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Approach to newborns exposed to HSV at the time of delivery
Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).
Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.
Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.
The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.
Obstetrical role and implications of testing
The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.
Calculation of relative neonatal risk
• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.
• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.
• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.
Pediatrician’s role and plan of care
The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.
The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.
In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):
• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.
• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.
• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.
For babies whose mothers have recurrent infection:
• Cerebrospinal fluid examination may be deferred.
• But the rest of the workup should be completed and IV acyclovir initiated.
• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.
Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).
Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.
Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.
The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.
Obstetrical role and implications of testing
The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.
Calculation of relative neonatal risk
• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.
• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.
• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.
Pediatrician’s role and plan of care
The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.
The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.
In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):
• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.
• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.
• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.
For babies whose mothers have recurrent infection:
• Cerebrospinal fluid examination may be deferred.
• But the rest of the workup should be completed and IV acyclovir initiated.
• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.
Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).
Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.
Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.
The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.
Obstetrical role and implications of testing
The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.
Calculation of relative neonatal risk
• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.
• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.
• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.
Pediatrician’s role and plan of care
The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.
The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.
In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):
• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.
• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.
• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.
For babies whose mothers have recurrent infection:
• Cerebrospinal fluid examination may be deferred.
• But the rest of the workup should be completed and IV acyclovir initiated.
• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.
Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
Growing EHR Pains
It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.
For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.
The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.
Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.
Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?
It is not all bad. There are definitely a number of things that I appreciate about having an EHR.
I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.
I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.
I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.
I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.
I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.
Dr. Chan practices rheumatology in Pawtucket, R.I.
It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.
For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.
The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.
Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.
Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?
It is not all bad. There are definitely a number of things that I appreciate about having an EHR.
I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.
I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.
I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.
I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.
I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.
Dr. Chan practices rheumatology in Pawtucket, R.I.
It has been 2 months since we implemented an electronic health record. I’ve made peace with it, but it is oh so far from perfect. Around the office, tempers are flared and people are grumpy. There are threats to quit by staff and doctors alike. Chaotic accurately describes what the first few weeks were like.
For a week, I had a greatly thinned schedule, but was pretty much back up to my usual 15-minute follow-up schedule by week 3. This meant, frankly, that if I did not want my patients to be waiting for hours beyond their appointment time, shortcuts had to be made. And 2 months in, the trend continues. I am definitely not able to dutifully fill out each and every blank that meaningful use requires me to fill out. There is just not enough time to document every follow-up patient’s family history and surgical history all over again. If you thought pointing-and-clicking were going to make life much easier for you, think again.
The issue is that the electronic record, rather than being a blank space, is essentially pages and pages of blanks to be filled out. So instead of freely typing as the patient jumps from, say, the history of their present illness to their family history to their systems review back to their present illness – because as we all know, our patients do not tell their stories in a nice linear fashion – I find myself having to interrupt the patient as I find the right blank on the right page.
Another sore point for me, and of course this issue predates the EHR, is that I don’t like having to reduce my patients to codes. I understand that codes are useful, but they can also be limiting and, frankly, idiotic. For example, Medicare in Rhode Island will no longer reimburse for zoledronic acid for patients coded as 733.00 (Osteoporosis NOS), but will cover if a patient is coded as 733.01 (postmenopausal/senile osteoporosis). I would like to know who came up with that rule and how they came up with it.
Codes also fall short of really capturing what a patient looks like. One lupus patient can look quite different from the next. Some of my patients are extremely sick and have complicated histories that have taken many months to piece together, and those four digits just do not capture that complexity and absolutely do not do justice to the patient. Patients do not fit neatly into boxes, so why must we be forced to make them fit?
It is not all bad. There are definitely a number of things that I appreciate about having an EHR.
I like being able to access patient records from home. It makes call a lot easier when you have the ability to look up a patient, know what meds they’re on, and document what you did for them over the weekend.
I like being able to hand the patient a document at the end of the visit outlining what we talked about. Although composing this definitely slows me down, it is helpful for some of the more forgetful patients in our panel who cannot be expected to remember their instructions for tapering their prednisone or that methotrexate is taken weekly, not daily.
I like that our system has a homunculus and will automatically calculate the Clinical Disease Activity Index for me and track down the patient’s progress. The system is too new for me to use this functionality, but I look forward to trying it out.
I like being able to electronically prescribe meds. The med list can get cluttered with old medications that the patient is not taking anymore (how often do patients change NSAIDs or go from gabapentin to cyclobenzaprine to amitriptyline?), and it can get quite confusing, but I’m sure in the long run it will make life much easier. When I fill out the blasted prior authorization forms, I will now be able to check on a single screen what generic drugs the patient has failed.
I must admit that the forthcoming Medicare penalty for not having an EHR was a big motivator for us to get on board. In the end, though, it shouldn’t be about avoiding penalties. It should be about providing better-quality care. And once most doctors are on board and Medicare has access to measurable data, I fervently hope that the data shows us that all of this pain was worth it.
Dr. Chan practices rheumatology in Pawtucket, R.I.
Talking with families about corporal punishment
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].
Atrial fibrillation: The unknown known
For a problem that has been on the back burner for decades, the treatment of atrial fibrillation has suddenly become a "marquis" diagnosis.
Age and technology have led to an explosion of interest in this arcane cardiac problem. Advertisements for new anticoagulants and thrombin inhibitors for "A Fib" have become almost as common as those for male impotency. The aging of the world population certainly has been a major factor in its increased incidence. New technology and pharmacology has driven the increase in clinical interest and has advanced our knowledge about the disease. Epidemiology data have provided important information about the natural history of paroxysmal atrial fibrillation (AF), and its relationship to chronic AF and its adverse effects on long-term mortality.
The importance of anticoagulant therapy for the prevention of systemic emboli and stroke has been the mainstay of therapy for almost 50 years. Although we have struggled with a variety of antiarrhythmic drugs, their shortcomings have been more than apparent. Most of us now use a rate-control strategy to control the tachycardia inherent in AF. The development of new factor Xa and direct thrombin inhibitor drugs have made the logistics of providing adequate thrombus prevention much simpler, if somewhat more expensive.
The elephant in the room is the increasing use of radiofrequency catheter ablation technology that has had some success in the prevention of AF arising from the tissue in the pulmonary vein–atrial interface. Numerous small studies have reported that this technology surpasses rhythm control with antiarrhythmic agents, a hurdle not too difficult to beat. The best results have been observed in patients with recurrent paroxysmal AF where maintenance of regular sinus rhythm has been the primary outcome measurement (JAMA 2014;311:692-700). Even here, recurrence after ablation has been common. The benefit of ablation therapy in patients with initial paroxysmal AF (N. Engl. J. Med. 2012;367:1587-95) or chronic persistent AF has been uncertain at best. As a result, the AHA/ACC/HRS (American Heart Association/American College of Cardiology/Heart Rhythm Society) guidelines have given a class I (evidence level A) recommendation for ablation therapy for symptomatic paroxysmal AF and class IIa (evidence level A) and IIb (evidence level B) for symptomatic recurrent paroxysmal and longstanding persistent AF when balanced against drug tolerability, respectively (J. Am. Coll. Cardiol. 2014 [doi:10.1016/j.jacc.2014.03.021]).
All of these clinical data are exciting and have led to enthusiasm for ablation technology despite the potential for nonfatal and rare fatal complication, based almost entirely on its ability to improve upon the dismal benefits of antiarrhythmic rhythm control. Even as we consider the benefit of ablation therapy, new techniques are being developed. The lack of mortality and morbidity data is a result of the short follow-up, usually limited to a year or two, and small sample size. This lack of long-term outcome data for ablation therapy should be of some concern to clinicians who have lived through the last few years. Many of my readers had not been born when we embarked on the ineffective and dangerous pharmacologic prevention of sudden death by pharmacologic suppression of ambient ventricular premature beats. Numerous surrogate measures of clinical benefit of a variety of therapeutic interventions have been disproven and disposed of in the subsequent years. The use of surrogate measures like the partial suppression of AF rather than morbidity and mortality outcomes to establish clinical benefit, have been largely discarded as a dead end.
The Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA), which is beginning to recruit more than 2,000 patients with new-onset or undertreated paroxysmal, persistent, or longstanding AF to be followed for over 4 years may answer the question of whether radiofrequency ablation therapy, rate control, or rhythm control provides the best clinical treatment of atrial fibrillation. The primary outcome will be the composite endpoint of total mortality, disabling stroke or serious bleeding, or cardiac arrest. An important secondary endpoint will be total mortality. Until its conclusion, we should proceed cautiously with expanding radiofrequency ablation therapy for the treatment of AF.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
For a problem that has been on the back burner for decades, the treatment of atrial fibrillation has suddenly become a "marquis" diagnosis.
Age and technology have led to an explosion of interest in this arcane cardiac problem. Advertisements for new anticoagulants and thrombin inhibitors for "A Fib" have become almost as common as those for male impotency. The aging of the world population certainly has been a major factor in its increased incidence. New technology and pharmacology has driven the increase in clinical interest and has advanced our knowledge about the disease. Epidemiology data have provided important information about the natural history of paroxysmal atrial fibrillation (AF), and its relationship to chronic AF and its adverse effects on long-term mortality.
The importance of anticoagulant therapy for the prevention of systemic emboli and stroke has been the mainstay of therapy for almost 50 years. Although we have struggled with a variety of antiarrhythmic drugs, their shortcomings have been more than apparent. Most of us now use a rate-control strategy to control the tachycardia inherent in AF. The development of new factor Xa and direct thrombin inhibitor drugs have made the logistics of providing adequate thrombus prevention much simpler, if somewhat more expensive.
The elephant in the room is the increasing use of radiofrequency catheter ablation technology that has had some success in the prevention of AF arising from the tissue in the pulmonary vein–atrial interface. Numerous small studies have reported that this technology surpasses rhythm control with antiarrhythmic agents, a hurdle not too difficult to beat. The best results have been observed in patients with recurrent paroxysmal AF where maintenance of regular sinus rhythm has been the primary outcome measurement (JAMA 2014;311:692-700). Even here, recurrence after ablation has been common. The benefit of ablation therapy in patients with initial paroxysmal AF (N. Engl. J. Med. 2012;367:1587-95) or chronic persistent AF has been uncertain at best. As a result, the AHA/ACC/HRS (American Heart Association/American College of Cardiology/Heart Rhythm Society) guidelines have given a class I (evidence level A) recommendation for ablation therapy for symptomatic paroxysmal AF and class IIa (evidence level A) and IIb (evidence level B) for symptomatic recurrent paroxysmal and longstanding persistent AF when balanced against drug tolerability, respectively (J. Am. Coll. Cardiol. 2014 [doi:10.1016/j.jacc.2014.03.021]).
All of these clinical data are exciting and have led to enthusiasm for ablation technology despite the potential for nonfatal and rare fatal complication, based almost entirely on its ability to improve upon the dismal benefits of antiarrhythmic rhythm control. Even as we consider the benefit of ablation therapy, new techniques are being developed. The lack of mortality and morbidity data is a result of the short follow-up, usually limited to a year or two, and small sample size. This lack of long-term outcome data for ablation therapy should be of some concern to clinicians who have lived through the last few years. Many of my readers had not been born when we embarked on the ineffective and dangerous pharmacologic prevention of sudden death by pharmacologic suppression of ambient ventricular premature beats. Numerous surrogate measures of clinical benefit of a variety of therapeutic interventions have been disproven and disposed of in the subsequent years. The use of surrogate measures like the partial suppression of AF rather than morbidity and mortality outcomes to establish clinical benefit, have been largely discarded as a dead end.
The Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA), which is beginning to recruit more than 2,000 patients with new-onset or undertreated paroxysmal, persistent, or longstanding AF to be followed for over 4 years may answer the question of whether radiofrequency ablation therapy, rate control, or rhythm control provides the best clinical treatment of atrial fibrillation. The primary outcome will be the composite endpoint of total mortality, disabling stroke or serious bleeding, or cardiac arrest. An important secondary endpoint will be total mortality. Until its conclusion, we should proceed cautiously with expanding radiofrequency ablation therapy for the treatment of AF.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
For a problem that has been on the back burner for decades, the treatment of atrial fibrillation has suddenly become a "marquis" diagnosis.
Age and technology have led to an explosion of interest in this arcane cardiac problem. Advertisements for new anticoagulants and thrombin inhibitors for "A Fib" have become almost as common as those for male impotency. The aging of the world population certainly has been a major factor in its increased incidence. New technology and pharmacology has driven the increase in clinical interest and has advanced our knowledge about the disease. Epidemiology data have provided important information about the natural history of paroxysmal atrial fibrillation (AF), and its relationship to chronic AF and its adverse effects on long-term mortality.
The importance of anticoagulant therapy for the prevention of systemic emboli and stroke has been the mainstay of therapy for almost 50 years. Although we have struggled with a variety of antiarrhythmic drugs, their shortcomings have been more than apparent. Most of us now use a rate-control strategy to control the tachycardia inherent in AF. The development of new factor Xa and direct thrombin inhibitor drugs have made the logistics of providing adequate thrombus prevention much simpler, if somewhat more expensive.
The elephant in the room is the increasing use of radiofrequency catheter ablation technology that has had some success in the prevention of AF arising from the tissue in the pulmonary vein–atrial interface. Numerous small studies have reported that this technology surpasses rhythm control with antiarrhythmic agents, a hurdle not too difficult to beat. The best results have been observed in patients with recurrent paroxysmal AF where maintenance of regular sinus rhythm has been the primary outcome measurement (JAMA 2014;311:692-700). Even here, recurrence after ablation has been common. The benefit of ablation therapy in patients with initial paroxysmal AF (N. Engl. J. Med. 2012;367:1587-95) or chronic persistent AF has been uncertain at best. As a result, the AHA/ACC/HRS (American Heart Association/American College of Cardiology/Heart Rhythm Society) guidelines have given a class I (evidence level A) recommendation for ablation therapy for symptomatic paroxysmal AF and class IIa (evidence level A) and IIb (evidence level B) for symptomatic recurrent paroxysmal and longstanding persistent AF when balanced against drug tolerability, respectively (J. Am. Coll. Cardiol. 2014 [doi:10.1016/j.jacc.2014.03.021]).
All of these clinical data are exciting and have led to enthusiasm for ablation technology despite the potential for nonfatal and rare fatal complication, based almost entirely on its ability to improve upon the dismal benefits of antiarrhythmic rhythm control. Even as we consider the benefit of ablation therapy, new techniques are being developed. The lack of mortality and morbidity data is a result of the short follow-up, usually limited to a year or two, and small sample size. This lack of long-term outcome data for ablation therapy should be of some concern to clinicians who have lived through the last few years. Many of my readers had not been born when we embarked on the ineffective and dangerous pharmacologic prevention of sudden death by pharmacologic suppression of ambient ventricular premature beats. Numerous surrogate measures of clinical benefit of a variety of therapeutic interventions have been disproven and disposed of in the subsequent years. The use of surrogate measures like the partial suppression of AF rather than morbidity and mortality outcomes to establish clinical benefit, have been largely discarded as a dead end.
The Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial (CABANA), which is beginning to recruit more than 2,000 patients with new-onset or undertreated paroxysmal, persistent, or longstanding AF to be followed for over 4 years may answer the question of whether radiofrequency ablation therapy, rate control, or rhythm control provides the best clinical treatment of atrial fibrillation. The primary outcome will be the composite endpoint of total mortality, disabling stroke or serious bleeding, or cardiac arrest. An important secondary endpoint will be total mortality. Until its conclusion, we should proceed cautiously with expanding radiofrequency ablation therapy for the treatment of AF.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.
Maintaining the Public Trust
Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.
The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.
Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.1
As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.
They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.
We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.
Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.
Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.2-4
Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
1. American Customer Satisfaction Index. ACSI Benchmarks for U.S. Federal Government 2013. http://www.theacsi.org/acsi-benchmarks-for-u-s-federal-government-2013. Published January 28, 2014. Accessed May 28, 2014.
2. Vasudevan MM, Hurr SD, Green MC, et al. The clinical impact of electronic consultation in diabetes care. Fed Pract. 2014;31(3):32-36.
3. Dunn EJ, McKinney KM, Martin ME. Empathic disclosure of adverse events to patients. Fed Pract. 2014;31(5):18-21.
4. Gillette MA, Frohnapple DJ, Knott A, Reeder D. Pharmacist-managed collaborative practice for chronic stable angina. Fed Pract. 2014;31(6):16-22.
Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.
The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.
Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.1
As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.
They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.
We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.
Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.
Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.2-4
Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
Being in the political crossfire is nothing new to the VA. The largest health care organization in the U.S. has seen its share of firestorms. And that’s okay. Transparency is essential for maintaining the public trust.
The mission to care for veterans and their families is one that the overwhelming majority of the 280,000 VA employees take extremely seriously. The reports of excessive wait times for veterans seeking care are disturbing to everyone inside and outside the VA. We fully expect the new Secretary of Veterans Affairs will act quickly to ensure that all veterans receive the care they deserve in a timely fashion.
Nevertheless, we remain concerned that the current climate may erode the trust that VA health care providers (HCPs) have earned. The vast majority continue to deliver high-quality care to a particularly vulnerable population. According to the latest American Customer Satisfaction Index, veterans are satisfied with the quality of care they receive at VA facilities. The VA, in fact, gets higher marks for its service than most other government agencies.1
As President Obama insisted in a May press conference: “Every single day, there are people working in the VA who do outstanding work and put everything they’ve got into making sure that our veterans get the care, benefits, and services that they need.” Unfortunately, not all critics recognize that commitment.
They should. There is important work being done by VA HCPs. For more than 30 years, Federal Practitioner has showcased the dedication of the men and women who deliver health care across government agencies. The VA has been the source of many important innovations over the years, like recognizing the importance of nurse practitioners in health care delivery. The VA Computerized Patient Record System exemplifies how an electronic health record system can improve health care.
We talk to many at the VA who are committed to sharing best practices, difficult case studies, and innovative programs, which often exist only because of the dedication and commitment of passionate HCPs. For example, Dr. Dewleen Baker of the VA San Diego Healthcare System who wanted to understand the causes of posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBIs) in the military and among veterans. Rather than waiting until veterans came in the door, Dr. Baker created a massive study in cooperation with the U.S. Marines and Navy so that subjects could have baseline evaluations before deployment and could be monitored throughout their lives. The results of the study may provide essential insight into PTSD and TBI and will benefit not only veterans, but all patients.
Veterans do, in fact, have unique concerns and deserve an agency focused on their care. Too many veterans, for example, return from their service with a desperate need for palliative care and prescriptions for opioids. Replacing pain with addiction, however, remains a significant concern. In response, the VA Pharmacy Benefit Management Service developed an opioid monitoring dashboard to improve prescribing practices and reduce the use of opioids. The dashboard allows the VA to both see patterns across the entire system and to make exceptions for individual veterans, ensuring that each veteran gets exactly the care he or she needs.
Every issue of Federal Practitioner is replete with similar examples of HCPs who provide the best care possible within the budget constraints set by Congress. Whether it’s the development of an e-consult program to speed access to diabetes specialists, a training program on how to disclose adverse events, or the development of a clinic for patients with chronic stable angina, VA HCPs are focused on meeting the demanding health care needs of veterans.2-4
Federal Practitioner will continue to highlight the great work that is being done across the federal health care system, even when it is not popular. The benefits of the medical research and health care innovations are shared by all Americans. They have earned our trust and respect. So, let us know what you think (email or Facebook), and please continue to share your experiences serving your patients. That’s why we’re here.
Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.
1. American Customer Satisfaction Index. ACSI Benchmarks for U.S. Federal Government 2013. http://www.theacsi.org/acsi-benchmarks-for-u-s-federal-government-2013. Published January 28, 2014. Accessed May 28, 2014.
2. Vasudevan MM, Hurr SD, Green MC, et al. The clinical impact of electronic consultation in diabetes care. Fed Pract. 2014;31(3):32-36.
3. Dunn EJ, McKinney KM, Martin ME. Empathic disclosure of adverse events to patients. Fed Pract. 2014;31(5):18-21.
4. Gillette MA, Frohnapple DJ, Knott A, Reeder D. Pharmacist-managed collaborative practice for chronic stable angina. Fed Pract. 2014;31(6):16-22.
1. American Customer Satisfaction Index. ACSI Benchmarks for U.S. Federal Government 2013. http://www.theacsi.org/acsi-benchmarks-for-u-s-federal-government-2013. Published January 28, 2014. Accessed May 28, 2014.
2. Vasudevan MM, Hurr SD, Green MC, et al. The clinical impact of electronic consultation in diabetes care. Fed Pract. 2014;31(3):32-36.
3. Dunn EJ, McKinney KM, Martin ME. Empathic disclosure of adverse events to patients. Fed Pract. 2014;31(5):18-21.
4. Gillette MA, Frohnapple DJ, Knott A, Reeder D. Pharmacist-managed collaborative practice for chronic stable angina. Fed Pract. 2014;31(6):16-22.
Bilingual Learning
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.
EBA: Reminder app improved multimedication adherence in elderly
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.
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 A1c 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.
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.
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 A1c 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.
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.
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 A1c 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.
On Twitter @sherryboschert
Bullying
Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).
As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.
Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.
Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).
One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.
"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.
Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.
When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.
Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).
As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.
Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.
Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).
One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.
"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.
Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.
When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.
Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
Bullying affects approximately 20% of children, according to a 2012 survey of 20,000 students in grades 3-12 (Bullying in U.S. Schools 2012 Status Report, published by the Hazelden Foundation 2013).
As pediatricians, we have all faced the grieving parent distraught by the ill treatment of their child. Many of us have probably felt helpless because it’s not a medical issue – or is it? I think we can all agree that it doesn’t start as a medical issue, but for sure it can end as one.
Anxiety, depression, cutting, abdominal pain, headaches, and weight loss can all be the end result of the stress of bullying. Some children are able to be honest about how they are feeling, but many internalize it and parents are sometimes the last to know. Approximately 160,000 students stay home from school everyday because of bullying, according to the National Association of School Psychologists.
Many school systems have adopted antibullying programs in which children are educated on the effects of bullying, how to treat their peers, and what to do if they are bullied. But some recent research shows that these programs may not be successful, and bullying rates are actually higher at schools that have implemented these programs, according to the Canadian Journal of School Psychology (2011;26:283-300).
One of the main differences with bullying now is that social media may play a significant role in the extent of the bullying. Facebook, Instagram, and Snapchat are vehicles that are used by the bully and that can make the extent of the damage much worse. Twenty years ago, a rumor had to spread by word of mouth; now, with just a touch of a button, hundreds of students can see and know of the ill-intended work of a bully.
"Bullycide" is a newly coined term that suggests a child committed suicide because she was bullied. The rate of these occurrences is rising largely because of the attention placed on bullying, but the media also serves as an information trail, which allows us to connect the dots more clearly.
Intervention that we can do as professionals is to identify things that may put a student at risk and try to intervene early. Severe acne, obesity, and social anxiety are all things that can be treated to improve a child’s self-esteem and make them less of a target. Parents are not always in tune to this because their love is unconditional, and they may not recognize the role these play. Using the well-child visit to uncover these issues and offer treatment for things that may not have been brought up.
When approached by parents who are seeking help, directing them to the stopbullyingnow.gov provides a great source of information that can help parents navigate dealing with the school and helping the child deal with stress. The CyberBully Hotline is a program that schools can implement that allows parents and student to anonymously report cyberbullying. This has been shown to be extremely effective in reducing the number of fights that occur.
Parents should be educated that any threat of suicide should be taken seriously, and an immediate intervention should be taken. 800-273-TALK is the suicide hotline that parents can use if they are concerned that their child is at risk. Emergency departments are equipped with social workers who can assess if hospitalization is necessary or if a child should be followed as an outpatient.
Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected].
Attacking Medical Errors in Dermatology
The times they are a-changin’
“... 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.
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.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.
“... 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.
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.
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.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.