Commentary

If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.

I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.

As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.

The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.

Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.

Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!

Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.

I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."

Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.

I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.

For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.

Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.

Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.

Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, 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].

If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.

I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.

As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.

The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.

Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.

Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!

Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.

I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."

Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.

I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.

For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.

Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.

Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.

Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, 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].

If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.

I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.

As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.

The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.

Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.

Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!

Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.

I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."

Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.

I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.

For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.

Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.

Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.

Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, 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].

Just my two cents. Have never been on a cruise. My wife thinks it's a bunch of old people eating too much and being entertained by a guy from the Catskills. Although my brother just completed an Alaskan cruise last week—his first. And the good news, he and his wife are still speaking.

Regarding health issues—your friend's wife's death sure was astonishing with regard to rapidity. Don't know that anything would have made a difference. There are going to be rare events like this, and there is no doubt that you do expose yourself to some medical isolation when going on a cruise.

I have to think that the ship physicians have to meet some minimum standards (although I don't know this).  A fellow I know in Florida, who's an emergency physician and apparently has the job of supplying the doctors for one of the large cruise lines, thinks it would be relatively easy to find certified emergency physicians.

And all of us on the dole, otherwise known as Medicare, should be immunized against flu, meningococcal infection, and herpes zoster. I would think the safest cruise would be one to Alaska, because you are close to shore lots of the time—which is not necessarily the case in cruises to the tropics.

Would give me grave concern if I had to be taken off a ship and sent to a hospital in some third world country (otherwise known as most of the tropics). I guess if you have some pre-existing significant medical problems, you could opt for the travel insurance that covers this sort of thing.

But the bottom line: Yes, you are assuming some health risks when you go on a cruise, but you could be assuming some similar risks if you go on a vacation to Mexico or most anywhere else outside the United States except, perhaps, major metropolitan areas. Yes, we spend twice as much per capita than anyone else on the planet for health care, but most of the time, if you really need it, we have great access to emergency care on dry land in the US. 

Just my two cents. Have never been on a cruise. My wife thinks it's a bunch of old people eating too much and being entertained by a guy from the Catskills. Although my brother just completed an Alaskan cruise last week—his first. And the good news, he and his wife are still speaking.

Regarding health issues—your friend's wife's death sure was astonishing with regard to rapidity. Don't know that anything would have made a difference. There are going to be rare events like this, and there is no doubt that you do expose yourself to some medical isolation when going on a cruise.

I have to think that the ship physicians have to meet some minimum standards (although I don't know this).  A fellow I know in Florida, who's an emergency physician and apparently has the job of supplying the doctors for one of the large cruise lines, thinks it would be relatively easy to find certified emergency physicians.

And all of us on the dole, otherwise known as Medicare, should be immunized against flu, meningococcal infection, and herpes zoster. I would think the safest cruise would be one to Alaska, because you are close to shore lots of the time—which is not necessarily the case in cruises to the tropics.

Would give me grave concern if I had to be taken off a ship and sent to a hospital in some third world country (otherwise known as most of the tropics). I guess if you have some pre-existing significant medical problems, you could opt for the travel insurance that covers this sort of thing.

But the bottom line: Yes, you are assuming some health risks when you go on a cruise, but you could be assuming some similar risks if you go on a vacation to Mexico or most anywhere else outside the United States except, perhaps, major metropolitan areas. Yes, we spend twice as much per capita than anyone else on the planet for health care, but most of the time, if you really need it, we have great access to emergency care on dry land in the US. 

Just my two cents. Have never been on a cruise. My wife thinks it's a bunch of old people eating too much and being entertained by a guy from the Catskills. Although my brother just completed an Alaskan cruise last week—his first. And the good news, he and his wife are still speaking.

Regarding health issues—your friend's wife's death sure was astonishing with regard to rapidity. Don't know that anything would have made a difference. There are going to be rare events like this, and there is no doubt that you do expose yourself to some medical isolation when going on a cruise.

I have to think that the ship physicians have to meet some minimum standards (although I don't know this).  A fellow I know in Florida, who's an emergency physician and apparently has the job of supplying the doctors for one of the large cruise lines, thinks it would be relatively easy to find certified emergency physicians.

And all of us on the dole, otherwise known as Medicare, should be immunized against flu, meningococcal infection, and herpes zoster. I would think the safest cruise would be one to Alaska, because you are close to shore lots of the time—which is not necessarily the case in cruises to the tropics.

Would give me grave concern if I had to be taken off a ship and sent to a hospital in some third world country (otherwise known as most of the tropics). I guess if you have some pre-existing significant medical problems, you could opt for the travel insurance that covers this sort of thing.

But the bottom line: Yes, you are assuming some health risks when you go on a cruise, but you could be assuming some similar risks if you go on a vacation to Mexico or most anywhere else outside the United States except, perhaps, major metropolitan areas. Yes, we spend twice as much per capita than anyone else on the planet for health care, but most of the time, if you really need it, we have great access to emergency care on dry land in the US. 

Coming to the end of yet another school physical season, my mind is focused on anticipatory guidance and well child care. Inevitably, nutrition is a main focus of these back to school visits – a very common question is, "Should my child take a vitamin?" While there are relatively clear recommendations for vitamin supplementation in infancy, there seems to be less clear consensus regarding vitamin supplementation in toddlers and school-aged children. Over my years of practice, I have developed a few guiding principles for my recommendations, which have definitely evolved over the years as more evidence becomes available.

• I always ask if a child is taking any kind of vitamin or other supplementation. Routine supplementation with a standard children’s multivitamin is very safe, and I essentially never discourage it. However, high doses of vitamins can be dangerous. Without being asked, most parents don’t think to mention vitamin use, but it is definitely something I want to know.

• For children who are not taking vitamins, but whose parents have concerns about their diet, I recommend a standard chewable multivitamin with iron. The risks of this type of vitamin supplementation are low, and the potential benefits great if a child isn’t getting everything he or she needs through the diet. Of course, I also take the opportunity to discuss strategies for improving diet and nutrition, since that is the best way to get your vitamins and minerals! For children who seem to have healthy well-balanced diets, I suggest it to parents as an option to consider. My recommendation in this situation is less strong, and more driven by parent preference. That said, I do let parents know that even children with seemingly good diets can sometimes not be getting enough of particular vitamins or minerals, most typically vitamin D, iron, or calcium.

• If a child is taking vitamins, or the parent is considering starting the child on vitamins, I recommend standard chewable children’s multivitamins (whatever brand is on sale) rather than gummy vitamins. Many brands of gummy vitamins have lower amounts of vitamin D or other vitamins than do their chewable counterparts. If a child really prefers gummy vitamins, I recommend that parents carefully compare the nutritional information to be sure that if they are going through the expense and trouble of giving a daily vitamin the child is getting all the vitamins and minerals that he or she needs. Lastly, parents should be reminded that vitamins are medications and should be safely stored! Thoughtfully used, vitamin supplements can be an important part of a healthy child’s nutrition.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

Coming to the end of yet another school physical season, my mind is focused on anticipatory guidance and well child care. Inevitably, nutrition is a main focus of these back to school visits – a very common question is, "Should my child take a vitamin?" While there are relatively clear recommendations for vitamin supplementation in infancy, there seems to be less clear consensus regarding vitamin supplementation in toddlers and school-aged children. Over my years of practice, I have developed a few guiding principles for my recommendations, which have definitely evolved over the years as more evidence becomes available.

• I always ask if a child is taking any kind of vitamin or other supplementation. Routine supplementation with a standard children’s multivitamin is very safe, and I essentially never discourage it. However, high doses of vitamins can be dangerous. Without being asked, most parents don’t think to mention vitamin use, but it is definitely something I want to know.

• For children who are not taking vitamins, but whose parents have concerns about their diet, I recommend a standard chewable multivitamin with iron. The risks of this type of vitamin supplementation are low, and the potential benefits great if a child isn’t getting everything he or she needs through the diet. Of course, I also take the opportunity to discuss strategies for improving diet and nutrition, since that is the best way to get your vitamins and minerals! For children who seem to have healthy well-balanced diets, I suggest it to parents as an option to consider. My recommendation in this situation is less strong, and more driven by parent preference. That said, I do let parents know that even children with seemingly good diets can sometimes not be getting enough of particular vitamins or minerals, most typically vitamin D, iron, or calcium.

• If a child is taking vitamins, or the parent is considering starting the child on vitamins, I recommend standard chewable children’s multivitamins (whatever brand is on sale) rather than gummy vitamins. Many brands of gummy vitamins have lower amounts of vitamin D or other vitamins than do their chewable counterparts. If a child really prefers gummy vitamins, I recommend that parents carefully compare the nutritional information to be sure that if they are going through the expense and trouble of giving a daily vitamin the child is getting all the vitamins and minerals that he or she needs. Lastly, parents should be reminded that vitamins are medications and should be safely stored! Thoughtfully used, vitamin supplements can be an important part of a healthy child’s nutrition.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

Coming to the end of yet another school physical season, my mind is focused on anticipatory guidance and well child care. Inevitably, nutrition is a main focus of these back to school visits – a very common question is, "Should my child take a vitamin?" While there are relatively clear recommendations for vitamin supplementation in infancy, there seems to be less clear consensus regarding vitamin supplementation in toddlers and school-aged children. Over my years of practice, I have developed a few guiding principles for my recommendations, which have definitely evolved over the years as more evidence becomes available.

• I always ask if a child is taking any kind of vitamin or other supplementation. Routine supplementation with a standard children’s multivitamin is very safe, and I essentially never discourage it. However, high doses of vitamins can be dangerous. Without being asked, most parents don’t think to mention vitamin use, but it is definitely something I want to know.

• For children who are not taking vitamins, but whose parents have concerns about their diet, I recommend a standard chewable multivitamin with iron. The risks of this type of vitamin supplementation are low, and the potential benefits great if a child isn’t getting everything he or she needs through the diet. Of course, I also take the opportunity to discuss strategies for improving diet and nutrition, since that is the best way to get your vitamins and minerals! For children who seem to have healthy well-balanced diets, I suggest it to parents as an option to consider. My recommendation in this situation is less strong, and more driven by parent preference. That said, I do let parents know that even children with seemingly good diets can sometimes not be getting enough of particular vitamins or minerals, most typically vitamin D, iron, or calcium.

• If a child is taking vitamins, or the parent is considering starting the child on vitamins, I recommend standard chewable children’s multivitamins (whatever brand is on sale) rather than gummy vitamins. Many brands of gummy vitamins have lower amounts of vitamin D or other vitamins than do their chewable counterparts. If a child really prefers gummy vitamins, I recommend that parents carefully compare the nutritional information to be sure that if they are going through the expense and trouble of giving a daily vitamin the child is getting all the vitamins and minerals that he or she needs. Lastly, parents should be reminded that vitamins are medications and should be safely stored! Thoughtfully used, vitamin supplements can be an important part of a healthy child’s nutrition.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.

The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.

Courtesy of George Washington University.

At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, compared with 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.

Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.

The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with shorter follow-up and no biochemical verification of quit rates, Dr. Abroms said.

Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.

People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.

Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.

Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she suggested.

Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.

She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit or stay quit (Am. J. Prev. Med. 2013;45:732-36).

On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested. Approximately 779,400 English-language apps for smoking cessation were downloaded per month for Android phones alone during the study period. (The iTunes App Store does not provide numbers for downloads.) That’s more than the approximately 100,000 calls per month to the national quit line in the same time period and 200,000 unique visitors per month to a leading website for smoking cessation, she reported.

"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."

A separate study found that an experimental "decision support system" app, created for use by nurses on smartphones and tablets, improved rates of screening and counseling for tobacco use by prompting nurses to screen for tobacco use and offered guideline-based treatment recommendations, reported Kenrick Cato, Ph.D. of Columbia University, New York, and his associates.

The 185 registered nurses who were enrolled in advanced practice degree programs handled 14,115 clinic visits, in which they asked patients about smoking status in 84% of visits and offered cessation counseling to 90% of those who expressed a willingness to stop smoking (Oncol. Nurs. Forum 2014;41:145-52).

That compares favorably with federal U.S. data suggesting that tobacco screening happens in approximately 60% of clinic visits, and fewer than 20% of patients get counseling on quitting, Dr. Cato said in a prepared statement released by the university. The federal Healthy People 2020 program aims for tobacco screening in 69% of office visits and counseling rates of 21%, he said.

If further development of the app confirms that it’s useful, it could light a fire under tobacco screening.

Dr. Abroms designed Text2Quit and receives royalties from sales. Dr. Cato reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.

The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.

Courtesy of George Washington University.

At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, compared with 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.

Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.

The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with shorter follow-up and no biochemical verification of quit rates, Dr. Abroms said.

Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.

People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.

Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.

Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she suggested.

Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.

She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit or stay quit (Am. J. Prev. Med. 2013;45:732-36).

On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested. Approximately 779,400 English-language apps for smoking cessation were downloaded per month for Android phones alone during the study period. (The iTunes App Store does not provide numbers for downloads.) That’s more than the approximately 100,000 calls per month to the national quit line in the same time period and 200,000 unique visitors per month to a leading website for smoking cessation, she reported.

"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."

A separate study found that an experimental "decision support system" app, created for use by nurses on smartphones and tablets, improved rates of screening and counseling for tobacco use by prompting nurses to screen for tobacco use and offered guideline-based treatment recommendations, reported Kenrick Cato, Ph.D. of Columbia University, New York, and his associates.

The 185 registered nurses who were enrolled in advanced practice degree programs handled 14,115 clinic visits, in which they asked patients about smoking status in 84% of visits and offered cessation counseling to 90% of those who expressed a willingness to stop smoking (Oncol. Nurs. Forum 2014;41:145-52).

That compares favorably with federal U.S. data suggesting that tobacco screening happens in approximately 60% of clinic visits, and fewer than 20% of patients get counseling on quitting, Dr. Cato said in a prepared statement released by the university. The federal Healthy People 2020 program aims for tobacco screening in 69% of office visits and counseling rates of 21%, he said.

If further development of the app confirms that it’s useful, it could light a fire under tobacco screening.

Dr. Abroms designed Text2Quit and receives royalties from sales. Dr. Cato reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.

The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.

Courtesy of George Washington University.

At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, compared with 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.

Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.

The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with shorter follow-up and no biochemical verification of quit rates, Dr. Abroms said.

Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.

People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.

Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.

Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she suggested.

Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.

She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit or stay quit (Am. J. Prev. Med. 2013;45:732-36).

On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested. Approximately 779,400 English-language apps for smoking cessation were downloaded per month for Android phones alone during the study period. (The iTunes App Store does not provide numbers for downloads.) That’s more than the approximately 100,000 calls per month to the national quit line in the same time period and 200,000 unique visitors per month to a leading website for smoking cessation, she reported.

"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."

A separate study found that an experimental "decision support system" app, created for use by nurses on smartphones and tablets, improved rates of screening and counseling for tobacco use by prompting nurses to screen for tobacco use and offered guideline-based treatment recommendations, reported Kenrick Cato, Ph.D. of Columbia University, New York, and his associates.

The 185 registered nurses who were enrolled in advanced practice degree programs handled 14,115 clinic visits, in which they asked patients about smoking status in 84% of visits and offered cessation counseling to 90% of those who expressed a willingness to stop smoking (Oncol. Nurs. Forum 2014;41:145-52).

That compares favorably with federal U.S. data suggesting that tobacco screening happens in approximately 60% of clinic visits, and fewer than 20% of patients get counseling on quitting, Dr. Cato said in a prepared statement released by the university. The federal Healthy People 2020 program aims for tobacco screening in 69% of office visits and counseling rates of 21%, he said.

If further development of the app confirms that it’s useful, it could light a fire under tobacco screening.

Dr. Abroms designed Text2Quit and receives royalties from sales. Dr. Cato reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.

Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.

Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan¹ examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.¹

Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.¹ Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.¹

Asan et al² quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).²

As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.

In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.

Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.

Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan¹ examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.¹

Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.¹ Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.¹

Asan et al² quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).²

As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.

In this time of evolving medical care, many factors are impinging on the physician-patient relationship. Unfortunately, one of the biggest barriers between our patients and us is a computer screen.

Before I started using an electronic health record (EHR) nearly 4 years ago, I was very anxious about the transition. How would I be able to maintain my patient volume while trying to create a comprehensive electronic document for each patient? Now I love my EHR. It creates a beautiful note quickly and effectively, and I can check all of my medical records from any location. I love e-prescribing, and, best of all, there is never a lost medical record. As I have become more connected to my EHR, however, I think my patients sometimes feel left out. As many of us can attest, it is often hard to maintain good eye contact and communication with patients while completing their electronic record.

Recently, several studies have evaluated the effects of novel technologies on interactions between the patient and health care professionals (HCPs). Montague and Asan¹ examined eye gaze patterns between patients and HCPs while EHRs were used to support patient care. Gaze was used because it provides a more objective and measurable indication of attention and communication. In their study, patient visits were recorded using 3 high-resolution video cameras placed at different angles to accurately capture gaze and avoid ambiguity of the gaze direction caused by a single camera angle. One hundred patients and 10 HCPs participated in the study.¹

Results indicated that on average HCPs spent nearly one-third of the visit length gazing at the EHR.¹ Paper medical records also were used during 79% of the visits with HCPs spending approximately 9% of the visit length gazing at the record. There were times when the patient gaze was undetermined and accounted for more than 28% of the visit length. This unknown gaze might have occurred when the HCP used the computer and the patient disengaged eye contact with the HCP. Another scenario recorded was when patients gazed at the HCP and the HCP gazed at the EHR, an event that accounted for more than 21% of the visit time. The investigators concluded that the patient-physician eye contact dynamic differed with EHRs compared to paper medical records. They also noted that when HCPs spent too much time looking at the computer screen in the examination room, nonverbal cues might have been overlooked. Also, the HCP’s ability to pay attention and communicate with patients was affected.¹

Asan et al² quantitatively examined and compared clinically experienced physician interactions with patients using paper medical records or EHRs in ambulatory primary care settings. Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits—40 with paper and 40 with EHRs—were recorded. The proportion of time physicians spent gazing at medical records was significantly more during EHR visits compared to paper chart visits (35.2% vs 22.1%; P=.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared to a paper medical record (52.6% vs 45.6%; P=.041).²

As our use of EHRs increases and evolves, it will be important to factor in these issues to maintain the centrality of the physician-patient rapport. We should attempt to place the computer screen and the patient in physical locations that facilitate the ability to maximally interact with the patient while entering the data. It will be important for those who design the next generation of EHRs to do so with this communication in mind. Until then, I will do my best to give the appropriate attention to both my patient and my EHR.