and Sierra Leone, followed by unprecedented Ebola spread – and quick responses in Nigeria and the Democratic Republic of the Congo, followed by declarations by the World Health Organization that Nigeria and then DRC had become Ebola-free.
Many factors play into early identification of infection outbreaks, but a new approach may be one of the best, especially once it fully catches on. It’s called participatory surveillance, and it means that everyone – or at least as many as can be persuaded – commits to regularly updating (usually weekly) a public health database on their health status.
While participatory surveillance is not being used in Africa, it’s being used elsewhere, including in the United States as the Flu Near You program. As also reported out of the same IMED meeting, Flu Near You is the best U.S. example of participatory surveillance, with a current database of about 100,000 U.S. enrollees. Ideally, the participants reply each week to a short survey that asks if they had any of 10 symptoms that can flag influenza, such as fever, headache, cough, sore throat, or fatigue.
When we first reported on Flu Near You nearly 2 years ago, it was an interesting concept just starting to roll out. Returning to Flu Near You for a second look a few weeks ago revealed that it had become a useful if still immature tool that had caught the notice of the Centers for Disease Control and Prevention (CDC).
Now it’s poised for the next step, which is where you come in: Sign up, and be active by responding to the weekly survey.
A CDC staffer in Atlanta told us that the agency already sees Flu Near You as a valuable adjunct to the flu surveillance it traditionally conducts. If the database is helpful for tracking national influenza trends with 100,000 Americans registered, imagine how much more informative it would be with 1 million, 10 million, or even more participants. The only way participatory surveillance succeeds is if people buy in and become part of the process. If enough people did that, the public health insights would soar.
Numbers are what’s holding Flu Near You back right now. Each of us has the ability to change that a little.
On Twitter @mitchelzoler
One of the biggest lessons so far from the West African Ebola outbreak is the importance of early identification of infectious disease outbreaks. That’s the best way to get a quick response, and a quick response can mean the difference between an outbreak’s control or spread.
As reported from the International Meeting on Emerging Diseases and Surveillance (IMED) in early November, the Ebola experience in Africa this past year has been marked by slow responses in Liberia and Sierra Leone, followed by unprecedented Ebola spread – and quick responses in Nigeria and the Democratic Republic of the Congo, followed by declarations by the World Health Organization that Nigeria and then DRC had become Ebola-free.
Many factors play into early identification of infection outbreaks, but a new approach may be one of the best, especially once it fully catches on. It’s called participatory surveillance, and it means that everyone – or at least as many as can be persuaded – commits to regularly updating (usually weekly) a public health database on their health status.
While participatory surveillance is not being used in Africa, it’s being used elsewhere, including in the United States as the Flu Near You program. As also reported out of the same IMED meeting, Flu Near You is the best U.S. example of participatory surveillance, with a current database of about 100,000 U.S. enrollees. Ideally, the participants reply each week to a short survey that asks if they had any of 10 symptoms that can flag influenza, such as fever, headache, cough, sore throat, or fatigue.
When we first reported on Flu Near You nearly 2 years ago, it was an interesting concept just starting to roll out. Returning to Flu Near You for a second look a few weeks ago revealed that it had become a useful if still immature tool that had caught the notice of the Centers for Disease Control and Prevention (CDC).
Now it’s poised for the next step, which is where you come in: Sign up, and be active by responding to the weekly survey.
A CDC staffer in Atlanta told us that the agency already sees Flu Near You as a valuable adjunct to the flu surveillance it traditionally conducts. If the database is helpful for tracking national influenza trends with 100,000 Americans registered, imagine how much more informative it would be with 1 million, 10 million, or even more participants. The only way participatory surveillance succeeds is if people buy in and become part of the process. If enough people did that, the public health insights would soar.
Numbers are what’s holding Flu Near You back right now. Each of us has the ability to change that a little.
On Twitter @mitchelzoler
What Matters: Salt substitutes to reduce blood pressure
Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.
Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.
However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.
In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO2, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.
Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.
Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.
Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.
Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.
Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.
However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.
In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO2, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.
Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.
Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.
Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.
Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Most of my counseling to patients about lowering blood pressure through self management is heavy on weight loss and light on dietary causes of high blood pressure – other than the obvious ones that make people gain weight.
Denial of the effects of dietary salt on blood pressure is not the issue. Rather, it is a time-hewn lack of confidence in the ability of patients to significantly and consistently modify their diet. Part of this may also relate to our inability to provide useful lifestyle tips on how to do so, other than the obvious referral to a dietitian. Telling them not to eat out does not solve this problem, because they can just as easily add salt at home.
However, a recent meta-analysis evaluating the effect of salt substitutes on blood pressure has reinvigorated my desire to counsel my patients on blood pressure self-management.
In this study, the investigators sought randomized, controlled trials with interventions lasting at least 6 months in duration (Am. J. Clin. Nutr. 2014;100:1448-54). Six cohorts were identified in the literature involving a total of 1,974 participants. Included studies took place in China and the Netherlands. Three studies used 65% NaCl/25% KCl/10% MgSO2, one used 41% NaCl/41% KCl/17% magnesium salt/trace minerals, and one used 65% NaCl/30% KCl/5% calcium salt and folic acid.
Salt substitutes had significant effects on systolic blood pressure with a mean difference of –4.9 mm Hg and on diastolic blood pressure with a mean difference of –1.5 mm Hg.
Overall, one may not be impressed with a 5–mm Hg change in systolic blood pressure. But this is the mean difference – and we presume population heterogeneity in response to salt substitution, such that some patients will respond to a higher degree than this and some to a lower degree. But we do not know which ones are which.
Population interventions aimed at reducing salt intake have been shown to be effective. The Finnish government, for example, collaborated with private industry and was able to achieve reductions in sodium content of food. That initiative resulted in a 33% reduction in the population’s average salt intake, a greater than 10–mm Hg decrease in the population average of both systolic BP and diastolic BP, and a 75%-80% decrease in both stroke and coronary artery disease mortality. Australia, Japan, and the United Kingdom were able to do similar things.
Because we are unlikely to ever see such organized political will exercised in the United States, it seems reasonable to recommend salt substitutes to our patients on an individual level. Adverse effects have been noted with salt substitutes in patients with kidney disease, however, which will have to be considered in that specific population of patients.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
You can’t get there from here
Readers of this column may recall that we have been following the fate of a small 14 primary care physician–owned accountable care organization bordering the Rio Grande River in Texas, the Rio Grande Valley Health Alliance. These physicians in 12 practices started with no infrastructure, no common electronic health records, or capital, and nonetheless took the plunge to become a Medicare Shared Savings Program accountable care organization beginning Jan. 1, 2013. It is time for an update on them.
Admittedly, I have been dragging my feet about an update, not because the results were poor, but because they were so great. With barely the minimum 5,000 beneficiaries, they saved more than $6 million in their first year. They are in the no-downside-risk plan, and thus got 50% of those savings. They have had time in 2014 to crunch the data even more to identify the 10% of patients driving more than 50% of costs and begin implementing complex high-risk patient management. For these reasons, I wager that they will do even better in 2014 through increased efficiencies.
How about quality? In the first year in the Medicare Shared Savings Program (MSSP), an ACO need only show the ability to report; they are not graded on their quality performance. But the Rio Grande Valley Health Alliance kept track internally, and the ACO regularly appears to be hitting the 90th percentile on the bulk of the 33 quality metrics. Their model tracked the elements for success outlined in previous columns.
So, why have I been I hesitant to report this?
Well, so many of you readers have called or written me to say that, while this type of physician-driven community or rural ACO with a primary care core makes sense, there is no way that you can get the money to organize and build the infrastructure necessary to succeed like RGVHA has. You would have to create a legal entity and apply to a program such as the MSSP, create infrastructure, track savings over a calendar year, then wait 6 or 8 months to get the results and the shared savings payment.
In sum, it’s a great idea. You are in the best position to drive high-value health improvement. You are located where the historic lack of access and medical infrastructure has resulted in high avoidable costs.
But the cruel irony is that, thanks to the fee-for-service system, those in the best position to drive value – primary care physicians – are in the worst position to front the necessary capital costs.
RGVHA was able to go forward because they were eligible for the now-gone Advance Payment Model program that advanced them the necessary operational costs. Their exciting success would ring hollow as a message to you if you couldn’t get this type of developmental financial support. Deferred shared savings and improved quality for your Medicare patients is a great concept – but this is a proverbial “you can’t get there from here” dilemma.
The CMS ACO investment model
The Centers for Medicare and Medicaid Services also saw this disconnect. So, CMS announced a new upfront infrastructure support program specifically to promote new small nonhospital* or managed care ACOs, rural ACOs, ACOs where there is low ACO penetration, and existing ACOs wanting to move toward taking financial risk. This prepaid shared savings builds on the Advance Payment Model program.
ACOs that plan to apply for the program in the next cycle and start in 2016 must have a preliminary prospective beneficiary assignment of 10,000 or less. CMS will give preference to new ACOs in rural or low-penetration areas, or in areas with exceptional need, or to ACOs with compelling proposals on how they would invest their funds and the CMS funds.
Each dollar given by CMS is a prepayment against the ACO’s shared savings distribution. If there are not enough shared savings, there is no further repayment obligation unless the ACO leaves the program before the 3-year program period.
Applications will be accepted during the summer of 2015, which is roughly the same time as the MSSP application period.
In my mind, this is the single best investment in improving health delivery and reining in runaway health care costs that CMS could have made. It will empower those in the best position to generate the highest quality at the lowest cost: readers like you.
This could be a game changer for primary care and rural care. But it won’t happen without physician leaders like those at RGVHA. The summer of 2015 seems a long way off, but the time to begin preparing your fully financed ACO is now!
* Exceptions to the nonhospital condition exist for critical access hospitals or inpatient prospective payment hospitals with 100 or fewer beds.
Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.
Readers of this column may recall that we have been following the fate of a small 14 primary care physician–owned accountable care organization bordering the Rio Grande River in Texas, the Rio Grande Valley Health Alliance. These physicians in 12 practices started with no infrastructure, no common electronic health records, or capital, and nonetheless took the plunge to become a Medicare Shared Savings Program accountable care organization beginning Jan. 1, 2013. It is time for an update on them.
Admittedly, I have been dragging my feet about an update, not because the results were poor, but because they were so great. With barely the minimum 5,000 beneficiaries, they saved more than $6 million in their first year. They are in the no-downside-risk plan, and thus got 50% of those savings. They have had time in 2014 to crunch the data even more to identify the 10% of patients driving more than 50% of costs and begin implementing complex high-risk patient management. For these reasons, I wager that they will do even better in 2014 through increased efficiencies.
How about quality? In the first year in the Medicare Shared Savings Program (MSSP), an ACO need only show the ability to report; they are not graded on their quality performance. But the Rio Grande Valley Health Alliance kept track internally, and the ACO regularly appears to be hitting the 90th percentile on the bulk of the 33 quality metrics. Their model tracked the elements for success outlined in previous columns.
So, why have I been I hesitant to report this?
Well, so many of you readers have called or written me to say that, while this type of physician-driven community or rural ACO with a primary care core makes sense, there is no way that you can get the money to organize and build the infrastructure necessary to succeed like RGVHA has. You would have to create a legal entity and apply to a program such as the MSSP, create infrastructure, track savings over a calendar year, then wait 6 or 8 months to get the results and the shared savings payment.
In sum, it’s a great idea. You are in the best position to drive high-value health improvement. You are located where the historic lack of access and medical infrastructure has resulted in high avoidable costs.
But the cruel irony is that, thanks to the fee-for-service system, those in the best position to drive value – primary care physicians – are in the worst position to front the necessary capital costs.
RGVHA was able to go forward because they were eligible for the now-gone Advance Payment Model program that advanced them the necessary operational costs. Their exciting success would ring hollow as a message to you if you couldn’t get this type of developmental financial support. Deferred shared savings and improved quality for your Medicare patients is a great concept – but this is a proverbial “you can’t get there from here” dilemma.
The CMS ACO investment model
The Centers for Medicare and Medicaid Services also saw this disconnect. So, CMS announced a new upfront infrastructure support program specifically to promote new small nonhospital* or managed care ACOs, rural ACOs, ACOs where there is low ACO penetration, and existing ACOs wanting to move toward taking financial risk. This prepaid shared savings builds on the Advance Payment Model program.
ACOs that plan to apply for the program in the next cycle and start in 2016 must have a preliminary prospective beneficiary assignment of 10,000 or less. CMS will give preference to new ACOs in rural or low-penetration areas, or in areas with exceptional need, or to ACOs with compelling proposals on how they would invest their funds and the CMS funds.
Each dollar given by CMS is a prepayment against the ACO’s shared savings distribution. If there are not enough shared savings, there is no further repayment obligation unless the ACO leaves the program before the 3-year program period.
Applications will be accepted during the summer of 2015, which is roughly the same time as the MSSP application period.
In my mind, this is the single best investment in improving health delivery and reining in runaway health care costs that CMS could have made. It will empower those in the best position to generate the highest quality at the lowest cost: readers like you.
This could be a game changer for primary care and rural care. But it won’t happen without physician leaders like those at RGVHA. The summer of 2015 seems a long way off, but the time to begin preparing your fully financed ACO is now!
* Exceptions to the nonhospital condition exist for critical access hospitals or inpatient prospective payment hospitals with 100 or fewer beds.
Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.
Readers of this column may recall that we have been following the fate of a small 14 primary care physician–owned accountable care organization bordering the Rio Grande River in Texas, the Rio Grande Valley Health Alliance. These physicians in 12 practices started with no infrastructure, no common electronic health records, or capital, and nonetheless took the plunge to become a Medicare Shared Savings Program accountable care organization beginning Jan. 1, 2013. It is time for an update on them.
Admittedly, I have been dragging my feet about an update, not because the results were poor, but because they were so great. With barely the minimum 5,000 beneficiaries, they saved more than $6 million in their first year. They are in the no-downside-risk plan, and thus got 50% of those savings. They have had time in 2014 to crunch the data even more to identify the 10% of patients driving more than 50% of costs and begin implementing complex high-risk patient management. For these reasons, I wager that they will do even better in 2014 through increased efficiencies.
How about quality? In the first year in the Medicare Shared Savings Program (MSSP), an ACO need only show the ability to report; they are not graded on their quality performance. But the Rio Grande Valley Health Alliance kept track internally, and the ACO regularly appears to be hitting the 90th percentile on the bulk of the 33 quality metrics. Their model tracked the elements for success outlined in previous columns.
So, why have I been I hesitant to report this?
Well, so many of you readers have called or written me to say that, while this type of physician-driven community or rural ACO with a primary care core makes sense, there is no way that you can get the money to organize and build the infrastructure necessary to succeed like RGVHA has. You would have to create a legal entity and apply to a program such as the MSSP, create infrastructure, track savings over a calendar year, then wait 6 or 8 months to get the results and the shared savings payment.
In sum, it’s a great idea. You are in the best position to drive high-value health improvement. You are located where the historic lack of access and medical infrastructure has resulted in high avoidable costs.
But the cruel irony is that, thanks to the fee-for-service system, those in the best position to drive value – primary care physicians – are in the worst position to front the necessary capital costs.
RGVHA was able to go forward because they were eligible for the now-gone Advance Payment Model program that advanced them the necessary operational costs. Their exciting success would ring hollow as a message to you if you couldn’t get this type of developmental financial support. Deferred shared savings and improved quality for your Medicare patients is a great concept – but this is a proverbial “you can’t get there from here” dilemma.
The CMS ACO investment model
The Centers for Medicare and Medicaid Services also saw this disconnect. So, CMS announced a new upfront infrastructure support program specifically to promote new small nonhospital* or managed care ACOs, rural ACOs, ACOs where there is low ACO penetration, and existing ACOs wanting to move toward taking financial risk. This prepaid shared savings builds on the Advance Payment Model program.
ACOs that plan to apply for the program in the next cycle and start in 2016 must have a preliminary prospective beneficiary assignment of 10,000 or less. CMS will give preference to new ACOs in rural or low-penetration areas, or in areas with exceptional need, or to ACOs with compelling proposals on how they would invest their funds and the CMS funds.
Each dollar given by CMS is a prepayment against the ACO’s shared savings distribution. If there are not enough shared savings, there is no further repayment obligation unless the ACO leaves the program before the 3-year program period.
Applications will be accepted during the summer of 2015, which is roughly the same time as the MSSP application period.
In my mind, this is the single best investment in improving health delivery and reining in runaway health care costs that CMS could have made. It will empower those in the best position to generate the highest quality at the lowest cost: readers like you.
This could be a game changer for primary care and rural care. But it won’t happen without physician leaders like those at RGVHA. The summer of 2015 seems a long way off, but the time to begin preparing your fully financed ACO is now!
* Exceptions to the nonhospital condition exist for critical access hospitals or inpatient prospective payment hospitals with 100 or fewer beds.
Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.
Let’s talk about poor concordance between diagnosis and treatment!
I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few topics for him to discuss:
• There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standardized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusiastic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physicians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
• The practice of medicine is local. In this region of North Carolina, however, the private practice of psychiatry is disappearing. It is almost impossible to start a successful practice, primarily because of managed care.
• The goals of psychiatric treatment have not been adopted by all professionals. This includes returning patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychiatric symptoms under control, with the least possible number of medication side effects.
• Treatment of psychiatric symptoms is highly individual, and therefore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in training or by the leadership of the APA.
• Treatment in psychiatry is a combination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a polypharmacy, and we must accept it and educate patients accordingly.
I hope that Dr. Nasrallah’s influential editorials will shed light on these topics, and begin a national and international debate on these issues.
V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina
I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few topics for him to discuss:
• There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standardized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusiastic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physicians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
• The practice of medicine is local. In this region of North Carolina, however, the private practice of psychiatry is disappearing. It is almost impossible to start a successful practice, primarily because of managed care.
• The goals of psychiatric treatment have not been adopted by all professionals. This includes returning patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychiatric symptoms under control, with the least possible number of medication side effects.
• Treatment of psychiatric symptoms is highly individual, and therefore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in training or by the leadership of the APA.
• Treatment in psychiatry is a combination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a polypharmacy, and we must accept it and educate patients accordingly.
I hope that Dr. Nasrallah’s influential editorials will shed light on these topics, and begin a national and international debate on these issues.
V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina
I enjoy the intellectual insights in Dr. Nasrallah’s From the Editor essays in Current Psychiatry. For future editorials, I suggest a few topics for him to discuss:
• There is poor concordance between diagnosis and treatment by psychiatrists, compared with other medical specialties, because we do not have tests or measures to employ both before and after treatment. In other words, we have not standardized our evaluation or treatment. Despite my 4 videos on YouTube and an e-book, Standardizing psychiatric care, I have not received an enthusiastic response or discussion from the American Psychiatric Association (APA) or academic psychiatrists— knowing that this step is crucial to integration of care with primary care physicians (PCPs) and other physicians. We must be a leader in training PCPs and other clinicians about how we care for our patients.
• The practice of medicine is local. In this region of North Carolina, however, the private practice of psychiatry is disappearing. It is almost impossible to start a successful practice, primarily because of managed care.
• The goals of psychiatric treatment have not been adopted by all professionals. This includes returning patients to optimal functioning at no less than 80% to 90% of their capacity in self care and professional, school, social, and home settings, and to having at least 85% of psychiatric symptoms under control, with the least possible number of medication side effects.
• Treatment of psychiatric symptoms is highly individual, and therefore the dosage of each medication must be titrated carefully. This important aspect of treatment has not been well-emphasized in training or by the leadership of the APA.
• Treatment in psychiatry is a combination of the right medication and lowest effective dosage to minimize side effects. Therefore it is a polypharmacy, and we must accept it and educate patients accordingly.
I hope that Dr. Nasrallah’s influential editorials will shed light on these topics, and begin a national and international debate on these issues.
V. Sagar Sethi, MD, PhD
Carmel Psychiatric Associates, PA
Charlotte, North Carolina
Eating fish during pregnancy
In Dr. Nasrallah’s Editorial on reducing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizophrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”
Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this literature and do not know which fish to recommend and avoid and the current status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?
Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania
Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I recommend omega-3 fatty acid supplements.
Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
In Dr. Nasrallah’s Editorial on reducing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizophrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”
Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this literature and do not know which fish to recommend and avoid and the current status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?
Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania
Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I recommend omega-3 fatty acid supplements.
Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
In Dr. Nasrallah’s Editorial on reducing the risk of schizophrenia in a child (For couples seeking to conceive, offer advice on reducing the risk of schizophrenia, Current Psychiatry, From the Editor, August 2014, p. 11-12, 44; [http://bit.ly/1zAcnUq]), he advised a couple to “Get a good obstetrician well before conception; get the mother immunized against infections; eat a lot of fish (omega-3 fatty acids)…”
Some people are concerned about mercury levels in fish and suggest limiting fish consumption during pregnancy. I do not follow this literature and do not know which fish to recommend and avoid and the current status of the evidence. If people still believe this, should I suggest omega-3 fatty acid supplements instead of eating a lot of fish?
Oommen Mammen, MD
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania
Dr. Nasrallah responds
I recommend wild salmon as the best source of omega-3 fatty acids from fish. I avoid farmed salmon because that’s where some contamination has been reported. Absent the availability of wild salmon, I recommend omega-3 fatty acid supplements.
Henry A. Nasrallah, MD
Professor and Chair Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
Most weight-loss apps are losers
Introducing overweight patients to one of the most popular weight-loss apps didn’t help them shed pounds in a prospective, randomized, controlled trial with 212 patients in primary care clinics.
The two-clinic study screened 633 patients with a body mass index of at least 25 kg/m2, most of whom did not own a smartphone (421) or were not interested in losing weight (135), with 86 patients declining the study for other reasons. The remaining 212 patients were randomized to 6 months of usual care or usual care plus the free MyFitnessPal app. Research assistants helped patients download the app during a regular clinic visit, showed them an instructional video developed by MyFitnessPal, and followed up a week later with a phone call to assist patients with any technical problems with the app.
Not much weight was lost in the following 6 months. The app group lost a mean of 0.03 kg and the control group gained a mean of 0.3 kg, a 0.3-kg difference between groups that was not statistically significant, Dr. Brian Y. Laing and his associates reported (Ann. Intern. Med. 2014 Nov. 18 [doi:10.7326/M13-3005]). Among the 158 patients with 6-month measurements, 13 of 71 in the app group lost 2.7 kg or more (18%), as did 14 of 87 in the control group (16%).
The groups also did not differ significantly in changes in systolic blood pressure, with the app group losing a mean of 0.3 mm Hg and the control group gaining a mean of 1.5 mm Hg, reported Dr. Laing, now of the Los Angeles County Department of Health Services.
Patients in the app group seldom bothered to open it after the first month, with open rates dropping from 94 patients in the first month (97%) to 34 patients in the sixth month (35%). The ones who stopped using it complained in a survey that the app was “tedious,” or said they were too busy or stressed to use it, or dropped it for other reasons.
There were a few hopeful signs, however, Dr. Laing said in an interview. A few patients continued using the app at least 30 times in month 6. The app group was more likely to report using a “personal calorie goal” significantly more often than the control group – a mean of 2 days per week, compared with a quarter-day per week, respectively. And perhaps outcomes might have been better if physicians instead of research assistants had introduced patients to the app and followed up, he speculated.
Success may depend more on the patient’s readiness for change than on the app itself. “There was a subset of patients who used the app a lot and appeared to lose more weight, but on average, there wasn’t a significant difference between the groups. I think what it tells us is the app still can be a very powerful tool for patients who are truly motivated to track calories, but not for everyone,” said Dr. Laing, who works on operational issues for the county and practices part-time as a family physician in a county clinic.
Dr. Laing still recommends MyFitnessPal to overweight patients if they answer his questions by saying they’re interested in losing weight and enjoy using a smartphone. But he adds a warning: If you want the app to work, “you’ll have to put some time into this” and spend 5 minutes or so entering calories at each meal.
“I’m a primary care physician. One thing we struggle with is the 10- to 15-minute visit. I think about how we can help patients lead healthy lives when they’re not in front of us except for 10 minutes twice a year,” he said. For the right patients, apps could help, he believes.
Dr. Laing was one of the investigators in a previous study that evaluated the quality of 23 of the top-rated free health and fitness apps. The apps seldom employed evidence-based theories of behavior change, they found. The mean behavioral theory score was 8 out of 100, and the mean persuasive technology score on the Fogg Behavioral Model was 2 out of a possible 6. The top-scoring app on both scales was Lose It! (Am. J. Prev. Med. 2013;45:583-9).
A separate study by other investigators rated 62 apps for the prevention of pediatric obesity and found that the apps were likely to incorporate expert-recommended behaviors such as eating five servings of fruit or vegetables per day (94%) but few adhered to expert-recommended strategies such as self-monitoring diet and physical activity (21%). Approximately half the apps addressed physical activity and consumption of fruit or vegetables and only 2% of apps addressed the child’s amount of screen time or the importance of family meals together, among other important behaviors (Child. Obes. 2014;10:132-44).
The company Weight Watchers funded a randomized study of 292 participants in the company’s programs that found they lost more weight by attending its in-person meetings than by using its app or online tools (Am. J. Med. 2013;126:1143e19-1143.324).
Dr. Laing reported having no financial disclosures. MyFitnessPal shared users’ log-on data with investigators for the study.
On Twitter @sherryboschert
Introducing overweight patients to one of the most popular weight-loss apps didn’t help them shed pounds in a prospective, randomized, controlled trial with 212 patients in primary care clinics.
The two-clinic study screened 633 patients with a body mass index of at least 25 kg/m2, most of whom did not own a smartphone (421) or were not interested in losing weight (135), with 86 patients declining the study for other reasons. The remaining 212 patients were randomized to 6 months of usual care or usual care plus the free MyFitnessPal app. Research assistants helped patients download the app during a regular clinic visit, showed them an instructional video developed by MyFitnessPal, and followed up a week later with a phone call to assist patients with any technical problems with the app.
Not much weight was lost in the following 6 months. The app group lost a mean of 0.03 kg and the control group gained a mean of 0.3 kg, a 0.3-kg difference between groups that was not statistically significant, Dr. Brian Y. Laing and his associates reported (Ann. Intern. Med. 2014 Nov. 18 [doi:10.7326/M13-3005]). Among the 158 patients with 6-month measurements, 13 of 71 in the app group lost 2.7 kg or more (18%), as did 14 of 87 in the control group (16%).
The groups also did not differ significantly in changes in systolic blood pressure, with the app group losing a mean of 0.3 mm Hg and the control group gaining a mean of 1.5 mm Hg, reported Dr. Laing, now of the Los Angeles County Department of Health Services.
Patients in the app group seldom bothered to open it after the first month, with open rates dropping from 94 patients in the first month (97%) to 34 patients in the sixth month (35%). The ones who stopped using it complained in a survey that the app was “tedious,” or said they were too busy or stressed to use it, or dropped it for other reasons.
There were a few hopeful signs, however, Dr. Laing said in an interview. A few patients continued using the app at least 30 times in month 6. The app group was more likely to report using a “personal calorie goal” significantly more often than the control group – a mean of 2 days per week, compared with a quarter-day per week, respectively. And perhaps outcomes might have been better if physicians instead of research assistants had introduced patients to the app and followed up, he speculated.
Success may depend more on the patient’s readiness for change than on the app itself. “There was a subset of patients who used the app a lot and appeared to lose more weight, but on average, there wasn’t a significant difference between the groups. I think what it tells us is the app still can be a very powerful tool for patients who are truly motivated to track calories, but not for everyone,” said Dr. Laing, who works on operational issues for the county and practices part-time as a family physician in a county clinic.
Dr. Laing still recommends MyFitnessPal to overweight patients if they answer his questions by saying they’re interested in losing weight and enjoy using a smartphone. But he adds a warning: If you want the app to work, “you’ll have to put some time into this” and spend 5 minutes or so entering calories at each meal.
“I’m a primary care physician. One thing we struggle with is the 10- to 15-minute visit. I think about how we can help patients lead healthy lives when they’re not in front of us except for 10 minutes twice a year,” he said. For the right patients, apps could help, he believes.
Dr. Laing was one of the investigators in a previous study that evaluated the quality of 23 of the top-rated free health and fitness apps. The apps seldom employed evidence-based theories of behavior change, they found. The mean behavioral theory score was 8 out of 100, and the mean persuasive technology score on the Fogg Behavioral Model was 2 out of a possible 6. The top-scoring app on both scales was Lose It! (Am. J. Prev. Med. 2013;45:583-9).
A separate study by other investigators rated 62 apps for the prevention of pediatric obesity and found that the apps were likely to incorporate expert-recommended behaviors such as eating five servings of fruit or vegetables per day (94%) but few adhered to expert-recommended strategies such as self-monitoring diet and physical activity (21%). Approximately half the apps addressed physical activity and consumption of fruit or vegetables and only 2% of apps addressed the child’s amount of screen time or the importance of family meals together, among other important behaviors (Child. Obes. 2014;10:132-44).
The company Weight Watchers funded a randomized study of 292 participants in the company’s programs that found they lost more weight by attending its in-person meetings than by using its app or online tools (Am. J. Med. 2013;126:1143e19-1143.324).
Dr. Laing reported having no financial disclosures. MyFitnessPal shared users’ log-on data with investigators for the study.
On Twitter @sherryboschert
Introducing overweight patients to one of the most popular weight-loss apps didn’t help them shed pounds in a prospective, randomized, controlled trial with 212 patients in primary care clinics.
The two-clinic study screened 633 patients with a body mass index of at least 25 kg/m2, most of whom did not own a smartphone (421) or were not interested in losing weight (135), with 86 patients declining the study for other reasons. The remaining 212 patients were randomized to 6 months of usual care or usual care plus the free MyFitnessPal app. Research assistants helped patients download the app during a regular clinic visit, showed them an instructional video developed by MyFitnessPal, and followed up a week later with a phone call to assist patients with any technical problems with the app.
Not much weight was lost in the following 6 months. The app group lost a mean of 0.03 kg and the control group gained a mean of 0.3 kg, a 0.3-kg difference between groups that was not statistically significant, Dr. Brian Y. Laing and his associates reported (Ann. Intern. Med. 2014 Nov. 18 [doi:10.7326/M13-3005]). Among the 158 patients with 6-month measurements, 13 of 71 in the app group lost 2.7 kg or more (18%), as did 14 of 87 in the control group (16%).
The groups also did not differ significantly in changes in systolic blood pressure, with the app group losing a mean of 0.3 mm Hg and the control group gaining a mean of 1.5 mm Hg, reported Dr. Laing, now of the Los Angeles County Department of Health Services.
Patients in the app group seldom bothered to open it after the first month, with open rates dropping from 94 patients in the first month (97%) to 34 patients in the sixth month (35%). The ones who stopped using it complained in a survey that the app was “tedious,” or said they were too busy or stressed to use it, or dropped it for other reasons.
There were a few hopeful signs, however, Dr. Laing said in an interview. A few patients continued using the app at least 30 times in month 6. The app group was more likely to report using a “personal calorie goal” significantly more often than the control group – a mean of 2 days per week, compared with a quarter-day per week, respectively. And perhaps outcomes might have been better if physicians instead of research assistants had introduced patients to the app and followed up, he speculated.
Success may depend more on the patient’s readiness for change than on the app itself. “There was a subset of patients who used the app a lot and appeared to lose more weight, but on average, there wasn’t a significant difference between the groups. I think what it tells us is the app still can be a very powerful tool for patients who are truly motivated to track calories, but not for everyone,” said Dr. Laing, who works on operational issues for the county and practices part-time as a family physician in a county clinic.
Dr. Laing still recommends MyFitnessPal to overweight patients if they answer his questions by saying they’re interested in losing weight and enjoy using a smartphone. But he adds a warning: If you want the app to work, “you’ll have to put some time into this” and spend 5 minutes or so entering calories at each meal.
“I’m a primary care physician. One thing we struggle with is the 10- to 15-minute visit. I think about how we can help patients lead healthy lives when they’re not in front of us except for 10 minutes twice a year,” he said. For the right patients, apps could help, he believes.
Dr. Laing was one of the investigators in a previous study that evaluated the quality of 23 of the top-rated free health and fitness apps. The apps seldom employed evidence-based theories of behavior change, they found. The mean behavioral theory score was 8 out of 100, and the mean persuasive technology score on the Fogg Behavioral Model was 2 out of a possible 6. The top-scoring app on both scales was Lose It! (Am. J. Prev. Med. 2013;45:583-9).
A separate study by other investigators rated 62 apps for the prevention of pediatric obesity and found that the apps were likely to incorporate expert-recommended behaviors such as eating five servings of fruit or vegetables per day (94%) but few adhered to expert-recommended strategies such as self-monitoring diet and physical activity (21%). Approximately half the apps addressed physical activity and consumption of fruit or vegetables and only 2% of apps addressed the child’s amount of screen time or the importance of family meals together, among other important behaviors (Child. Obes. 2014;10:132-44).
The company Weight Watchers funded a randomized study of 292 participants in the company’s programs that found they lost more weight by attending its in-person meetings than by using its app or online tools (Am. J. Med. 2013;126:1143e19-1143.324).
Dr. Laing reported having no financial disclosures. MyFitnessPal shared users’ log-on data with investigators for the study.
On Twitter @sherryboschert
5 ways to convey empathy via digital technology
The influence of technology on the patient-physician relationship has been the subject of many discussions and publications. While a physician facing a computer screen throughout much of the office encounter is a vision no one believes is in the best interest of either the patient or the relationship, empathy as an admired professional trait and a successful tool in medicine is gaining support among the medical establishment. The question as to whether physicians can learn empathy has been examined. The benefits (real or potential) of digital technology in revitalizing this human interaction and technology’s potential to convey empathy must be considered. I will attempt to place some of these tools in a bit of a new light.
1. Encourage patients to utilize the patient portal.
Stage 2 of meaningful use requires that 5% of Medicare patients receive information via a patient portal; this has resulted in little less than an exercise in compliance. True interaction via the portal is not taking place. The catch-22 is that the portals provided by electronic health record (EHR) vendors are the least costly, but also the least useful. Providers are not enthusiastic about portals for good reason. Clinicians are fearful that office workflow cannot accommodate the potential volume of digital interactions. They also do not have the digital tools necessary to make the portal experience as beneficial as it can be.
Notwithstanding these barriers, I believe that a physician who encourages the use of the portal with conversations focused on patients’ participation in their own care will be seen as empathetic. Stressing the fact that the patient is being given a tool that delivers information (even if it is only a lab result) portrays the provider as a partner in care. The patient portal is the starting point of introducing patients to digital health technology. If it is the portal which is closest to the patient’s care touch point, other technologies will seem less intimidating and more relevant.
2. Prescribe apps and websites.
The days of a physician’s rolling eyes at a patient’s mention of information garnered on the Internet should be over. More than 90% of physicians use reference apps to treat patients. The power of digital technology to educate patients cannot be minimized. According to the Pew Research Internet Project (2013), one in three American adults have gone online to self-diagnose. Physicians agreed with that diagnosis 41% of the time. Is this reason to tout the Internet as a clinical diagnostician? I would hope not. However, it does demonstrate that the Digital Age of health care has arrived. It cannot be ignored. In the United Kingdom, the National Health Service will begin accrediting apps to be prescribed in 2015. If one thinks of patient education and self-monitoring instructions as important for patient care, then the natural extension of digitally delivering these tools should not send shock waves across the landscape. IMS Health offers technology for the prescribing of health apps and analytics for apps. Clearly, obstacles remain for app prescribing to enter mainstream medicine, the most significant being quality assurance regarding clinical effectiveness and data privacy and security. However, there are some excellent apps from which patients can benefit. In the nutritional arena, GoMeals and Fooducate are useful, as is Alivecor ECG for symptomatic heart rhythm monitoring. There are also several good smoking cessation apps. Further, there are text messaging programs which have proved not only popular but effective, specifically the smoking cessation offering SmokefreeTXT and the prenatal care program text4baby.
3. Participate in social media.
In 2010, the American Medical Association adopted guidelines for professionalism in social media. Among 22 other interesting statistics on health care in social media, are these two: More than 40% of consumers say that information found via social media affects the way they deal with their health, and 60% of social media users are the most likely to trust social media posts and activity by doctors over any other group.
4. Have your hospital start online patient support groups.
There are relative benefits to both in-person support groups and online patient support groups. My mother was a patient at a major cancer center, and I tweeted asking whether they had an online support group, as my mother enjoyed the in-person meetings, which she could no longer attend. The hospital account, having realized the importance of such outreach, responded with the establishment of an online group the following week. This type of patient service creates a sense of health care community, which is invaluable to both patient satisfaction and provider-patient relationships.
5. Utilize mobile technologies to facilitate patient engagement via self-monitoring.
The mere suggestion of recommending an app to have a patient log their blood pressure or follow their glucose is a signal of the importance of shared management and decision making. Apps that allow a person to track their activity or food consumption are simple yet meaningful. Patients are longing for tools they can use themselves or utilize as caregivers.
Empathy can be conveyed directly as emotional support or indirectly with actions described above. It is ironic that technology, cold and inhumane in a solitary context, can be transformed and seen as empathetic if it is offered in a humanistic way.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.
The influence of technology on the patient-physician relationship has been the subject of many discussions and publications. While a physician facing a computer screen throughout much of the office encounter is a vision no one believes is in the best interest of either the patient or the relationship, empathy as an admired professional trait and a successful tool in medicine is gaining support among the medical establishment. The question as to whether physicians can learn empathy has been examined. The benefits (real or potential) of digital technology in revitalizing this human interaction and technology’s potential to convey empathy must be considered. I will attempt to place some of these tools in a bit of a new light.
1. Encourage patients to utilize the patient portal.
Stage 2 of meaningful use requires that 5% of Medicare patients receive information via a patient portal; this has resulted in little less than an exercise in compliance. True interaction via the portal is not taking place. The catch-22 is that the portals provided by electronic health record (EHR) vendors are the least costly, but also the least useful. Providers are not enthusiastic about portals for good reason. Clinicians are fearful that office workflow cannot accommodate the potential volume of digital interactions. They also do not have the digital tools necessary to make the portal experience as beneficial as it can be.
Notwithstanding these barriers, I believe that a physician who encourages the use of the portal with conversations focused on patients’ participation in their own care will be seen as empathetic. Stressing the fact that the patient is being given a tool that delivers information (even if it is only a lab result) portrays the provider as a partner in care. The patient portal is the starting point of introducing patients to digital health technology. If it is the portal which is closest to the patient’s care touch point, other technologies will seem less intimidating and more relevant.
2. Prescribe apps and websites.
The days of a physician’s rolling eyes at a patient’s mention of information garnered on the Internet should be over. More than 90% of physicians use reference apps to treat patients. The power of digital technology to educate patients cannot be minimized. According to the Pew Research Internet Project (2013), one in three American adults have gone online to self-diagnose. Physicians agreed with that diagnosis 41% of the time. Is this reason to tout the Internet as a clinical diagnostician? I would hope not. However, it does demonstrate that the Digital Age of health care has arrived. It cannot be ignored. In the United Kingdom, the National Health Service will begin accrediting apps to be prescribed in 2015. If one thinks of patient education and self-monitoring instructions as important for patient care, then the natural extension of digitally delivering these tools should not send shock waves across the landscape. IMS Health offers technology for the prescribing of health apps and analytics for apps. Clearly, obstacles remain for app prescribing to enter mainstream medicine, the most significant being quality assurance regarding clinical effectiveness and data privacy and security. However, there are some excellent apps from which patients can benefit. In the nutritional arena, GoMeals and Fooducate are useful, as is Alivecor ECG for symptomatic heart rhythm monitoring. There are also several good smoking cessation apps. Further, there are text messaging programs which have proved not only popular but effective, specifically the smoking cessation offering SmokefreeTXT and the prenatal care program text4baby.
3. Participate in social media.
In 2010, the American Medical Association adopted guidelines for professionalism in social media. Among 22 other interesting statistics on health care in social media, are these two: More than 40% of consumers say that information found via social media affects the way they deal with their health, and 60% of social media users are the most likely to trust social media posts and activity by doctors over any other group.
4. Have your hospital start online patient support groups.
There are relative benefits to both in-person support groups and online patient support groups. My mother was a patient at a major cancer center, and I tweeted asking whether they had an online support group, as my mother enjoyed the in-person meetings, which she could no longer attend. The hospital account, having realized the importance of such outreach, responded with the establishment of an online group the following week. This type of patient service creates a sense of health care community, which is invaluable to both patient satisfaction and provider-patient relationships.
5. Utilize mobile technologies to facilitate patient engagement via self-monitoring.
The mere suggestion of recommending an app to have a patient log their blood pressure or follow their glucose is a signal of the importance of shared management and decision making. Apps that allow a person to track their activity or food consumption are simple yet meaningful. Patients are longing for tools they can use themselves or utilize as caregivers.
Empathy can be conveyed directly as emotional support or indirectly with actions described above. It is ironic that technology, cold and inhumane in a solitary context, can be transformed and seen as empathetic if it is offered in a humanistic way.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.
The influence of technology on the patient-physician relationship has been the subject of many discussions and publications. While a physician facing a computer screen throughout much of the office encounter is a vision no one believes is in the best interest of either the patient or the relationship, empathy as an admired professional trait and a successful tool in medicine is gaining support among the medical establishment. The question as to whether physicians can learn empathy has been examined. The benefits (real or potential) of digital technology in revitalizing this human interaction and technology’s potential to convey empathy must be considered. I will attempt to place some of these tools in a bit of a new light.
1. Encourage patients to utilize the patient portal.
Stage 2 of meaningful use requires that 5% of Medicare patients receive information via a patient portal; this has resulted in little less than an exercise in compliance. True interaction via the portal is not taking place. The catch-22 is that the portals provided by electronic health record (EHR) vendors are the least costly, but also the least useful. Providers are not enthusiastic about portals for good reason. Clinicians are fearful that office workflow cannot accommodate the potential volume of digital interactions. They also do not have the digital tools necessary to make the portal experience as beneficial as it can be.
Notwithstanding these barriers, I believe that a physician who encourages the use of the portal with conversations focused on patients’ participation in their own care will be seen as empathetic. Stressing the fact that the patient is being given a tool that delivers information (even if it is only a lab result) portrays the provider as a partner in care. The patient portal is the starting point of introducing patients to digital health technology. If it is the portal which is closest to the patient’s care touch point, other technologies will seem less intimidating and more relevant.
2. Prescribe apps and websites.
The days of a physician’s rolling eyes at a patient’s mention of information garnered on the Internet should be over. More than 90% of physicians use reference apps to treat patients. The power of digital technology to educate patients cannot be minimized. According to the Pew Research Internet Project (2013), one in three American adults have gone online to self-diagnose. Physicians agreed with that diagnosis 41% of the time. Is this reason to tout the Internet as a clinical diagnostician? I would hope not. However, it does demonstrate that the Digital Age of health care has arrived. It cannot be ignored. In the United Kingdom, the National Health Service will begin accrediting apps to be prescribed in 2015. If one thinks of patient education and self-monitoring instructions as important for patient care, then the natural extension of digitally delivering these tools should not send shock waves across the landscape. IMS Health offers technology for the prescribing of health apps and analytics for apps. Clearly, obstacles remain for app prescribing to enter mainstream medicine, the most significant being quality assurance regarding clinical effectiveness and data privacy and security. However, there are some excellent apps from which patients can benefit. In the nutritional arena, GoMeals and Fooducate are useful, as is Alivecor ECG for symptomatic heart rhythm monitoring. There are also several good smoking cessation apps. Further, there are text messaging programs which have proved not only popular but effective, specifically the smoking cessation offering SmokefreeTXT and the prenatal care program text4baby.
3. Participate in social media.
In 2010, the American Medical Association adopted guidelines for professionalism in social media. Among 22 other interesting statistics on health care in social media, are these two: More than 40% of consumers say that information found via social media affects the way they deal with their health, and 60% of social media users are the most likely to trust social media posts and activity by doctors over any other group.
4. Have your hospital start online patient support groups.
There are relative benefits to both in-person support groups and online patient support groups. My mother was a patient at a major cancer center, and I tweeted asking whether they had an online support group, as my mother enjoyed the in-person meetings, which she could no longer attend. The hospital account, having realized the importance of such outreach, responded with the establishment of an online group the following week. This type of patient service creates a sense of health care community, which is invaluable to both patient satisfaction and provider-patient relationships.
5. Utilize mobile technologies to facilitate patient engagement via self-monitoring.
The mere suggestion of recommending an app to have a patient log their blood pressure or follow their glucose is a signal of the importance of shared management and decision making. Apps that allow a person to track their activity or food consumption are simple yet meaningful. Patients are longing for tools they can use themselves or utilize as caregivers.
Empathy can be conveyed directly as emotional support or indirectly with actions described above. It is ironic that technology, cold and inhumane in a solitary context, can be transformed and seen as empathetic if it is offered in a humanistic way.
Dr. Scher is an electrophysiologist with the Heart Group of Lancaster (Pa.) General Health. He is also director of DLS Healthcare Consulting, Harrisburg, Pa., and clinical associate professor of medicine at the Pennsylvania State University, Hershey.