Commentary

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).

Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?

Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making.  The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.

What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.

Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.

Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.

In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.

Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.

“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.

In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.

So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.

Dr. Rikkers is Editor in Chief of ACS Surgery News

According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.

Initial assessment

The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.

Testing

The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.

It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.

Immunization and preventive health screening

Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:

• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.

• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.

• Influenza. Annual flu shot should be given.

• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.

• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.

Ongoing monitoring

The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.

CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A_1c, and liver function studies all require frequent monitoring.

Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.

The bottom line

The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.

References

Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.

Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.

According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.

Initial assessment

The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.

Testing

The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.

It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.

Immunization and preventive health screening

Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:

• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.

• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.

• Influenza. Annual flu shot should be given.

• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.

• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.

Ongoing monitoring

The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.

CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A_1c, and liver function studies all require frequent monitoring.

Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.

The bottom line

The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.

References

Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.

Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.

According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.

Initial assessment

The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.

Testing

The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.

It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.

Immunization and preventive health screening

Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:

• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.

• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.

• Influenza. Annual flu shot should be given.

• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.

• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.

Ongoing monitoring

The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.

CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A_1c, and liver function studies all require frequent monitoring.

Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.

The bottom line

The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.

References

Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.

Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.

How often have you read "Neighbor Rosicky" by Willa Cather?

Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.

It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.

At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.

I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.

But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.

It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").

So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often have you read "Neighbor Rosicky" by Willa Cather?

Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.

It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.

At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.

I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.

But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.

It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").

So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How often have you read "Neighbor Rosicky" by Willa Cather?

Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.

It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.

At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.

I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.

But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.

It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").

So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!

Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?

Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.

There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"

The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.

It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).

Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!

But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.

Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.

Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.

How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.

Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.

Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.

Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.

To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!

Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?

Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.

There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"

The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.

It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).

Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!

But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.

Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.

Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.

How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.

Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.

Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.

Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.

To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!

Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?

Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.

There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"

The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.

It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).

Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!

But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.

Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.

Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.

How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.

Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.

Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.

Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.

To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.

The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.

Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.¹

As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.

They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.

We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.

Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.

Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.^2-4

Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.

The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.

Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.¹

As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.

They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.

We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.

Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.

Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.^2-4

Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.

The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.

Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.¹

As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.

They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.

We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.

Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.

Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.^2-4

Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.