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Outgoing Chair’s Welcome
By Antoinette L. Laskey, MD, MPH, FAAP
Outgoing Chair, Section on Young Physicians
The NCE is almost here and there is no more exciting place to be this fall than Washington, D.C. This year’s meeting will be a perfect opportunity for you to use the power of your voice to advocate for your patients, your patients’ families and for future patients. The Washington office of the AAP tells us that our Representatives and Senators want to hear directly from those who deal with the realities of health care in America. They appreciate the opportunity to talk to real doctors caring for real people. It’s crucial, as the debate surrounding how best to reform the healthcare system continues, that the voices of pediatricians speaking for children be heard.
The Washington office is working hard to get us the most up-to-date information regarding the current standings in the debate. You can stay informed by becoming a Key Contact. As a Key Contact, you can team up with the AAP Department of Federal Affairs to truly advocate for your patients. The AAP reaches out to its Key Contacts to speak directly to legislators as hot topics are being debated and voted on. To become a Key Contact, login to the Member Center of the AAP website and click on “Federal Affairs, Be a Key Contact” under the Advocacy heading. The AAP Department of Federal Affairs provides Key Contacts with all the necessary information to have a high impact conversation with law-makers.
Young Physicians will be practicing in the health care environment that is being crafted today for decades to come. Play a role in that process! Sign up for the Federal Advocacy Action Network and become a Key Contact today. If you will be at the NCE, consider contacting your legislators while you are there. And finally, if you will be at the NCE, we look forward to seeing you at the Young Physicians’ program all day Sunday and the Young Physicians’ reception Sunday night.
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Incoming Chair’s Welcome
By Christina Vo, MD, FAAP
Incoming Chair, Section on Young Physicians
What an exciting time to be a young pediatrician! Not only has the AAP made a directed effort to increase young physician participation and satisfaction, for the first time in decades, our national government is focusing on Health Care Reform. The SOYP hopes to guide you through these transitions and help you find your role as a practicing pediatrician.
Your district representatives on the SOYP Executive Committee attended the annual meetings with District leaders this summer. We met district and national AAP leaders, including the candidates for AAP President. We had the chance to offer advice on how chapters could get young physicians involved and constantly reminded the districts when young physicians should be considered.
The SOYP Executive Committee has also participated in bimonthly conference calls with Dr. Judith Palfrey, the current President-elect of the AAP, and other AAP leaders. One of the major topics of these calls has been Health Care Reform: updates from the Committee of Federal Government Affairs (COFGA). There have also been discussions on how to get information to young pediatricians and getting young pediatricians’ voices heard. You should have received an email from your District Representative describing how to get weekly email notifications from COFGA; they are brief yet helpful summaries of what is happening in Washington right now. You can also check out the COFGA website to learn how to contact your Senator or Congressman about the future of health care.
This coming year, the SOYP Executive Committee will be revisiting our strategic plan. I have the honor of being your section chair for that process. As you may remember from last year’s referendum, the SOYP Executive Committee now elects the chair of the section each year. As the District IX Representative, I hope that my becoming chair encourages other districts to think as progressively as District IX when it comes to young physician involvement. Our district has established young physician point persons for state advocacy, made the young physician representative an integral part of the board and added a young physician to the state pediatric council (a group of pediatricians and insurance company representatives working to resolve payment and other issues).
In order to continue this type of forward-thinking, our section needs to hear from you, especially this year when we will be focusing on our strategic plan. Please check out YPConnection, our section’s online networking site. It has been revamped and we want you to use it to talk with each other and to tell us, your representatives what is most important to you. Find district groups as well as an advocacy group. Start a group of your own! I look forward to becoming your “friend” on YPConnection.
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Editor's Note
By Dennis Kuo, MD, MHS, FAAP
At this point you would have to be living in a really thick well-insulated bubble to not have heard that Congress is discussing health care reform. Perfect strangers now come up to me and ask me my opinion on health care reform. Well, not really, but it’s not that far from the truth. Recently I sat down at a dinner across from a person I’d never met, and after he learned that I was a physician, the next words out of his mouth were “public or private?”
There is a larger point here. People are curious to know what I, as a physician, think about health care. I have no doubt all of you fellow SOYP members are in the same position. Because we are very much on the front lines of the health care debate, we know intimately about what’s going on when families don’t have health insurance or a primary care doctor. And we know what happens when Medicaid reimbursements are inadequate to maintain the expenses of our practices. I have a few stories, and I’m sure you do, too.
This edition of the SOYP newsletter, as always, presents your stories to share with colleagues. Drs. Chung and Fisher also discuss health care reform developments and Dr. Chung offers important ways that you can get involved to speak on behalf of children…because children cannot speak for themselves.
Finally, this is my last SOYP Newsletter editor’s note, as I’m turning over the editor position to Gracie and a new co-editor to be named. The growth of this newsletter was made possible with tremendous support from AAP staff, the SOYP executive committee, and you, the members of SOYP. Thank you for sending in the numerous articles and stories over the last four and a half years that I have enjoyed reading and reviewing. Keep ‘em coming!
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District IX Report September 2009
By Christina Vo, MD, FAAP
District IX has always been one of the leaders in terms of making sure young physicians are involved in district and chapter activities. I am proud to be serving as your SOYP Chair this year, having run on a platform stating that District IX leads the way and other districts can learn from ours.
This last month we are proud to have Jamie Powers, MD join the state Pediatric Council as a young physician representative. This group of pediatricians and insurance company representatives are working together (believe it or not!) to resolve problems including payment for vaccines, acceptance of new codes, and other issues particular to private practice.
Our District Chair, Myles Abbott, MD, FAAP also brought together a group of young pediatricians in the Sacramento area in order to establish a set of pediatricians who could testify at our state legislature on issues related to the health of children. A few words from a pediatrician can go a long way when discussing bills with state senators and representatives; often more effective than a lobbyist.
The legislative season is coming to a close in California. There have been a lot of developments lately. Please check out the AAP-CA blog to learn more about legislative issues pertinent to pediatricians: www.aap-ca.org. The following is a list of interesting bills this season. By the time this article is published we should have the final vote on these bills.
(Information in italics is background or commentary.)
AB 1422: Funding Healthy Families AAP-CA has decided to support this bill despite the AAP-CA policy on staying neutral regarding laws which levy taxes. The loss of funds to Healthy Families this year jeopardizes health care to over 600,000 kids. This bill passed and was signed by the governor.
AB 1422 (Bass) would raise money for the Healthy Families Program to cover state budget cuts by establishing a temporary gross premiums tax for Medi-Cal Managed Care plans. These plans currently pay a state tax of 5% that will end Oct. 1, 2009. AB 1422 would establish a short-term 2% tax instead that would sunset in two years, to bridge the time until longer-term solutions to Healthy Family cuts can be found. This tax on the plans would provide California the state matching funds needed to draw down increased federal funds. Because AB 1422 brings in more money to these programs than it takes from them in the tax, there is no registered industry opposition to the bill, and the Association of California Health Plans supports it. AB 1422 also would increase the modest premiums under Healthy Families only for those at over 150% of the poverty level.
The bill text can be viewed at: http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_1401-1450/ab_1422_bill_20090825_amended_sen_v96.html
AB 2: Individual health care coverage This bill takes a step that may help patients qualify for health care coverage. Of course, if national health care reform makes a big difference, this bill will not be necessary but for now it is a step in the right direction.
Thousands of Californians have had their health insurance policies unfairly cancelled by insurance companies after they got sick. This CMA-sponsored bill, which would require that insurers be subject to an independent, automatic external review before rescinding coverage, is a reintroduction of legislation that last year passed with bipartisan support through the Senate and Assembly, only to be vetoed by Governor Schwarzenegger. The bill passed out of the Assembly by a vote of 45 to 26 and is currently in the Senate Appropriations Committee.
The bill text can be viewed at http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=ab_2&sess=CUR&house=B&author=de_la_torre
AB 719: Food Stamps for Foster Kids AAP-CA supports programs that promote the health and well-being of youth. This has included support during their initial transition to adulthood, particularly for vulnerable populations.
AB 719 creates a transitional food stamps program for foster youth who age out of the foster care system, and who are not eligible for the California Work Opportunity and Responsibility to Kids (CalWORKs) or Supplementary Security Income program. The eligible youth will receive the maximum benefit allotted for a household size of one for 12 months, and will be exempt from reporting during the certification period. This bill will make it easier for foster youth to receive food stamps.
The bill text can be viewed at http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=ab_719&sess=CUR&house=B&author=bonnie_lowenthal
AB 962: Gun Ammunition Requirements This bill is consistent with AAP policies and goals of decreasing gun violence and injury to children and youth.
AB 962 combats the easy accessibility to handgun ammunition that fuels gun violence, including unintentional and intentional injury to children and youth. While it is illegal to sell a gun to a felon, it is legal to sell or supply a felon with ammunition. This measure would cut off easy access to handgun ammunition to ensure that handgun ammunition may not be legally sold to criminals, gang members, and youth. The bill would require that handgun ammunition dealers obtain a Department Of Justice Handgun Ammunition Vendor’s License and to record sales which would be made available to law enforcement for crosschecking purchases.
The bill text can be viewed at http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_0951-1000/ab_962_bill_20090622_amended_sen_v97.html
AB 1049: California Safely Surrendered Tax Check Off AAP-CA supported the passage of the Safely Surrendered Baby Law that permits legal surrender of newborns in California, to prevent injury and death to unwanted infants. However, there remains insufficient public awareness of the process and other barriers to its use, as evidenced by the over 400 babies that were illegally abandoned in California last year.
AB 1049 would allow voluntary taxpayer contributions to fund outreach, to expand awareness on the Safely Surrendered Baby Law, and to ensure the law is enforced. The bill gives taxpayers the opportunity to contribute to the California Safely Surrender Baby Research Fund when they fill out their state income tax form.
The bill text can be viewed at http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1049_bill_20090629_amended_sen_v95.html
http://www.aap-ca.org/
AB 98: Maternity Services This bill is consistent with AAP policy relative to the importance of access to prenatal care.
AB 98 requires every individual or group health insurance policy to cover maternity services. Under current law, the Knox-Keene Health Care Service Plan Act of 1975, health care service plans are required to provide maternity services as a basic health care benefit. California Department of Insurance-regulated health insurance policies, however, are not required to cover maternity services. The bill would define maternity services to include prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, and inpatient hospital maternity care, including labor and delivery and postpartum care.
The bill text can be viewed at http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=ab_98&sess=CUR&house=B&author=de_la_torrehttp://www.aap-ca.org/
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2009 Annual Meeting of the AMA House of Delegates
By Lloyd D. Fisher, MD, FAAP
Delegate from the AAP-YPS to the AMA-YPS
The American Medical Association House of Delegates (HOD) met in Chicago from June 13th through June 17th to debate hundreds of resolutions and reports affecting the practice of medicine. As your AMA-YPS delegate I attended the Young Physicians Assembly where YPS members representing every state and specialty meet the day prior to the HOD meeting to discuss issues specific to young physicians and also instruct the YPS delegates to the HOD in how to vote on all of the resolutions. The “hot” topic at this year’s meeting, of course, was health system reform. This meeting took place before HR 3200 or any of the Congressional bills currently on the table were released, but we all knew they were coming. Below is a summary of just a few of the resolutions that were discussed. For complete details of the meeting and text of all of the resolutions, go to http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates/2009-annual-meeting.shtml
- Maintenance of certification (MOC) – As more and more specialty boards including the American Board of Pediatrics have implemented new criteria for recertification which includes ongoing and longitudinal study and practice improvement, there has been much concern raised that some of these requirements are overly burdensome. This report from the AMA Council on Medical Education sought to ensure that MOC changes and implementation are fair, purposeful, and reasonable. Some of the many provisions in this report are that any changes in MOC must be reasonable and take into consideration the time it will take to develop proper structures allowing physicians to meet the requirements, should not occur more frequently than the interval for each MOC cycle, should not result in a significant increase in cost to participants, and should not reduce the physician workforce by being temporally inflexible.
- Physician workforce – A few resolutions dealing with the current shortage of physicians in certain specialist and geographic areas were brought forth. The House passed policy stating that any federal health care reform should have provisions to increase the physician workforce, the Centers for Medicare and Medicaid services should explore ways to fund more residency slots, and the cap on GME funding imposed by the 1997 Balanced Budget Act be rescinded.
- The Patient Centered Medical Home concept - a major interest of the AAP continues to be a hotly debated topic at AMA meetings. Most agree with the medical home in theory, but there is much disagreement with how payments to medical homes should be structured and from what source they should come. What was eventually passed was a policy stating that the AMA supports the model, incentives need to be designed to enhance care coordination, and that all health plans should be mandated to use a standard set of criteria in determining which practices and providers qualify as a medical home.
- Payment for email consultations – As more and more technology is developed and our patients have more methods in which to communicate with their “medical home”, reimbursement for services provided outside of a traditional visit need to be developed. This resolution asked the AMA to work with the Federal Government to have Medicare and Medicaid provide reimbursement for these services. Through the debate of this topic it became clear that there are many other types of non-traditional visits that should be reimbursed besides simply email. The House opted to refer this to the Board of Trustees to further explore the topic and report back at the next meeting.
- EHRs and e-prescribing - With the recent passage of the American Recovery and Reinvestment Act of 2009 (aka The Stimulus Bill), there are now incentives for physicians to adopt EHRs and electronic prescribing. There is much concern though, that in addition to incentives, there will also be penalties to practices that do not adopt these technologies. There were a variety of resolutions asking the AMA to work with the government and the insurers to not levy penalties. The HOD was overwhelmingly in support of these resolutions.
- Student debt - Always of interest to young physicians is the issue of medical student debt. Currently there is an income cap on deducting interest paid on student loans so that most physicians in practice do not qualify for this deduction. Despite the fact that a physician’s income is greater than many others, the educational debt they incur is even greater. The YPS submitted a resolution, which did pass the house, asking the AMA to draft legislation to change the tax code allowing for the ability to deduct interest on loans to not be phased out above a certain income level.
- Health Care Reform – this was the 1000 pound gorilla in the room during the entire meeting. There were numerous resolutions on the topic. The AMA-HOD, being a diverse body made of physicians from every state and every specialty, had delegates representing all views on the political spectrum. Resolutions ranged from a completely government controlled single payer socialized health care system on one end to resolutions banning any government intervention in the financing or delivery of health care on the other extreme. Ultimately, after much comprise, a policy was passed which leaves the AMA some latitude in remaining at the table as legislation progresses. Rather than supporting any specific legislation or any specific proposals, the HOD decided to adopt a set of guiding principles that should be adhered to in any health care reform legislation. The final text is as follows:
That our American Medical Association support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice, and universal access for patients.
As the legislative process continues, many different bills and amendments will come up. As the HOD only meets twice a year, the AMA officers need to have some flexibility in negotiating with Congress. The House, in its wisdom, by developing these principles, is allowing the officers the ability to approve or disapprove of future legislation based upon whether it meets these basic goals.
There were many other resolutions and reports discussed as well. If you would like more information on this meeting or about AMA-HOD meetings in general, feel free to contact me at lfisher@massmed.org.
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Are You Proud of Your Profession? What We Can Learn From the Fire Service
By Dan Hale, MD, FAAP
The pager screeches again at midnight. Not the hospital pager: the Fire Department Motorola audio pager. It screeches with a distinctive deep “BOOOO,” then a high pitched “EEEEEE,” followed by the urgent dispatcher call “Calling all Kittery Firefighters. Report to the fire station, you have a fire call. Respond to 79 Seapoint Road for a structure fire. Repeat. Calling all Kittery Firefighters. You have a fire call. Time of call 11:58.”
I jump out of bed in a well-rehearsed routine: put on the already laid out clothes including heavy socks (it is January.) Put on my boots loosely--untied to save time and because I will be putting on my fire boots at the station in 3 minutes. Brush off the snow on the Jeep’s windshield, jump in, turn on the red light fire flasher, and head to the station to get on one of the three fire apparatus that will head from our station to the scene.
What physician in his or her right mind would sign up for more call than they already have? Furthermore, what business does a physician have volunteering for the fire service? I joined the Kittery Fire Department in September 2004 as a volunteer because I wanted to give back to my town and country. In college I volunteered at the soup kitchen, in medical school I volunteered at the free clinic, in residency I volunteered at the homeless clinic, and now I was going to volunteer at the Fire Department. I wanted to do something different, outside of work. Firefighting is in my blood – my grandfather, uncle, and cousin have all been firefighters. The events of September 11, 2001 reminded me of the need to volunteer and what our first responders do every day.
At work as a pediatric hospitalist, fellow physicians refer patients to me for admissions, request I attend deliveries to care for the newborn, or ask me for a consult in the Emergency Room. All of it is an established pattern in which my expertise and opinion is trusted. This volunteer firefighter activity was definitely out of my comfort zone.
On the night I arrived at the fire station to ask to be a volunteer, mandatory monthly training was scheduled. That month was SCBA (self contained breathing apparatus) training. They had a “smoke trailer” in use – an indoor maze with tight areas and ladders filled with artificial smoke so you could not see. They put a SCBA pack on me, gave me a three minute lesson on how to use it, and sent me and a buddy in. We made it out together and I passed the first test for claustrophobia and to see if I really wanted to do this.
We rolled up to the Seapoint Beach structure fire, my first one, four months after I joined. I had no idea what to expect. My lieutenant told me to stick with him – I was still a “probie”, a probationary firefighter, because I had not yet met full training requirements so I was not allowed to enter a burning building. I helped him put up ladders to the windows and roof and could feel the heat from the building. One of the first crew firefighters came out for a new air bottle. He asked me to help him change his bottle because it would save time if he could leave the pack on while I did it. I started to help and then quickly realized I had no idea how to do it as I had not learned yet. A driver noticed and came over and changed it so quickly I could not even tell what hoses he was connecting.
That structure fire was almost a complete loss. An ember from the woodstove probably landed on the hardwood floor and set the home on fire while the owners were out at dinner. Luckily no one was injured. During salvage and overhaul, the Chief asked me to take some heat-damaged family photographs off the wall and carry them to the owner standing outside. She tearfully accepted. After this incident, I knew I wanted to make volunteer firefighting a second career rather than a volunteer duty. I wanted to be able to help my neighbor in time of need, I wanted to learn how to be an efficient team member, and I did not want to get hurt or hurt anyone doing it.
I took six weeks off a year later and went to the New Hampshire Fire Academy for Recruit School. In boot camp like settings, they drilled the fundamentals of firefighting, rescue skills, and survival into me. Just like the military, they broke us down (One instructor said “you guys fight fire like a bunch of high school punks”) then built us up and gave us confidence.
After the transition to being as proficient as possible at my new second career, I realized medicine and firefighting are not as different as I thought. Being a good firefighter makes me a better physician, and by being a better physician, I can be a solid firefighter. In medical school I went to a Grand Rounds given by a representative from the airline industry. At that point, patient safety was still not being talked about consistently. He gave examples of checklists and how to make safety a part of your daily work.
Firefighting is an example of another inherently dangerous field that has even more analogies for safety. The Fire Service has analogies that relate more closely to the medical field: Safety, Planning, Training, Commitment and Professionalism, and Community Outreach.
Safety is the number one concern in the Fire Service. “Everyone goes home safely,” the Chief always says. We have a buddy system to make sure your partner is always there if needed. We do weekly equipment checks, and check the equipment before we need it, and check it again before we put it away.
The Fire Service has contingency plans for almost every emergency. Extensive pre-planning is done for multiple situations. What apparatus is needed if a school burns? How many personnel would be required? Would we need to activate mutual aid from a neighboring town?
Training is essential for planning, safety, and to assure we can perform a task correctly the first time every time. In addition to initial training, we often have refresher training. If you cannot hook up a fire hydrant correctly in training, you can be assured your officer will make you perform the duty repeatedly until you get it right.
The professionalism and commitment to the Fire Service is legendary. Firefighters are available for the citizens in a manner that goes beyond just a job. When the pager goes off, we drive to the station because a neighbor is calling us in a time of need. If there is a car with leaking motor oil one or two guys might show up, but for a call of a lost child or a neighbor’s home on fire almost the entire department will show up no matter what time of day. Firefighters take pride in the long tradition of service.
Community service is a natural extension of the firefighting profession. Fire kills more Americans than all natural disasters combined. In 2008, 3,320 civilians lost their lives as the result of fire.1 From 1985-1994 an average of 5,277 civilians a year lost their lives as the result of fire.2 Education is the primary lifesaver where fires are concerned. Fire codes, smoke detectors, sprinklers, and town investment in the local fire department have reduced fire deaths consistently.
Safety, Planning, Training, Commitment and Professionalism, and Community Outreach should also be premier goals in the medical community. How many physicians roll their eyes at the extra safety steps required in the hospital now? When was the last time you led a mock code or were part of an exercise for pandemic planning? Do you believe we are also part of a long line of tradition that can better the lives of our patients? These are the real lessons we can learn from the Fire Service.
Dan Hale, MD, FAAP is a volunteer firefighter for the Kittery Fire Department. In his spare time he is a pediatric hospitalist at Central Maine Medical Center in Lewiston, Maine and The Barbara Bush Children’s Hospital in Portland, Maine.
References
- U.S. Fire Administration data. FEMA publication.
- Fire in the United States 1985-1994. FEMA publication.
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Father's Day
By Varsha Puri, DO
Practicing at a low-income community clinic promises days of delight, anguish, struggles and achievements. Serving those who are dealing with the newfound realities of living an impoverished life is part of my everyday. I am also routinely faced with the consequences of fatherless families.
No child is inherently an outright delinquent. However, many of my patients come with the life scars of an old veteran: failing multiple classes, fighting with others, or taking their anger out on their siblings at home. Many of us pediatricians hang our heads low, accepting broken and disjointed homes as a reality of our society. I am so accustomed, in fact, that my intake on a well child exam caters to addressing these problems.
Though nothing in particular changed in clinic today, something caught me by surprise. My afternoon clinic hours were typical, and my routine of scrambling to keep up with waiting patients persisted as usual. I looked up suddenly and saw a rather husky man wandering the clinic hall. He didn’t fit in to our peach pastel walls and circus animal framed pictures, to say the least. I inquired: “Excuse me sir, is your child in one of the rooms?” "I'll be waiting in the waiting room," he said with a quiver in his voice. I felt like I had just interrupted a previous conversation, but that was his reply to my question. “I’m sorry, is your child here?” I asked. This time I turned to Sylvia, my medical assistant, for answers. Perhaps the situation made more sense to her. “He’s the father of your next patient,” Sylvia explained. (Okay, now we’re getting somewhere.) "Is your child here for a well child check?" I asked the father. "Yeah, but I can't be in the room when she gets her shots," he replied. “I just can’t be there when she cries. My wife knows. She’s in the room.”
This tall, husky, Lakers-jersey wearing irony standing in front of me had me chuckling on the inside. However, I kept a stern face, and briskly escorted the man back into the patient's room. Inside awaited mom, holding a very petite two-year old that had fallen asleep in her arms. Next to me sat her 4-year old sister and the patient’s Lakers diaper bag. "Have a seat, let's go over a few things," I instructed.
We started our review of the five million questions I ask during a well child check. “Do you have any concerns today? Is there any cough-cold-fever-vomiting-diarrhea-constipation?" (If I could put it all into one word I would. It would sound something like: “any cofevomitediarripation?”) I continue: “Do you have any concerns about her behavior?"
The dad explained that she has tantrums at times. Tantrums are not atypical for a two year old, but it is the extent of them that gives me a gauge on disciplining and parenting skills. "I defer to him. He's home with the girls most of the day," mom explained. The father quickly replied: "Oh, I put her on time-out." That is music to a pediatrician's ears. If I had a "Dad of the Day" badge, I would have given it to him.
We transitioned into talking about her diet. The girl was petite, though still growing quite fine. I continued with my barrage of five million questions: “Do you have any difficulties around eating?” A quiet silence fell over the room. He didn't say much, his face said it all; it was a face of defeat. After a while a pediatrician just knows; I could just envision the father and his daughter at lunch with one plate of food, four precisely sliced hot dog pieces, two spoons of corn and a ½ slice of bread on the side. The two-year old in malicious defiance will sit there for thirty minutes and only drink her milk. Then 6' 5", 220 pound dad will sit down next to her. At first he will try the method of gentle coercion, followed by bribery. Her mouth will close tightly in protest. Bribery gets tossed out the kitchen window. Empty threats thunder down from burly dad in his Laker's jersey: "Lela, you have to eat this or else..." The protest rises. Dad pushes harder and is… once again defeated by his petite 25-pound daughter.
Despite the trepidations of parenthood, strong parents, like the couple sitting in front of me, endure these battles with determination and love. At the end of our, likely emotionally draining, discussion I sat in admiration for this father. Nothing else mattered for him but the emotional and physical health of his two daughters. As much as his dedication rings through his actions, his uncertainty rings even clearer.
“I want to compliment your style and commitment to raising your daughters,” I told him as he was about to leave. “Thank you,” he responded, “I never am quite sure, but I am just trying to do the best I can.” At that moment it became clear to me that he rarely gets positive reinforcement and support for his courageous actions.
Though I believe the true gift lies in the children they raise, I realize that kind, supportive words to nurture fathers needs to become part of our daily practice. So much of my attention goes into identifying and helping the fatherless families, of which there are too many. Similarly, so much of society's attention goes into highlighting the fatherless homes in which so many of our lower economic youth are raised. This Saturday I left wondering, why not give more attention and praise to all those men out there doing it right? My hats go off to all the wonderful fathers, especially the ones who come in for their child's well child checks, as you have made a pediatrician's day.
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Health Care Reform - How Can You Participate?
By Sandy L. Chung, MD, FACHE, FAAP
“You are the first pediatricians who have come to our office,” remarks a staff member of a Congressman.
This was a comment made to us during one of many visits to Capitol Hill during a meeting of the AAP’s Committee of Federal Government Affairs (COFGA) in September where I served as your SOYP liaison. This comment was especially distressing, since by that time four of the five proposed health care reform bills had already been written... and no pediatrician had visited this Congressman?
Now, before you take that comment the wrong way, please be aware that the AAP has been extremely active on the Hill and our AAP Department of Federal Affairs staff members have been very busy lobbying on our behalf. Their hard work has been instrumental in making sure that most of the plans are fairly strong regarding pediatric-oriented legislation. Regardless of the comment said to us, it is very likely that this Congressman’s office had already been given information about the pediatric issues or may have been visited by AAP staff members. However, these staff members are not pediatricians.
Our lobbyists are very bright, extremely well-informed, and effective. They know these plans inside and out and they understand our issues – but they are not doctors. “I am more likely to listen to a physician who has expertise in his profession, than a lobbyist,” said a state delegate. This is even truer if that doctor is a voting constituent.
There are several pediatricians who are active in advocacy and your Executive Committee is working hard to try to ensure that the health care reform legislation is pediatric-friendly. However, when you are considering the enormity of what is at stake, I would say to you that “several” pediatricians is not enough. We NEED more pediatricians to become involved.
There are over 60,000 pediatricians who are members of the AAP and over 4,000 of them are members of SOYP. As members of SOYP, we are the generation of physicians who will have to work the longest within the framework of any new healthcare reform. The rest of our careers are going to be shaped by this legislation. So, it is in our best interest to get involved now. It is not too late! The health care reform debate has truly only just begun since the Senate Finance bill was released on September 16.
Regardless of whether of not you are for or against health care reform, it is vital that you help to make sure that IF health care reform happens, children will not be left off worse than they are now. The debates over whether or not healthcare reform happens, or whether or not a public option should be included are entirely different discussions. However, if a health care reform bill is passes, WE need to make sure that children are taken care of and that pediatricians are not left in the dust.
How to get involved? The AAP has several great resources on their website in their Advocacy section. The Webinar from August 13 will give you a great overview of the issues and outlines talking points. It is a little outdated since the Senate Finance bill (the Baucus plan) was not available at the time, but the overall concepts and talking points remain the same.
- Call your Congressman. While this may sound intimidating, they are just people like us who chose to go into politics as their careers instead of medicine. Many of the people who you went to college with may have gone on into politics. They weren’t intimidating in college, they shouldn’t be now.
- Write your Congressman. I’ve been told that handwritten letters get more notice. This may not work for us since we are doctors… but if you write neatly, it might work! However, a type-written letter or e-mail may also be reasonable to do. Mass e-mails or form letters tend to be ignored, so make it personal.
- Visit your Congressman. This may also seem intimidating if you’ve never done it. It’s a very pretty building, with lots of marble… but truly, it’s just an office building. The security is less difficult than going to the airport, because you don’t have to take off your shoes!
- For those of you who live quite a distance from Washington, DC, visiting your Congressman is not an easy thing to do. However, if you are attending NCE this year, you will be only a few blocks away from the Capitol. Hopefully, there will be organized opportunities for us to go as a group. Make an appointment if you can. But even without an appointment, you can always drop by. If you are not able to see your Congressman, try to talk to their staff. This is an effective way to get your opinions made known.
What should you talk about or write about? Many physicians are overwhelmed by the complexity of what is being done. The alphabet and number soup of bills is daunting and confusing (HR 3200, America’s this and America’s that, on and on).
But you don’t need to be an expert to talk to Congress. What you can provide is the “real life” picture of the current status of health care. You have stories of patients who can’t see specialists because there’s no one who accepts Medicaid nearby. You have parents who can’t afford their $10 copays. You have children who show up in status asthmaticus because the parents couldn’t afford to refill their asthma meds. The stories are invaluable and give the legislators “faces” and real people to attach to the legislation.
To get specific about the plans, there are three main points that we want to ensure that all the plans include.
- Cost – Preventing increased costs for low-income families.
Most of the proposed bills set a floor so that all Medicaid will cover all families that are below 133% of Federal Poverty Level (FPL). The families that are just above 133% but below 300-400% FPL (depending on the bill) will be put into the health insurance exchange with subsidies. So they will have to buy their own insurance but will get help from the federal government.
While this in theory sounds good, there is a problem with this since many states currently cover up to 200% to 300% of FPL. Many states have used CHIP funding to make this happen. Some of the proposed bills will phase out CHIP funding in a few years. This means that states will no longer have the federal CHIP dollars, and in this economy, will likely REDUCE their Medicaid eligibility down to 133% FPL. Therefore, those families in the 133%-200% (or 300%) that used to get the great benefits that Medicaid and CHIP programs offered, are now going to be forced out into the Exchange where benefits may not be as good. Additionally, the out-of-pocket costs to these families will be higher. In some of the plans, the Exchange subsidies do not cover the increase in costs to the families that get moved over.
- Benefits – Making sure that “essential benefits package” is based on EPSDT (Bright Futures) and NOT the U.S. Preventative Services Task Force recommendations.
All of the bills state that health insurance plans that are included in the Exchange need to provide an “essential benefits package.” We need to make sure that the legislation defines those benefits for children based on EPSDT (also known as Bright Futures). In adult medicine, they use the U.S. Preventative Services Task Force (USPSTF) recommendations. These recommendations have inadequate pediatric-oriented recommendations. For example, for developmental screening, it states, “The USPSTF concludes that the evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age.” Also, there are NO recommendations for hearing screens past the newborn period. These are just a few of the problems with this. If you take a look at the USPSTF recommendations, you will see how inadequate these recommendations are for children. By specifying that EPSDT (Bright Futures) recommendations will be used, children are more likely to receive these needed services and we are more likely to be reimbursed for performing them.
- Access – Paying 100% Medicare for Medicaid.
We all know that Medicaid is paid below Medicare rates. This is an inequity that does not make any sense. Just because our patients are smaller, it doesn’t mean that our payments should be! Because Medicaid rates are left up to the states, there is tremendous variability and all are below 100% Medicare. The average reimbursement is somewhere around 65-70% of Medicare and some states are as low as 22% of Medicare. As states face massive budget difficulties, reimbursements are likely to drop even more.
With reimbursements this low, there will not be enough providers who accept Medicaid. This is already a problem for access to general pediatricians as well as to needed pediatric subspecialists. Only by leveling reimbursement to a more reasonable level on par with our adult medicine colleagues, will there be any hope of having enough providers to see all these children.
The three issues listed above are certainly not the only issues that the AAP is addressing. Other important issues include workforce shortages, medical home models, and scope of practice. However, I would recommend that if you contact your legislator, you hone in on these three issues. You can always add in others that you feel passionate about. As a group, we will be more effective if our messages are clear, defined, and fairly uniform.
So, please, take this information and do something with it. Your future career may depend on it!
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| Clinical Experience and Pearls |
Interpreting Genetic Test Reports
By Peter B. Kang, MD, FAAP
Genetic testing is becoming increasingly available for a variety of disorders. This includes not only traditional Mendelian diseases, but also common conditions such as breast cancer that do not follow easily discernible inheritance patterns. More and more frequently, general pediatricians and pediatric subspecialists order genetic tests, sometimes with confusing results.
In the best-case scenario, the ordering pediatrician receives a clear answer from the test report, identifying a pathogenic mutation or excluding such mutations. But a number of test reports state the following mysterious conclusion: “Sequence variant of unclear significance.” The term “variant” means that the DNA sequence analyzed in that patient is different from the reference sequence that the laboratory uses. But variants include both disease-causing mutations and benign polymorphisms. How can a pediatrician tell the difference? There are several ways of analyzing a variant further, which may be used in different combinations depending on the particular circumstances.
- Most importantly, does a possible mutation fit in with the clinical context? If a genetic test demonstrates a variant of unknown significance in gene X and the patient’s symptoms are very different from what is typically seen with mutations in gene X, a pediatrician should be pretty skeptical of this variant.
- A basic question is what the consequences of the variant are. If the variant creates a premature stop codon or changes the reading frame, it is often pathogenic. In most cases when a sequence variant is deemed to have unclear significance, there is a single base pair change that causes a single amino acid change.
- One major clue is how well the variant tracks with the disease trait in the family. For dominantly inherited conditions, if the variant is present in all affected family members and not present in unaffected family members, that is consistent with a pathogenic mutation. In some dominant conditions, variable penetrance can confuse the picture somewhat, so this possibility should be considered if the variant otherwise seems to be a pathogenic mutation. For recessive conditions, two copies of the variant (or two different variants) are needed to cause disease, and unaffected individuals may have either no variants or just one (carrier status). Another new wrinkle is the possibility that a genetic variant confers risk for a disease rather than the disease itself, as in the case of breast cancer.
- Another piece of information that may help is whether the variant is present in a set of unrelated control individuals from an ethnically-matched population. Testing 100 control DNA samples is usually considered sufficient. If the variant is not present among such a set, it implies that the carrier frequency is lower than is usually seen with a benign polymorphism, and suggests that the variant may be a pathogenic mutation. Some test laboratories have batches of control DNA that they test, but they are not always ethnically-matched.
- Species conservation is important. If the variant causes an amino acid change, it is more likely to be pathogenic if the amino acid in question is conserved across a number of species. Some genetic testing laboratories generate this information for the pediatrician, other times the pediatrician may have to look up this information directly. Two helpful websites are http://www.ncbi.nlm.nih.gov/ and http://genome.ucsc.edu/.
All pediatricians should be able to determine the answers to items 1, 2, and 3. Item 4 can only be performed by the testing laboratory or a research laboratory. Items 2 and 5 can be determined either by the pediatrician or testing laboratory. The testing laboratories that are most helpful are the ones that determine items 2, 4, and 5 for the pediatrician whenever there is a sequence variant of unclear significance.
When there is more than one clinical genetic laboratory that offers testing for a particular gene, a pediatrician should use the one that offers the more reliable, prompt, and thorough analysis for a reasonable cost. Insurance coverage of genetic testing may be limited in some cases, thus pediatricians should be aware of the cost of genetic testing in case the patient is required to pay some or all of the fees out of pocket. As most genetic testing laboratories do not advertise aggressively, the reputations of various laboratories spread largely by word of mouth and by the personal experience of the pediatrician. A pediatrician should not hesitate to try a different laboratory if recurrent problems occur with the first one.
A pediatrician should also be aware of the need for genetic counseling for individuals and families who undergo genetic testing. If the pediatrician is not comfortable providing direct genetic counseling, he or she should be ready to refer the family to a licensed genetic counselor for further discussion and interpretation. General pediatricians may also wish to refer some of these patients to a pediatric subspecialist. For genetic disorders affecting a particular organ system, it may be helpful for a general pediatrician to consult informally with a subspecialist before sending genetic testing.
Genetic testing is a powerful tool that is quietly revolutionizing medical care. When used properly, it can provide information that can clarify a diagnosis and help a family understand a disease process affecting their child. However, when ordered indiscriminately and misinterpreted, genetic testing can be a costly means of spreading misinformation and false diagnoses. A pediatrician does not need to be a formally-trained geneticist to order genetic tests, and should not be afraid to do so, but it is critical to be fully aware of the nuances and consequences of the reports that result from such testing.
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Acute Abdomen or Pelvic Osteomyelitis: What is the Diagnosis?
By Waldo N. Henriquez Barraza, MD, FAAP
A fifteen-year old female presents to the emergency department (ED) with a 5-day history of right lower quadrant (RLQ) pain associated with one episode of food content vomiting, tactile fever and chills. Her pain is moderate, sharp, intermittent, non-radiating and no relief is obtained with pain medications. Her past medical history is unremarkable and she is not sexually active.
On physical examination, the patient appears uncomfortable. Her temperature is 101.7, pulse is 116 beats/min, blood pressure is 91/42 and respiratory rate is 20. Her abdomen is soft, non-distended, with no guarding or rigidity, but she reports localized tenderness in the RLQ. Bowel sounds are present without masses or organomegaly. Pelvic exam done by the gynecology service in the ED is normal.
The white blood cell count is 7.2x10 3/mcL, the hemoglobin 11.6 g/dL, the hematocrit 33.8% and the platelet count is 196x10 3/mcL. The girl has a normal concentration of sodium, potassium, chloride, urea nitrogen, creatinine and glucose. Findings on urinalysis are normal and urine pregnancy test is negative. The patient was admitted to the pediatric floor for observation with possible diagnosis of appendicitis and a surgical consult was requested. An abdominal computerized tomography reveals a right ovarian cyst but no evidence of appendicitis. Serial exams lead to the correct diagnosis.
Discussion
A few hours after the admission, the abdominal exam suggested tenderness localized to the iliac crest, but x-rays of the hip and pelvis were unremarkable. In light of the persistent pain and normal x-rays, a nuclear medicine scan was ordered which demonstrated increased uptake in the right iliac crest. Magnetic resonance imaging (MRI) of the hip and pelvis confirmed a subperiosteal abscess of the right iliac bone. Intravenous Clindamycin was started and the patient underwent incision and drainage of the abscess. Initial blood culture was positive for Staphylococcus aureus but repeat was negative. The patient was seen by orthopedics after discharge and postoperative course was uneventful. Pustular acne was not described on admission exam but treatment was initiated upon discharge.
Pelvic osteomyelitis is described as a diagnostic challenge in children. Different authors describe these cases as difficult, sometimes hard to recognize and even missed diagnoses. The fact that osteomyelitis in children often results from hematogenous spread involving the metaphyses of long bones makes the diagnosis of acute hematogenous osteomyelitis of the pelvis very rare and often not recognized. Te Pas AB et al, reported 2 cases in 2002: one in a 15-year-old girl with pain in the right lower abdomen (similar to our case) and a 9-year-old boy with pain in the left thigh, where an elevated sedimentation rate and C-reactive protein led to a suspicion of osteomyelitis. Grippi in 2006 studied 15 children with infections of the sacroiliac joint to determine the usefulness of specific examinations and studies to aid in the early diagnosis of this condition. The authors found that tenderness to palpation over the sacroiliac joint was present in all 9 patients who had this examination performed, and the flexion abduction external rotation test was positive in 10 of 12 patients (83%) who had this test done. Laboratory indicators of infection were elevated in most patients, and 6 patients (46%) had positive blood cultures, most commonly growing Staphylococcus aureus (something very similar to what was found in our patient as well) They concluded that the early diagnosis of this condition is best made on the basis of clinical and laboratory findings. However, Wathne KO et al, stated that signs and symptoms are often not well defined and blood tests (ESR, CRP etc.) are often of limited value. Thus, they recommended that examination of children suspected of suffering osteomyelitis should include both a bone scan and MRI.
Conclusion
Acute hematogenic osteomyelitis of the pelvis in children may simulate an acute abdomen and females are affected more frequently than males (3:1). This is an uncommon infection often diagnosed late because of poor localization of symptoms and inadequate physical examination. An erroneous laparotomy may be performed because the right side of the pelvis is twice as likely to be involved as the left, and the pain may be referred to the hip, thigh, or abdomen, suggesting acute appendicitis. This case highlights the importance of a thorough physical examination to choose the appropriate radiological evaluation to prevent a delay in the diagnosis and unnecessary intervention. Bone scan is about 90% sensitive and should be considered when the diagnosis of acute appendicitis is doubtful and clinical findings arouse the possibility of pelvic osteomyelitis. MRI is the best radiographic imaging technique for the identification of subperiosteal abscesses for possible surgical intervention.
References
- Weber-Chrysochoou C, Corti N, Goetschel P, Altermatt S, Huisman TA, Berger C.
Pelvic osteomyelitis: a diagnostic challenge in children. J Pediatr Surg. 2007
Mar;42(3):553-7.
- Grippi M, Zionts LE, Ahlmann ER, Forrester DM, Patzakis MJ. The early
diagnosis of sacroiliac joint infections in children. J Pediatr Orthop. 2006
Sep-Oct;26(5):589-93.
- Ford LS, Ellis AM, Allen HW, Campbell DE. Osteomyelitis and pyogenic
sacroiliitis: A difficult diagnosis. J Paediatr Child Health. 2004
May-Jun;40(5-6):317-9.
- Zvulunov A, Gal N, Segev Z. Acute hematogenous osteomyelitis of the pelvis in
childhood: Diagnostic clues and pitfalls. Pediatr Emerg Care. 2003
Feb;19(1):29-31.
- te Pas AB, Feith SW, Wit JM. [Osteomyelitis in children: sometimes hard to
recognize]. Ned Tijdschr Geneeskd. 2002 Aug 17;146(33):1547-50.
- Wathne KO, Babovic A, Nordshus T. [Acute osteomyelitis in young children--a
diagnostic challenge]. Tidsskr Nor Laegeforen. 2001 May 30;121(14):1693-6.
- Abbott GT, Carty H. Pyogenic sacroiliitis, the missed diagnosis? Br J Radiol.
1993 Feb;66(782):120-2.
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Emergency Preparedness in the Office
By Seth L. Toback, MD, MMM, FAAP
One can hardly listen to the nightly news without hearing the word “preparedness.” As physicians in the United States brace their offices to manage the first influenza pandemic in 32 years, we must not forget to prepare for the everyday emergency. In the US, there is currently no national medical body that requires pediatricians to maintain any degree of life-saving skills, despite the perception that the ability to save a life lies at the heart of being a physician. The lack of any organizational pressure to maintain life-saving certification coupled with the rapid pace of a primary care office has resulted in a great deficiency of care. Simply put, a child who chokes on a penny while in the waiting room of his or her physician’s office may encounter an entire staff that has not taken advanced or even basic life saving since residency or nursing school.
My interest in this area began shortly after starting in private practice as a card-carrying member of the SOYP. I was troubled to learn that almost one year before joining my group, a young girl had died right in our office of overwhelming sepsis, yet no substantial changes had been made to our emergency kit or staff education. Being the eager new physician, I dove into the literature on office emergency preparedness. I found a whole host of authors who all had a different opinion on what emergency medications and equipment belonged in a primary care office. I also noted that all of these pediatricians happened to be emergency medicine physicians, and I felt it was time for a little input from the realm of primary care.
The journey to improve my office’s preparedness began by diving into our emergency kit. With dust mask in hand, and a little trepidation in my heart, I opened the box. There was an assortment of yellowing band-aids, dried cracked alcohol pads, some miscellaneous vials, and plastic packages along with a large syringe that I had not seen before. As I had become a Pediatric Advance Life Support (PALS) instructor as a third year resident, I felt pretty confident that I could at least identify emergency drugs and equipment, yet I had clearly never seen the likes of a pre-filled intracardiac epinephrine syringe before. Visions of my senior partner, balding forehead gleaming with sweat, taking the place of John Travolta in the infamous Uma Thurman “resuscitation” scene of Pulp Fiction filled my mind as I tossed the syringe into the sharps container.
As it turns out, my office was not the first to be somewhat inadequately (or creatively) stocked with emergency equipment. A study conducted in New England found that one-quarter to one-third of primary care offices lacked even the most basic emergency equipment, such as an oxygen tank or a nebulizer. One in six offices lacked epinephrine. This lapse in preparedness also extends to office staff education and emergency planning. Another study found that less than one in five pediatricians were PALS certified and an equivalent percentage of office staff were basic life support (BLS) certified. Also, a survey by the American Academy of Pediatrics revealed that only 37% of offices had a written protocol for the appropriate action to be taken in the event of an emergency.
The lackluster preparation in primary care offices may be in part due to the perceived infrequent nature of pediatric emergencies. Their incidence has been estimated at between one and thirty-eight emergencies per office per year, depending mostly on how one defines an emergency. (I guess one physician’s acute asthmatic is another physician’s routine sick visit.) In 7 years of private practice I have seen one child in cardiac shock, one unresponsive hypoglycemic episode, a few seizures and at least a dozen children in respiratory distress. I hypothesize that the acuity being seen in the office may even be rising as parents become more and more frustrated with emergency room waiting times, and subsequently bring sicker children to their primary care physician. This may even be exacerbated by the current economy where parents may hope to avoid any co-pay, especially an ED co-pay.
Fortunately, preparing a primary care office for the vast majority of pediatric emergencies can be done with minimal expenditure of time and money. Physicians and nurses can become PALS certified in a sixteen hour course (eight hours for recertification), while the rest of the office staff can become CPR certified in as little as six hours (ninety plus minutes for recertification).
Apart from what education is recommended, most physicians I discuss this topic with want to know what equipment they “really” need. Several publications are available that suggest how best to equip your office for pediatric emergencies, but I believe that only one can be considered as a gold standard: the American Academy of Pediatrics policy statement Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers by the Committee on Pediatric Emergency Medicine. In addition, the somewhat outdated AAP text, Childhood Emergencies in the Office, Hospital and Community: Organizing Systems of Care also has some good material. Practice Management Online has a summary of the policy as well, at http://practice.aap.org/content.aspx?aid=2057.
But before you ask your office manager to photocopy these equipment lists and run off to your local medical supply store, I would like to comment on the rift between what is recommended in these lists and what can be feasibly done in a busy private practice. This statement was authored by almost every type of pediatrician (emergency medicine, critical care, anesthesia etc.) except for a primary care pediatrician, and some of the suggestions reflect this. One recommendation that I found concerning was stocking intubation equipment in the office is considered “strongly suggested”. The AAP statement puts its recommendations into only two categories, “essential” and “strongly suggest”, yet I think they should revive the old “optional” category used in previous texts and put intubation equipment here. Although as young physicians you may feel that your intubation skills have yet to wane since residency, this is undoubtedly not true for the entire office. Studies with experienced EMTs have shown that pediatric intubation is no better than bag-mask resuscitation and carries a high risk of errors. My own research with primary care providers has shown that many don’t feel comfortable with their intubation skills, yet many still stock the equipment....a recipe for a malpractice suit.
I do think that the list of essential equipment listed in the statement is excellent, and serves as a great starting point for creating an office emergency kit. The list in its entirety may be tailored to suit the specific needs of your patient population and the staffs’ comfort using the medications and equipment. If your office follows these suggestions and already has a few of the more costly items such as a pulse oximeter, an office can be adequately equipped to manage the majority of pediatric emergencies for about $600.
Preparation for medical emergencies begins with a change in attitude. In the past practitioners have neglected office preparedness, claiming that the rarity of emergencies, time and financial constraints were to blame. Physician apathy, denial, and frustration with administrative time demands also play a substantial role. As young physicians who can still recall (painfully) their nights in the pediatric ICU, you could be the catalyst to bring your office up to speed. Working on office preparedness is a great niche which a young physician can fill quite readily, giving you a part of the office you can “own”. It’s also an excellent way to warn up your practice management and administrative skills which are so essential to practice today. Let the office take advantage of your skills, knowledge and enthusiasm. Just because you have left an academic residency program does not mean that you have to give up being academic. I suggest you spend a little time and some of your senior partner’s money preparing for a cause that directly benefits your office’s patients in their greatest time of need.
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SOYP Educational Program: Not your Dads's CME: Young Physicians Managing Work, Family, Future and Self
Sunday October 18, 2009
9:00 AM - 3:00 PM
Renaissance Hotel, Congressional Hall B
The mission of this year's Section on Young Physicians academic program is to address the particular educational needs of the Academy's Young Physicians and to demonstrate the importance and advantages of actively participating in the Academy. To attain these goals, we will be offering programming on topics identified as salient to this population including but not limited to negotiating strategies, protecting the Medical Home, the benefits of belonging to AAP, how to become an advocate, and self-care for physicians. Throughout the conference our speakers will include both staff and current leaders from throughout the AAP. The format of the day will be didactic lectures in the morning followed by afternoon break out sessions for participants who would like to discuss the presented materials in more detail in a small group setting.
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Young Physicians Reception
Sunday October 18, 2009
7:00 PM - 8:00PM
Washington Convention Center, Room 207A
As a new generation of advocates for children you'll find this the perfect event for making connections! Join us for a fabulous array of food, drinks, and prizes.
Sponsored by Nestle Nutrition
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