Commentary

Living in Washington, a very multicultural community, I am regularly asked by parents about bilingual language development. Sometimes this is when the parents’ primary language is something other than English, and sometimes it is when parents are considering bilingual school placements (including, in full disclosure, my children’s own school). Frequently, families raise concerns about the impact bilingual education will have on their young child’s language development, their ability to attain fluency in the English language, or to even to learn in other languages.

First, and foremost, I am able to reassure parents that the preponderance of research – an evidence base that is rapidly growing – suggests that bilingual education does not cause language delays or problems with English fluency. In fact, there is increasing evidence that bilingual education actually has linguistic and cognitive advantages for children’s education and ability to learn. That said there are some unique things for parents and providers to be aware of during the period of language acquisition. One area that causes frequent confusion is that young children – younger than age 2 years – may appear to be language delayed if both languages are not assessed. For a typically developing bilingual child, some of his or her emerging words may be in one language, some may be in the other. Assessed independently, delays may appear to be present, but assessed together language development is right on track. Not uncommonly, young children "mix and match" vocabulary and grammatical syntax in both languages – again, this is a normal part of bilingual language development. As with children in monolingual environments, it is important to provide many and varied stimulating experiences – lots of talking and books no matter how many languages are spoken!

Families whose dominant home language is something other than English should feel comfortable speaking their primary language at home. Children are language sponges and will develop their English language skills normally with routine exposure outside the home and a high-quality school environment. Additionally, there is evidence that English-language learners learn English better and more fluently in a bilingual environment. All of that said, for children whose speech development does not seem to be typical, every effort should be made to have a speech and language evaluation (and therapy if needed) done in the child’s primary language. This can be a challenge in any community, and often requires advocacy and persistence on the part of the pediatrician to identify possible options.

Lastly, bilingual education takes time. The research shows – and my experience as the parent of one bilingual and one emerging bilingual child supports this – that proficiency can take several years and perhaps longer, depending on the richness and intensity of exposures. Parents should be encouraged to ask questions and work closely with their children’s doctors and teachers if there are any questions. Every child is different, and different children may require different supports or approaches.

Finally, my personal observation has convinced me that there are intangible benefits of bilingualism in children. The richness of experience and pride in the accomplishment of learning another language, and the greater understanding my children and their peers have of other cultures and the global community is remarkable. I see them apply these lessons in other and unexpected places (and sometimes dubious ones ... such as when my son’s elementary school soccer team decided to call plays to each other in Spanish in order to outsmart the other team). Both the research and my own personal experience make me very comfortable in reassuring and supporting parents who are hoping to promote bilingual language acquisition in their children.

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.

Living in Washington, a very multicultural community, I am regularly asked by parents about bilingual language development. Sometimes this is when the parents’ primary language is something other than English, and sometimes it is when parents are considering bilingual school placements (including, in full disclosure, my children’s own school). Frequently, families raise concerns about the impact bilingual education will have on their young child’s language development, their ability to attain fluency in the English language, or to even to learn in other languages.

First, and foremost, I am able to reassure parents that the preponderance of research – an evidence base that is rapidly growing – suggests that bilingual education does not cause language delays or problems with English fluency. In fact, there is increasing evidence that bilingual education actually has linguistic and cognitive advantages for children’s education and ability to learn. That said there are some unique things for parents and providers to be aware of during the period of language acquisition. One area that causes frequent confusion is that young children – younger than age 2 years – may appear to be language delayed if both languages are not assessed. For a typically developing bilingual child, some of his or her emerging words may be in one language, some may be in the other. Assessed independently, delays may appear to be present, but assessed together language development is right on track. Not uncommonly, young children "mix and match" vocabulary and grammatical syntax in both languages – again, this is a normal part of bilingual language development. As with children in monolingual environments, it is important to provide many and varied stimulating experiences – lots of talking and books no matter how many languages are spoken!

Families whose dominant home language is something other than English should feel comfortable speaking their primary language at home. Children are language sponges and will develop their English language skills normally with routine exposure outside the home and a high-quality school environment. Additionally, there is evidence that English-language learners learn English better and more fluently in a bilingual environment. All of that said, for children whose speech development does not seem to be typical, every effort should be made to have a speech and language evaluation (and therapy if needed) done in the child’s primary language. This can be a challenge in any community, and often requires advocacy and persistence on the part of the pediatrician to identify possible options.

Lastly, bilingual education takes time. The research shows – and my experience as the parent of one bilingual and one emerging bilingual child supports this – that proficiency can take several years and perhaps longer, depending on the richness and intensity of exposures. Parents should be encouraged to ask questions and work closely with their children’s doctors and teachers if there are any questions. Every child is different, and different children may require different supports or approaches.

Finally, my personal observation has convinced me that there are intangible benefits of bilingualism in children. The richness of experience and pride in the accomplishment of learning another language, and the greater understanding my children and their peers have of other cultures and the global community is remarkable. I see them apply these lessons in other and unexpected places (and sometimes dubious ones ... such as when my son’s elementary school soccer team decided to call plays to each other in Spanish in order to outsmart the other team). Both the research and my own personal experience make me very comfortable in reassuring and supporting parents who are hoping to promote bilingual language acquisition in their children.

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.

Living in Washington, a very multicultural community, I am regularly asked by parents about bilingual language development. Sometimes this is when the parents’ primary language is something other than English, and sometimes it is when parents are considering bilingual school placements (including, in full disclosure, my children’s own school). Frequently, families raise concerns about the impact bilingual education will have on their young child’s language development, their ability to attain fluency in the English language, or to even to learn in other languages.

First, and foremost, I am able to reassure parents that the preponderance of research – an evidence base that is rapidly growing – suggests that bilingual education does not cause language delays or problems with English fluency. In fact, there is increasing evidence that bilingual education actually has linguistic and cognitive advantages for children’s education and ability to learn. That said there are some unique things for parents and providers to be aware of during the period of language acquisition. One area that causes frequent confusion is that young children – younger than age 2 years – may appear to be language delayed if both languages are not assessed. For a typically developing bilingual child, some of his or her emerging words may be in one language, some may be in the other. Assessed independently, delays may appear to be present, but assessed together language development is right on track. Not uncommonly, young children "mix and match" vocabulary and grammatical syntax in both languages – again, this is a normal part of bilingual language development. As with children in monolingual environments, it is important to provide many and varied stimulating experiences – lots of talking and books no matter how many languages are spoken!

Families whose dominant home language is something other than English should feel comfortable speaking their primary language at home. Children are language sponges and will develop their English language skills normally with routine exposure outside the home and a high-quality school environment. Additionally, there is evidence that English-language learners learn English better and more fluently in a bilingual environment. All of that said, for children whose speech development does not seem to be typical, every effort should be made to have a speech and language evaluation (and therapy if needed) done in the child’s primary language. This can be a challenge in any community, and often requires advocacy and persistence on the part of the pediatrician to identify possible options.

Lastly, bilingual education takes time. The research shows – and my experience as the parent of one bilingual and one emerging bilingual child supports this – that proficiency can take several years and perhaps longer, depending on the richness and intensity of exposures. Parents should be encouraged to ask questions and work closely with their children’s doctors and teachers if there are any questions. Every child is different, and different children may require different supports or approaches.

Finally, my personal observation has convinced me that there are intangible benefits of bilingualism in children. The richness of experience and pride in the accomplishment of learning another language, and the greater understanding my children and their peers have of other cultures and the global community is remarkable. I see them apply these lessons in other and unexpected places (and sometimes dubious ones ... such as when my son’s elementary school soccer team decided to call plays to each other in Spanish in order to outsmart the other team). Both the research and my own personal experience make me very comfortable in reassuring and supporting parents who are hoping to promote bilingual language acquisition in their children.

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.

A tablet-based app designed for elderly Spaniards taking multiple medications seemed to improve treatment adherence rates but not clinical outcomes in a randomized controlled study of 99 patients.

The 48 patients in the control group received oral and written information on the safe use of their medications in the 3-month single-blind trial. The other 51 patients took home a tablet computer (either an iPad 2 or a BQ Verne) with a medication self-management app that the investigators created and called ALICE. The app incorporated personalized prescriptions and medical advice from patients’ physicians, showed images of each medication and its packaging, provided alerts and multiple reminders to take a medication, and transmitted monitoring information to a caregiver.

Courtesy Wikimedia Commons/Dvortygirl/Creative Commons

The rate of self-reported adherence (measured on the four-item Morisky Medication Adherence Scale) increased by a significant 28% in the app group and did not change significantly in the control group. The rate of missed doses decreased by a significant 27% in the app group and increased slightly in the control group, reported José Joaquin Mira, Ph.D., and his associates (J. Med. Internet. Res. 2014;16:e99).

The rate of medication errors that involved taking the wrong drug or dose did not change significantly in the app group as a whole but decreased significantly by 41% among patients who had reported making two or more medication errors before the study.

Levels of glycated hemoglobin, blood pressure, and self-perceived health status did not change significantly in either the app or control groups. Cholesterol levels increased by 5% in both groups, which was statistically but not clinically significant, reported Dr. Mira of Miguel Hernández University, Elche, Spain.

"Three months may not be long enough to observe differences" in any clinical effects of using the app, he suggested. On the other hand, it’s unknown whether the app would be effective in the long term.

Of the 99 patients, 72 (73%) took more than five types of drugs per day and 36 were under the care of more than one doctor (36%).

Among the 51 patients in the app group, medication adherence rates at the end of the study were better in the 28 patients who had never used a computer, tablet, or smartphone (55%) than in those who had some familiarity with the technology.

The app users received up to 2 hours of instruction on how to use the app and had a phone number to call for technical support. Support was needed by 30 patients (59%), mostly related to charging the tablet’s battery or restarting the system. Mean satisfaction scores for the app were high (8 out of a possible 10) and 88% of users said the app improved their medication use or helped to a certain extent, with 12% saying it did not help.

The investigators designed the app with input from 23 patients, three physicians, and four pharmacists. "This study should change the expectations of developers and mobile phone companies, encouraging them to develop apps and devices suited to older patients with multimorbidity," Dr. Mira wrote.

Clinical trials of apps to improve medication adherence are in their infancy.

Unpublished results from a separate uncontrolled study of PatientPartner, a mobile game app that offers iterative guidance, suggest that medication adherence improved by 37% (from 37% to 58%) among 100 patients with diabetes who had been nonadherent. Adherence to diet recommendations increased by 24%, adherence to exercise recommendations increased by 14%, and hemoglobin A_1c levels decreased from 10.7% to 9.7%, the company that makes the app reported in a press release.

Investigators at the University of Arkansas, Fayetteville, evaluated 160 currently-available medication adherence apps for smartphones in a separate study, ranked them by the desirability of their features, and then tested the top 10 using a standard medication regimen. Their top three picks were MyMeds (free), RxmindMe (free), and MyMedSchedule (part of a subscription system from MyMeds.com), reported Lindsey Dayer, Pharm.D., and her associates (J. Am. Pharm. Assoc. 2013;53:172-181). Though these aren’t clinical outcomes, it gives medical and pharmacy care providers some basis for recommending one adherence app over another, the investigators suggested.

Dr. Mira and Dr. Dayer reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

A tablet-based app designed for elderly Spaniards taking multiple medications seemed to improve treatment adherence rates but not clinical outcomes in a randomized controlled study of 99 patients.

The 48 patients in the control group received oral and written information on the safe use of their medications in the 3-month single-blind trial. The other 51 patients took home a tablet computer (either an iPad 2 or a BQ Verne) with a medication self-management app that the investigators created and called ALICE. The app incorporated personalized prescriptions and medical advice from patients’ physicians, showed images of each medication and its packaging, provided alerts and multiple reminders to take a medication, and transmitted monitoring information to a caregiver.

Courtesy Wikimedia Commons/Dvortygirl/Creative Commons

The rate of self-reported adherence (measured on the four-item Morisky Medication Adherence Scale) increased by a significant 28% in the app group and did not change significantly in the control group. The rate of missed doses decreased by a significant 27% in the app group and increased slightly in the control group, reported José Joaquin Mira, Ph.D., and his associates (J. Med. Internet. Res. 2014;16:e99).

The rate of medication errors that involved taking the wrong drug or dose did not change significantly in the app group as a whole but decreased significantly by 41% among patients who had reported making two or more medication errors before the study.

Levels of glycated hemoglobin, blood pressure, and self-perceived health status did not change significantly in either the app or control groups. Cholesterol levels increased by 5% in both groups, which was statistically but not clinically significant, reported Dr. Mira of Miguel Hernández University, Elche, Spain.

"Three months may not be long enough to observe differences" in any clinical effects of using the app, he suggested. On the other hand, it’s unknown whether the app would be effective in the long term.

Of the 99 patients, 72 (73%) took more than five types of drugs per day and 36 were under the care of more than one doctor (36%).

Among the 51 patients in the app group, medication adherence rates at the end of the study were better in the 28 patients who had never used a computer, tablet, or smartphone (55%) than in those who had some familiarity with the technology.

The app users received up to 2 hours of instruction on how to use the app and had a phone number to call for technical support. Support was needed by 30 patients (59%), mostly related to charging the tablet’s battery or restarting the system. Mean satisfaction scores for the app were high (8 out of a possible 10) and 88% of users said the app improved their medication use or helped to a certain extent, with 12% saying it did not help.

The investigators designed the app with input from 23 patients, three physicians, and four pharmacists. "This study should change the expectations of developers and mobile phone companies, encouraging them to develop apps and devices suited to older patients with multimorbidity," Dr. Mira wrote.

Clinical trials of apps to improve medication adherence are in their infancy.

Unpublished results from a separate uncontrolled study of PatientPartner, a mobile game app that offers iterative guidance, suggest that medication adherence improved by 37% (from 37% to 58%) among 100 patients with diabetes who had been nonadherent. Adherence to diet recommendations increased by 24%, adherence to exercise recommendations increased by 14%, and hemoglobin A_1c levels decreased from 10.7% to 9.7%, the company that makes the app reported in a press release.

Investigators at the University of Arkansas, Fayetteville, evaluated 160 currently-available medication adherence apps for smartphones in a separate study, ranked them by the desirability of their features, and then tested the top 10 using a standard medication regimen. Their top three picks were MyMeds (free), RxmindMe (free), and MyMedSchedule (part of a subscription system from MyMeds.com), reported Lindsey Dayer, Pharm.D., and her associates (J. Am. Pharm. Assoc. 2013;53:172-181). Though these aren’t clinical outcomes, it gives medical and pharmacy care providers some basis for recommending one adherence app over another, the investigators suggested.

Dr. Mira and Dr. Dayer reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

A tablet-based app designed for elderly Spaniards taking multiple medications seemed to improve treatment adherence rates but not clinical outcomes in a randomized controlled study of 99 patients.

The 48 patients in the control group received oral and written information on the safe use of their medications in the 3-month single-blind trial. The other 51 patients took home a tablet computer (either an iPad 2 or a BQ Verne) with a medication self-management app that the investigators created and called ALICE. The app incorporated personalized prescriptions and medical advice from patients’ physicians, showed images of each medication and its packaging, provided alerts and multiple reminders to take a medication, and transmitted monitoring information to a caregiver.

Courtesy Wikimedia Commons/Dvortygirl/Creative Commons

The rate of self-reported adherence (measured on the four-item Morisky Medication Adherence Scale) increased by a significant 28% in the app group and did not change significantly in the control group. The rate of missed doses decreased by a significant 27% in the app group and increased slightly in the control group, reported José Joaquin Mira, Ph.D., and his associates (J. Med. Internet. Res. 2014;16:e99).

The rate of medication errors that involved taking the wrong drug or dose did not change significantly in the app group as a whole but decreased significantly by 41% among patients who had reported making two or more medication errors before the study.

Levels of glycated hemoglobin, blood pressure, and self-perceived health status did not change significantly in either the app or control groups. Cholesterol levels increased by 5% in both groups, which was statistically but not clinically significant, reported Dr. Mira of Miguel Hernández University, Elche, Spain.

"Three months may not be long enough to observe differences" in any clinical effects of using the app, he suggested. On the other hand, it’s unknown whether the app would be effective in the long term.

Of the 99 patients, 72 (73%) took more than five types of drugs per day and 36 were under the care of more than one doctor (36%).

Among the 51 patients in the app group, medication adherence rates at the end of the study were better in the 28 patients who had never used a computer, tablet, or smartphone (55%) than in those who had some familiarity with the technology.

The app users received up to 2 hours of instruction on how to use the app and had a phone number to call for technical support. Support was needed by 30 patients (59%), mostly related to charging the tablet’s battery or restarting the system. Mean satisfaction scores for the app were high (8 out of a possible 10) and 88% of users said the app improved their medication use or helped to a certain extent, with 12% saying it did not help.

The investigators designed the app with input from 23 patients, three physicians, and four pharmacists. "This study should change the expectations of developers and mobile phone companies, encouraging them to develop apps and devices suited to older patients with multimorbidity," Dr. Mira wrote.

Clinical trials of apps to improve medication adherence are in their infancy.

Unpublished results from a separate uncontrolled study of PatientPartner, a mobile game app that offers iterative guidance, suggest that medication adherence improved by 37% (from 37% to 58%) among 100 patients with diabetes who had been nonadherent. Adherence to diet recommendations increased by 24%, adherence to exercise recommendations increased by 14%, and hemoglobin A_1c levels decreased from 10.7% to 9.7%, the company that makes the app reported in a press release.

Investigators at the University of Arkansas, Fayetteville, evaluated 160 currently-available medication adherence apps for smartphones in a separate study, ranked them by the desirability of their features, and then tested the top 10 using a standard medication regimen. Their top three picks were MyMeds (free), RxmindMe (free), and MyMedSchedule (part of a subscription system from MyMeds.com), reported Lindsey Dayer, Pharm.D., and her associates (J. Am. Pharm. Assoc. 2013;53:172-181). Though these aren’t clinical outcomes, it gives medical and pharmacy care providers some basis for recommending one adherence app over another, the investigators suggested.

Dr. Mira and Dr. Dayer reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”

These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.

Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.¹ Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.² After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.

I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost.This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).³ Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.

For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.

“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”

These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.

Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.¹ Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.² After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.

I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost.This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).³ Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.

For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.

“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”

These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.

Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.¹ Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.² After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.

I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost.This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).³ Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.

For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.

While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.

However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.

Joseph E. Badolato, DO
Seattle, Wash 

I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.

In my area, I can care for 20 patients for the cost of one computed tomography Some subspecialists earn triple (and even quadruple) what FPs do, and there's really no reason for this.scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.

James A. Taylor, DO
Jackson, Mich

While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.

However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.

Joseph E. Badolato, DO
Seattle, Wash 

I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.

In my area, I can care for 20 patients for the cost of one computed tomography Some subspecialists earn triple (and even quadruple) what FPs do, and there's really no reason for this.scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.

James A. Taylor, DO
Jackson, Mich

While I appreciate Dr. Hickner’s optimism for the future of family medicine (J Fam Pract. 2014;63:127), the reality is that family physicians (FPs) have been—and still are—considered cheap labor by insurers and hospital systems. Some subspecialists earn triple (and even quadruple) what FPs do, and there’s really no reason for this. FPs shoulder the burden for the vast majority of acute and chronic health care in this country. FPs bring in more revenue per provider to hospital systems and are able to provide more efficient, cost-effective care than subspecialists. Despite this, we are still not recognized financially.

However, I do share some of Dr. Hickner’s optimism, although for a different reason. I work for a company that contracts directly with larger, self-insured companies to provide medical care for their employees. Our focus is preventive medicine, wellness, and behavioral change, but we also provide occupational health services and one-on-one health coaching. Our resources go directly to patient care and we can reduce employer health care costs by as much as 30% due to fewer emergency department visits and hospitalizations and less time lost from work. This model offers hope in a broken health care system. I’m once again enjoying practicing cost-effective medicine that is truly patient-centered.

Joseph E. Badolato, DO
Seattle, Wash 

I want to thank Dr. Hickner for sharing his reasons for optimism, but feel compelled to refute his comment that “the health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.” Speaking with my colleagues across all specialties, I’ve learned there has been an inexorable decrease of payment for physician services under the guise of controlling costs or stamping out fraud and abuse. The meteoric rise in health care costs has been driven by nonphysician services—especially technology, but also by third-party insurers (including Medicare and Medicaid), government paperwork requirements, and skyrocketing pharmaceutical costs—but blamed on physicians.

In my area, I can care for 20 patients for the cost of one computed tomography Some subspecialists earn triple (and even quadruple) what FPs do, and there's really no reason for this.scan, or 40 patients for the cost of a magnetic resonance imaging scan. Physician services—not physician extenders, information technology, and the rest—are the best value in medicine today. Our focus needs to be on training and rewarding physicians for their dedication and service with proper reimbursement. I think the Affordable Care Act’s version of medical care has failed and will continue to fail without universal physician support to eliminate it.

James A. Taylor, DO
Jackson, Mich

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Last month’s editorial “Pre” Prehospital Care described a new era of making very potent lifesaving medications (epinephrine, naloxone) and devices (AEDs) available to the public without prescription, to be used on anyone in dire need of such lifesaving treatment.

So, if we are making some of our most potent tools available to the public, how are we repurposing the 21^st-century ED to treat other conditions and patients? As noted in the 2013 Rand Report on the Evolving Role of EDs in the United States (http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.pdf), for many people, the ED has become the place to go—or be sent—for CT scans, MRIs, additional blood work, observation and treatment, or admission to the hospital. Increased patient volume, prolonged stays, and newer, complex patient needs are making the large, urban ED a more difficult environment in which to ensure that each patient receives the correct dose of the correct medication, at the correct time. This is especially true for pain meds. The 21^st-century ED is also increasingly the place where the emergent diagnostic and therapeutic needs specific to an aging population are appropriately addressed.   

In this issue of EM, Michael Stern, MD, and Mary Mulcare, MD, consider the advantages of treating elderly patients with emergencies in a purpose-built geriatric emergency department (GED), utilizing specific bedside clinical protocols designed to rapidly diagnose and treat the elderly without causing iatrogenic problems and prolonged hospital stays. Also in this issue, Peter Byers, MD, and Associate Editor in Chief, Francis Counselman, MD, take EM readers through a grand tour of modern pain management for the most common painful conditions typically presenting to an ED, while avoiding both undertreatment and the overprescribing that leads to dependency and abuse.

Prescribing the correct medications and doses for older adults and younger children, and choosing and correctly dosing pain meds—along with a myriad of other prescribing needs required of multitasking, overworked, EPs—all can be substantially aided by a pharmacist stationed in the ED 24/7. An ED pharmacist can help guide the choices and doses of meds administered in the ED, and also provide help with outpatient prescriptions. Alerting the EP to possibly dangerous drug interactions and helping with medication reconciliation are but two of the many important patient care and patient safety services ED pharmacists can provide.

A recent story about ED pharmacists on National Public Radio (NPR) noted that at Children’s Medical Center in Dallas, 10 full-time ED pharmacists are assigned to the pediatric ED where they provide 24-hour review of every one of the almost 20,000 weekly prescriptions and medication orders in real time (http://www.npr.org/blogs/health/2014/06/09/318567633/hospitals-put-pharmacists-in-the-er-to-cut-medication-errors. June 9, 2014.). Also noted in the NPR story was a February 2013 Annals of Emergency Medicine study by Cesarz et al (2013;61[2]:209-214) finding that EM pharmacists intervened in 8.5% of adult prescriptions and 23.6% of pediatric prescriptions.

The issues related to pain meds alone could probably keep an ED pharmacist busy for an entire shift, and hospitals are now beginning to pilot pain-management teams in the ED. Though some may bemoan the evolution toward specialty teams à la football instead of baseball, a team consisting of as few as one NP or PA, working together with EPs to assess, reassess, and manage their ED patients’ pain, will not only improve an ED’s record of compliance with the CMS ED core measure of “door-to-pain treatment time,” but will help address the concerns raised by Drs Byers and Counselman, and Drs Stern and Mulcare about the under- and overtreatment of pain.

In the 21st century, EPs can look forward to a very different ED than the one in which we worked in the 1970s and 1980s. The large urban 21st-century ED will have discrete areas for pediatric, adult, elderly, and psychiatric patients, while ED pharmacists and pain management providers will aid EPs, NPs, PAs, and RNs in delivering state-of-the-art care for our patients.

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.

DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.

"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.

Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.

iPad app bested technician performance

The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.

The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.

Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.

The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.

The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.

For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).

Still need humans

Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.

When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.

In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.

More inclusive and comprehensive

Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.

The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.

Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.

"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.

Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.

[email protected]

On Twitter @whitneymcknight

DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.

"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.

Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.

iPad app bested technician performance

The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.

The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.

Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.

The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.

The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.

For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).

Still need humans

Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.

When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.

In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.

More inclusive and comprehensive

Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.

The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.

Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.

"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.

Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.

[email protected]

On Twitter @whitneymcknight

DALLAS – The superior performance of an iPad-based app for the self-administration of the multiple sclerosis performance test, when compared with a technician-administered one, could mean big changes in how data are collected and interpreted for the purposes of clinical trials and disease management, according to an expert.

"There are some important implications of this," said Dr. Richard Rudick, who was director of the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic until recently accepting a position with Biogen Idec as vice president, development sciences, Value-Based Medicine Group.

Among the considerations implicated by the findings is that unfiltered, accurate patient data could be transferred in real time to the "cloud" where it would be available for immediate viewing, as well as kept for future study. This would give clinicians new ways to "collect, display, aggregate, and analyze neurological performance," Dr. Rudick said at a meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.

iPad app bested technician performance

The app-based multiple sclerosis performance test (MSPT) was developed by Dr. Rudick and his colleagues to simulate the technician-based one in all aspects and comprises the walking speed test, the manual dexterity test, the low-contrast visual acuity test, and the processing speed test. These approximate the MSPT’s timed 25-foot walk test, the 9-hole peg test, the Sloan low-contrast visual acuity test, and the Symbol Digit Modalities Test.

The industry-sponsored, cross-sectional validation study matched 49 healthy controls with 51 patients according to age, sex, and education. Roughly three-quarters of the study arm had relapsing MS, and a quarter had the progressive form of the disease.

Participants were tested at a single site via each modality, once in the morning and then again in the afternoon. The test/retest results were consistent and correlative, according to Dr. Rudick. "They were highly reliable, whether the technician did it, or the iPad," he said.

The question was whether the two tests were measuring the same thing. Because data for all aspects of each test were comparable, Dr. Rudick concluded that the tests were comparable.

The most important measure was how well the app version separated the two study groups, when compared with the ability of the technician-based test, according to Dr. Rudick. "In virtually every case, except for the visual, the iPad actually does a little bit better than the technician in distinguishing the MS patients from the healthy controls," he said.

For example, in the timed 25-foot walk test administered by the technician, the mean score in the MS group was 7 (P less than .001; standard deviation, 4.28), while the mean score for the walking speed test in the MS group was 7.26 (P less than .001; SD, 4.25). In the healthy controls group, the mean score for the technician-given test was 4.24 (P less than .001). That group’s mean score for the self-given walking speed test was 4.27 (P less than .001; SD, 4.27).

Still need humans

Patient-reported outcomes were also correlative to both forms of the tests. However, in an interview after the presentation, Dr. Rudick said that patient-reported cognitive impairment doesn’t usually correlate with the actual measurements used in neurocognitive testing. "What does seem to correlate with patients reporting cognitive impairment is if they are depressed. Then the depression score matches the patient-reported cognitive impairment better than the actual cognitive test score does," he said.

When Dr. Rudick asked the audience, which included many physician assistants and registered nurses in addition to physicians, whether they would embrace the use of this technology, the majority assented. However, during the discussion following the presentation, Neil Jouvenant, a physician assistant at the University of Nebraska Medical Center in Omaha, said there are some patients for whom this technology would not be appropriate, such as those who walk with difficulty.

In an interview, Mr. Jouvenant said that in addition, "you still need a technician to instruct and encourage patients. If the iPad were to instruct a patient to ‘get up now, strap this to your back, and walk 25 feet,’ they won’t because they don’t really think they can. There is a fine line between someone who can walk a certain distance and someone who can’t." The technician can help in those situations, he said.

More inclusive and comprehensive

Although Dr. Rudick agreed that at least for now, this technology is not appropriate for all patients, the technology does hold promise for those who would have been excluded in the past, such as patients who live in rural areas but would like to participate in clinical trials.

The collection of normative data from healthy adults will also mean that clinical interpretations of MSPT scores will have broader utility in MS patients and groups, and the technology can be adapted to yield additional data such as specific measurements for balance and speed.

Dr. Patricia Coyle, professor of psychiatry and neurology at the State University of New York at Stony Brook, and director of the MS comprehensive care center there, said in an interview that technology such as this has the power to "revolutionize" disease management, particularly if it is collected into a central database accessible to any clinician or researcher.

"There are only so many MS patients, and we don’t have a good idea of their disease activity. They’re not tracked. No one’s trying to pull that data together," she said. But having these data "potentially would mean revolutionizing" the field.

Novartis funded the study on the MSPT app. Dr. Rudick said that he has received consulting fees from Genzyme and Novartis. Dr. Coyle reported she has financial relationships with Biogen Idec, Genentech, and Genzyme, among others.

[email protected]

On Twitter @whitneymcknight

You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!

What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.

All over down under

Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film   one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.

Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.

In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.

Green gobbling

Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”

A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.

Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.

The young and the restless

What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.

Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.

David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!

What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.

All over down under

Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film   one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.

Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.

In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.

Green gobbling

Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”

A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.

Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.

The young and the restless

What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.

Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.

David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

You know you have it somewhere in your head: a short list of stuff you’re just too bad at to even attempt, at least not in public. For some of us, it’s dancing. For others, it’s golf (my own congenital incompetence at golf has saved me countless hours and dollars, not to mention the confusion that ensues when someone leaves their clubs at the club so they can go to the clubhouse for a club). Tragically, my list includes gardening. If you ever hear someone say that I have a “green thumb,” get me on IV antibiotics stat, because that’s a nasty infection!

What’s saddest is how much my gardening ambition outstrips my skill. Last year, for example, everyone in the family agreed that our tomato was among the better ones they had ever eaten a small bite of. Worse yet, I now have a neighbor with a back yard dominated by a professionally installed network of raised beds already producing enough organic microgreens to fill a green minivan. I’m hoping to barter with her once our vegetables come in. Perhaps I’ll offer her this year’s tomato.

All over down under

Can we all just agree to stop trying to disprove conspiracy theories? I mean, has your crazy great-uncle ever said, “You know, I watched the Zapruder film   one more time, and actually there really was just a lone gunman.” I don’t think so. Likewise, let’s accept that for the next 100 years, vaccine-hesitant parents are going to insist that the link between vaccines and autism just hasn’t been adequately studied, just like climate change, evolution, and why celebrities give their children weird names.

Now that Sydney Medical School Associate Professor Guy Eslick has published the ultimate meta-analysis of vaccines and autism, I vote that we never, ever spend another nickel researching this topic. Eslick’s team of Aussies aggregated data from five cohort studies and five case-control studies, to include a total of more than1.25 million children, comparing autism rates between vaccinated and unvaccinated children. You already know the results, even if you haven’t read the study, because you know that autism spectrum disorders don’t result from postnatal insults: zero correlation between vaccines and autism.

In the words of the Melbourne Herald Sun, this study should have “settled the debate,” especially since Dr. Eslick has no grants from or ties to vaccine manufacturers. But what about the Trilateral Commission? Agenda 21? The Rothschilds? We only know one thing for sure: What you don’t know can hurt you.

Green gobbling

Did you, too, have that grandmother who told you carrots would give you night vision? I remember gorging on the orange vegetables and then stumbling around the yard in the dark, twisting my ankle on mole tunnels. It’s possible that I was also hoping for laser vision: “A B-minus on my spelling test?! Take that, Mrs. Mulherin!”

A new study out of Chicago, however, suggests that not all kids are as gullible as I was which, I suppose, will cut down on the rates of ankle sprains. According to author Dr. Ayelet Fishbach of the University of Chicago's Booth School of Business, the absolute worst way to get kids to eat any food is to tell them it will make them “healthy,” which includes taller, stronger, smarter, or less constipated. Ironically, the same logic works brilliantly to sell young men overpriced plastic barrels of powdered protein.

Among the 270 3- to 5-year-old children studied, the more adults emphasized the health benefits of a given food, the less of it the kids ate. They apparently subscribed to a “zero sum game” theory of food: The positive health properties of any given food must be subtracted proportionately from its taste. The implication for parents is clear: We must immediately band together to convince children that broccoli will give them cavities and gummy worms improve eyesight. Just don’t forget to stock up on Ace bandages.

The young and the restless

What parent of a preschooler hasn’t occasionally wished there was something you could give them to make them behave? Actually, according to a new report from the Centers for Disease Control and Prevention (CDC), there are around 10,000 young children in the US whose parents have stopped wishing. That’s the estimated number of 2- to 3-year-old children who are being prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD). CDC officials and other child behavior experts suggest that the doctors prescribing these meds be put in time out.

Aside from the little issue that stimulant medications have never been tested for safety and efficacy in young children, there’s the problem of diagnosing ADHD in preschoolers. After all, the definition of ADHD can be boiled down to, “has the attention span of a 3-year-old,” a problem that’s nearly universal among 3-year-olds. I’ll come out and say that I think the docs prescribing these meds to young children deserve a rotten tomato, and that’s the one thing I know how to grow.

David L. Hill, M.D., FAAP is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.