Are You Connected?
Antoinette Laskey MD, FAAP
It's been several months since we introduced one of our new benefits of being a member of the Section on Young Physicians, YPConnection. We’re excited to see so many of our members taking advantage of this unique networking site designed specifically for people like you. In this closed community of pediatricians in the beginning of their careers, you will find others who share your interests, ask the same questions as you and are encountering the same challenges and successes. Many of our new members are excited to find friends from medical school or residency already on the site. YPConnection makes it easy to reconnect with friends you have made along the way.
Besides being a great place to connect to others like you, there are also groups to join of others with similar interests. There are geographic groups like YPs in Florida or the District IV or VI groups. This is a great way to connect with others and talk about hot topics in your area. We also have forums that are getting more attention each day. Currently there are forums on education (those who will be needing to recertify in their Boards should look here to talk to others who are going through or have gone through the same thing), child advocacy, work-life balance, leadership, job search and local issues. If you have something to say or have a question, this a great place to post.
Some of our members would like the opportunity to blog about what they have going on in their world. Dr. Vo has a parenting as a pediatrician blog. Other members may want to blog about their experience setting up a practice or making a career change.
Another important change we have made in the Section on Young Physicians is staying connected while going green. One of our most popular features is our newsletter. Our newsletter continues to grow in size and content and is successful because you make it so!
With the increasing size and popularity, we felt it was essential to realize the environmental impact we were having. You, our members, told us that you share this concern and may also prefer the flexibility of e-newsletters. We heard you and are offering this improved version. With the e-newsletter, you can quickly find the articles you want to read, have access to expanded content and not have one more thing to clutter up your desk. We think you’ll like the changes we have made and encourage you to share your thoughts as well as your ideas for articles with us.
Our section is about keeping YPs connected, to one another and to the AAP. If you have ideas on how we can do this better, drop me a line, alaskey@iupui.edu. We look forward to hearing from you. Sign up for your space on YPConnection.
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Dennis Kuo MD, MHS, FAAP
My family and I are about to move a thousand miles for a new and terrific job opportunity. This is our fourth interstate move since medical school, which gives me an opportunity to reflect about how some things have changed over the years.
For one, for licensing and credentialing, I had to compile information from two previous state medical licenses, two hospital affiliations, two teaching appointments, and four liability insurance companies (including residency). You can imagine this took much more of my time than when I applied for my first medical license and hospital privileges eight years ago. In addition, I was fingerprinted for the first time in my life as part of a criminal background check. Is this a new trend?
For another, my family and its attendant needs have grown significantly. Right after medical school my wife and I rented a U-Haul and moved ourselves into our first house. Now we have professional (yay!) movers, house selling and purchase, schools and camps, and lots of insurance policies to manage. “Dull” is not a word that describes our current state of affairs.
One thing that has stayed constant is AAP membership. The networking and resources have been invaluable by connecting me with new colleagues and maintaining old friendships no matter where I have gone. SOYP is your home in the Academy, and with the newsletter, YoungPeds Connection, your district reps, and local chapters, I encourage you to “stay connected” no matter where life takes you.
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AAP Grand Rounds Contributing Section Editor for SOYP
Andi L. Shane MD, MPH
I am delighted to represent the SOYP as a contributing section editor to AAP Grand Rounds, a monthly publication comprised of summaries and expert comments on recently published journal articles. My responsibility is to scan journals searching for articles that may be pertinent and interesting to young pediatricians. I welcome your input and suggestions of recently published articles in peer-reviewed journals that you feel might be worthy of a summary in AAP Grand Rounds. Furthermore, I would be most appreciative of volunteers to prepare summaries of an article that may be pertinent, and I am happy to work with such volunteers to submit their summaries for publication to AAP Grand Rounds. The link to further information about AAP Grand Rounds, including a sample issue, is: http://aapgrandrounds.aappublications.org/
Recent publications from our section, prepared under the guidance of Michael Cabana, former SOYP section editor, include:
“The Changing Epidemiology of Childhood Diabetes “ by Joyce Lee , AAP Grand Rounds 2006; 15: 18a-19a
“E-mail and Parent/Physician Communication” by Terry Kind, AAP Grand Rounds 2005; 14: 34
“Will There Be Enough Pediatric Neurologists?” by Scott A. Shipman, AAP Grand Rounds 2005; 14: 5-6
Please feel free to contact me at your convenience to share ideas, articles, or suggestions via email andishane@pol.net. I look forward to representing the SOYP in this endeavor.
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Single Payer “American Style”
Robert Zarr MD, MPH, FAAP
I think the most important part of Hirotaka Yamashiro’s “Children and Single Payer Health Care: Pros and Cons,” was the comment about equity of care. Although it is important to discuss pediatrician’s relatively low reimbursement rates, more important is that America’s children receive quality care without bankrupting their families. Let’s not forget that we still have 9 million children without health insurance. These 9 million children forego necessary care, and suffer unnecessarily because of it. There is no doubt that the average Canadian child has better access to primary care than his/her American counterpart. The Canadian pediatrician, with lower office overhead, either specialist or primary care, is reimbursed with fewer hassles and more timely than his/her American counterpart. I would posit that what Canada has IS a good system that is under-funded. Canada’s neighbor to the South, in contrast, has a terribly wasteful and dysfunctional system with the largest private health insurance bureaucracy in the world. Our problem is not that we spend too little, but that we have no system. America spends twice as much per capita on health care as Canada, yet we have generally worse health outcomes. Currently more than 60% of US total health expenditures is publicly financed, and this amount is more than most developed countries spend total. Americans already pay for health care, but just don’t get it. Every developed country in the world, except the US, has government assured health insurance. Most spend half of what we do. Falling at number 37 in health outcomes, according to the World Health Organization, seems to suggest that the US has much to learn from other countries, and not vice versa. While every other developed country’s health care system most certainly has areas for improvement, none is in such a crisis as ours. We need a publicly financed but privately delivered health care system, which would be more equitable to all American children and their pediatricians. What we need in the US is single payer “American style.”
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Tug o' War: Trying to Understand the Minds and Hearts of Children in Divorce
Alberto Carranza MD, FAAP
I can honestly say I have lived a privileged personal and professional life, and I thank God everyday for this. Being a pediatrician in an Emergency Room setting allows me to experience a variety of cases, from the common cold to the full code. More important than this, I live, day after day, the entire spectrum of emotions that human beings experience when their family members are ill, from happiness when a child gets well to the grief of losing a loved one.
There are certain circumstances in our specialty that may be “difficult”, even for the most warm-hearted and dedicated pediatrician out there. The 3 year old with temper tantrums, the 8 year old that disrupts class, the teenager that “cuts” herself. Have any of you wondered how many of these behavioral patterns occurred because of a divorce? I wish to share with you my personal own life, to both create awareness, as well as to vent my own emotions.
My sister and I were born in the beautiful island of Puerto Rico to a Puerto Rican mother and a Nicaraguan father. My mother grew up poor, but in a large, very close family with deep rooted Catholic values, where matrimony was sacred. My father’s upbringing was completely opposite. He grew up in a very wealthy family that was very fragmented and full of deceit. His family lost everything during the war which is the reason he immigrated to Puerto Rico where he met my mother.
Their beginnings were humble, yet my father progressed from college to graduate school to the work force to Vice President of one of the biggest textile industries in this side of the hemisphere. My mother, at his side always, worked at home indoctrinating moral values. We had a beautiful house near the beach, good friends and a great life. I grew up genuinely happy. I thought my parents were perfect. I was the envy of all my friends who were victims of divorce in their early years; we were the Latino Brady Bunch.
Just this last year, I have battled with the thought that all I knew has been erased. My parents are getting divorced after 36 years of marriage, their relationship a victim of miscommunication and distrust. My father has gone back to Nicaragua, and never calls or visits. My mother now lives in financial difficulty and sadness. We remain very close. She expected these to be her “Golden Years”, yet she calls them her “Rusty Years”. I have cried myself dry with the all these thoughts. I have not taken this change in life well despite all my efforts.
I sought out different ways of dealing with the pain, which I have found to be extremely difficult. Talking to my wife and sister, bicycling 100 miles, reading inspirational books, praying to God, and yes, going to the internet. Interestingly, I discovered (or rediscovered) Elizabeth Kubler Ross’ Five Stages of Grief of her 1969 book “On Death and Dying”. To my surprise, I have unknowingly experienced the Five Stages of Grief during this very difficult time.
Denial: “This can’t be happening, my family was perfect.”
Anger: “Dad, how could you do this to mom, to us?”
Bargaining: “Maybe we can work this out. I just want us to be together forever.”
Depression: “I don’t care anymore.
Acceptance: “It is the best for the family; everything is going to be OK.”
An excerpt from a survey done by The National Center for Health Statistics between 1995-2004 states that “43 percent of first marriages end in separation or divorce within 15 years.” I mention this because as pediatricians, more often than not, we will encounter situations like this with our patients, and we need to understand how to identify and deal with these difficult issues.
Jill Greenstein, a psychologist at Putnam Valley Elementary School near New York City, involved a group of students to come up with advice for parents and children going through divorce. The “Banana Splits”, as they were called, came up with “The Bill Of Rights for Children Whose Parents are Separated or Divorced”. Here is a summary of what these brilliant little minds came up with:
- The right not to be asked to "choose sides" between their parents.
- The right not to be told the details of bitter or nasty legal proceedings going on between their parents.
- The right not to be told "bad things" about the other parent's personality or character or behavior.
- The right to privacy when talking to either parent on the telephone.
- The right not to be cross-examined by one parent after visiting the other parent.
- The right not to be asked to be a messenger from one parent to the other.
- The right not to be asked by one parent to tell the other parent untruths.
- The right not to be used as a confidant regarding the legal proceedings between the parents.
- The right to express feelings, whatever these feelings may be.
- The right to choose not to express certain feelings.
- The right to be protected from parental warfare.
- The right not to be made to feel guilty for loving both parents.
This experience has made me put more effort into identifying children, parents, and co-workers that are hurting, just as I have in the last year. It may be the temper tantrum, the disruption in class, the cutting, the excessive crying or the recurrent medical ailments. Sit down, talk and listen to both parents and more importantly, to your patient. Pick and choose from the “Bill of Rights” based on different circumstances, as it may prove itself an invaluable resource in dealing with such difficult matters. I hope my story serves to remind all pediatricians to not only focus on the clinical practice but also to embrace the emotional aspects of our profession.
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Back to School, Online
Taylor Sawyer DO
Going back to school:
Last September I went back to school to get my master’s degree in education through an online program offered by the University of Cincinnati and Cincinnati Children's Hospital Medical Center. Since that time, each week I check the online classroom to see my new assignment. I complete readings, write essays, and work on group projects with other members of my class. I turn in my assignments by uploading them to the ‘Discussion Board’ of my online classroom. Here, other members of the class can read my postings and respond. Likewise, I can read some of theirs and reply back. I am constantly surprised by the degree of interaction on the Discussion Board. It is like an academic chat-room. Each week my assignments are evaluated by the instructor who provides feedback by either posting a response or sending an e-mail. Many of my courses allow me to incorporate actual projects I am working on. To date I have used the program to help me develop a simulation curriculum for my pediatric department and a problem-based learning module. My recent experience caused me to reflect on the idea of physicians going back to school, and on the modern option of attending courses online.
Another degree?
For some of you the thought of going back to school to obtain another degree may be unthinkable. For others it may be something you have been considering for a while but just not had the opportunity. Medicine today is an incredibly complex and diverse field. Not everything you need to learn can be taught during four years of medical school. Modern medical research involves incredibly complicated microbiologic and genetic testing for which a master’s degree in the biologic sciences (MS) may be very helpful. For those with an interest in population-based medicine or disease prevention a master’s degree in public health is of obvious benefit. The “business of medicine” has become an increasingly important component of medical practice, so for those running their own practice a master’s degree in business administration seems like an obvious advantage. For those interested in academic medicine, a master’s degree in education could prove extremely useful.
The American Board of Pediatrics does not keep statistics on the number of pediatricians with graduate degrees in addition to their medical degree. I have, however, noticed a trend in recent years of more and more physicians with masters or doctorate degrees. Figure 1 below gives some evidence of this trend. This graph is derived from authorship in the Articles section of Pediatrics from 1987-2007. While this graph may not reflect the overall trend in the country, I think it is interesting to note that at least as far as authors in Pediatrics, an ever increasing number are obtaining graduate degrees in addition to their medical degree. With the increasing complexity of modern medicine, and especially medical research, this trend is not hard to understand.
* Based on authorship in Articles section of Pediatrics.
Data from Pediatrics 1987; 79(1):1-153, 1997; 99(1): 1-99, 2007;119(1): 1-108.
Why online?
According to Laidlaw and Hesketh the two key factors that distinguish distance education (a.k.a. online learning) from other educational venues are time and place. Online education is unique in that it allows the learner to study when they want and where they want. With online education it is possible for learners in distant locations, or small towns to study at large universities without having to move to that location, or take time off from work to attend school. We are all busy people and juggling personal and professional obligations can at times seem overwhelming. Attending classes online allows you to set your own schedule, work at your own pace and complete readings and assignments at your convenience. If you want to turn in your assignment at midnight on Friday, that’s fine; if you want to read and respond to other people’s work while you’re on call in the hospital, that’s okay too. As for myself, I have made a habit of waking up early on Saturdays and Sundays to complete my weekly assignments.
Online, really?
I know what you are thinking, ‘aren’t all those online universities just a bunch of diploma mills where you can get a master’s degree as easy as a degree in television repair?’ Certainly some universities offering advanced degrees online are dubious. Many online universities exist nowhere else but in cyberspace, and the degree they grant may be worth no more than the paper it is printed on. There are, however, many prestigious universities offering online degree programs aimed at busy professionals like us. To assist in identifying reputable programs the Council for Higher Education Accreditation(CHEA) maintains a database of institutions and programs accredited by recognized United States accrediting organizations. Currently the database contains information on over 17,000 programs that are accredited by U.S. accrediting organizations recognized either by CHEA or by the U.S. Department of Education. Schools recognized as accredited in the CHEA database are thus very likely to be legitimate. As with any educational endeavor it makes sense to investigate the school you are interested in, contact the administrators and other students if possible, and make an informed decision before writing your first tuition check.
What’s available?
For those of you interested in pursuing an online degree there are many options available from a variety of institutions. Many master’s degrees can be obtained completely online with no in-class time required. Doctoral degrees, however, typically require at least some in-class time. With only a brief search I was able to find completely online degrees for each of the degrees listed above: Master’s in Public Health (MPH), Master’s in Business Administration (MBA), Master’s of Science (MS) and Master’s in Education (MEd). Of course, various other degrees and certificate programs are available. When starting a search for a degree program it may also be worthwhile to contact your local university to see if they offer this option. You may be surprised by what is available.
Things to Consider:
Perhaps the first issue for a young physician, and prospective online student, to consider is financial cost. Most online master’s courses require 30-45 credit hours, at a cost of $400-$600 per credit hour. With this tuition, the average total cost to complete an online degree will range between $15,000- $30,000. For those of us just starting to pay-off their medical school loans, the thought of accumulating even more student debt may seem absurd. Fortunately, there is financial assistance available for online degree programs. Many online programs have grants and financial aid available for adult learners. Additionally, some physicians may be able to acquire funding through their department or institution. Those on active duty in the military, or with prior service, may qualify for the Montgomery GI Bill.
Time commitment is the second thing to think about when considering an online degree. Depending on the course and the work involved, a typical 3 credit hour course can involve anywhere from 3 to 12 hours of work per week. For those in a busy practice, or with a hectic call schedule, this time commitment may be too much to take on. Luckily, most online degree programs allow students to space out their education over three to four years rather than the traditional two years for a master’s degree. At this pace you only have to complete one online course a quarter.
Conclusion:
With the increasing complexity of modern medicine, obtaining a graduate degree may be valuable to some physicians, and may assist in achievement of career goals. It appears that more and more physicians are obtaining graduate degrees. However, for busy young physicians taking time out of a burgeoning career to go back to school full-time to obtain such a degree may not be feasible. The option of obtaining a degree online seems like a good alternative. There are, however, things to consider when pursuing an online degree such as program choice, financial cost, and time commitment.
I am currently in my third quarter as an online student. I complete assignments on nights and weekends and try to slip in reading whenever possible. It is not easy, but my experience so far has been very good. I’m expanding my knowledge and am constantly introduced to new ideas and concepts. More importantly, I can put what I learn to practical use in my current position.
References:
- Council for Higher Education. Database of Institutions and Programs Accredited by Recognized United States Accrediting Organizations. www.chea.org/search/default.asp. Accessed April 29, 2008.
- Laidlaw JM, Hesketh EA. Chapter 12, Distance Education. In Dent JA. A Practical Guide for Medical Teachers: Elsevier Churchill Livingston. 2nd Ed. 2001. p.106-112
Disclaimer: The views expressed in this manuscript are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
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MODIFIERS: How They Can Improve Your Practice's Bottom Line
Jill Stoller MD, FAAP
A modifier is a numerical code that provides the means to indicate to the payer that a service or procedure that you have performed has been altered by specific circumstances. In pediatric practice there are only a few modifiers that are used on a regular basis. Knowing how to use modifiers correctly can significantly enhance your practice’s revenue.
The most important modifier used in pediatrics is the –25 modifier. This modifier is used to indicate that on the day a service or procedure was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. This separate service must be substantiated by appropriate documentation of the additional service provided in the patient’s medical record. A common example is the child that comes in for their yearly preventive medicine (well-care) visit. This is billed using the appropriate 99391-5 code. If the child has an acute illness at that time which requires separate evaluation and management services then a 99212-5 would be billed additionally with the –25 modifier appended to that code.
Example: 4 year-old child presents for his annual preventive medicine (well child) visit. Hearing and vision screening are performed, as well as hemoglobin testing. The child is a known asthmatic and presents with two days of nocturnal cough and wheezing with exercise. You perform the well-visit exam and give all the appropriate preventive counseling. You then address the acute asthma exacerbation giving particular attention to the physical exam of the upper and lower respiratory systems and then spend time discussing medication adjustments and home management of the child’s asthma.
The visit should be coded as follows:
99393 (well-care visit)
99251 (hearing screen) All linked to ICD-9 V20.2
99173 (vision screen)
36416 (finger-stick blood draw)
85018 (hemoglobin)
AND
99213-25 or 99214-25 linked with ICD-9 493.12
By using modifier –25 in this manner you should be paid for both the preventive medicine services and the sick visit service. Most of the major insurance companies are now reimbursing for well and sick visits on the same date of service, but you must code the visit appropriately with the use of modifier –25.
The next most commonly used modifier in pediatric practice is the –59 modifier. This modifier is used to indicate to payers that a separate and distinct procedure has been performed in addition to another E/M service or procedure during the same visit.
Examples:
- A one year-old child is seen for fever of 103 of two days duration accompanied by irritability, loose stools and decreased oral intake. A complete history and physical exam is performed. The pediatrician then performs a sterile bladder catheterization to obtain urine for urinalysis and urine culture.
The visit should be coded as follows:
99214 (sick visit)
53701-59 (bladder cath) All linked to ICD-9 780.6 (FUO)
81000 (urine dipstick)
99000 (lab handling fee for processing urine culture)
- An 18-month-old child is seen for their preventive medicine (well child care) visit. As per AAP recommendations the MCHAT screen for autism is performed and scored. This visit is occurring during regularly scheduled evening hours
The visit should be coded as follows:
99392 (well-visit )
96110-59 (developmental screen) All linked to ICD-9 V20.2
99051-59 (Sat/evening hour code)
Learning to use these two modifiers correctly on a regular basis is important for two reasons. First, your claims will be paid in a timelier manner because they will be “clean claims”. Second, you will be paid for services you may not have captured without the proper use of these modifiers. There are still some insurers that refuse to pay for two E/M services for one patient on the same date of service. Make sure to appeal these denials with copies of the chart notes. If they still deny the claim fill out the AAP Hassle Factor form (www.aap.org/moc/reimburse/hasslefactor/HassleForm.cfm) and contact your state AAP chapter for help. If more offices appeal these and let the state and national AAP know of the problem, the more likely we are to get systemic changes enacted with these insurance companies.
Learning how to code properly is just one aspect of running an efficient, productive practice. Promoting the value of pediatric practice by teaching pediatricians how to implement the proper tools for success is the goal of the Section on Administration and Practice Management (SOAPM). We encourage all the members of the Section on Young Physicians to learn more about SOAPM and become a member of our very active section! You can apply for Section membership on-line at:
www.aap.org/moc/memberservices/sectionform.cfm
If you have any questions about SOAPM please email Heather Fitzpatrick at hfitzpatrick@aap.org.
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Financial Planning for Young Physicians
Peter B. Kang MD, FAAP
Personal finance can be a minefield for young physicians who often have to juggle loan payments, mortgage payments, and new families. Here are some tips to keep on top of your finances
.Loan, credit card, and mortgage payments:
Just when you feel you are finally making a decent income, student loans, mortgages, and credit card payments can come crashing down on your head. The one major piece of debt many young physicians face from the beginning is a thick wad of student loans. If you have credit card debt on top of this it is usually better to pay off that as soon as possible, since most credit card accounts charge a higher interest rate than student loans. If you do not own your home already, it is a good idea to see how your finances settle out with your new income and loan payments over the first few months or year after finishing your training. This will give you a chance to save for a down payment, and also give you an indication of how much of a monthly payment is realistic for you (it may not be true anymore, but until recently, many banks and mortgage companies would happily approve mortgages beyond what would be prudent for someone to commit to, so you cannot rely on what they tell you). With the real estate market looking shaky these days, you may be able to find a good bargain, but such a commitment only makes sense if you know you will be in that area for at least 5 years or so, as it may be difficult to sell on short notice. Don’t forget to include taxes, homeowner’s association fees, and insurance in your estimated monthly payment, and if you are thinking of buying a condominium, remember the condo association or maintenance fees! Taxes can run several hundred dollars a month, and condo fees can be over $500 a month depending on the location, size of the unit, and whether utilities are included. Most young physicians see an appreciable bump in their income after finishing training, but for pediatricians this bump may be lower than in other specialties. It is advisable to see what your actual take-home pay will be in a new job before making new major financial commitments.
Retirement and college tuition plans:
There are a number of ways to save for retirement for yourself or college for your children. If you work for a hospital or other large practice group, you may be offered a 403(b) or 401(k) plan (this may have been the case during your training). 403(b) plans are used by academic and non-profit institutions, and 401(k) plans by for-profit companies. You can decide to contribute a portion of your salary, before taxes, to such an account. Taxes will apply when you withdraw funds during retirement. In some cases, your employer will supplement or match your contribution. Don’t pass up this opportunity, as it is free money! Keep in mind that there are penalties for early withdrawal, but some exceptions may apply depending on the plan. Individual retirement accounts (IRAs) are accounts you set up directly with a financial institution, without the involvement of your employer. These contributions are pre-tax, up to a certain income level (it is a mixed blessing if you are over the limit). A Roth IRA is a specific IRA variant in which you contribute after-tax dollars, but benefit later from tax-free withdrawals. The limit on annual contributions is $5,000 for 2008 ($10,000 for a couple filing jointly), and is scheduled to rise in increments thereafter. There are income limits to Roth IRAs also, currently $99,000 annual income for single filers for full contributions, and $114,000 for partial contributions. For joint filers, the limit is currently $156,000 annual income for full contributions, and $166,000 for partial contributions. A 529 plan, or “qualified tuition plan”, is a tax-advantaged plan similar in structure to a retirement plan in which you can save for your child or children’s future college tuition.
Insurance:
Automobile insurance is mandatory and most young physicians are familiar with this, as well as property insurance, but many are not familiar with various forms of life insurance. Term life insurance is often less expensive than permanent life insurance, especially for young physicians. However, a term life insurance policy has no cash value and always has a limited “term” (hence the name). Over the long term, this can represent a poor use of your limited funds, as term insurance becomes increasingly expensive as you get older. The vast majority of term life insurance policies never pay a benefit. Those of you employed by a hospital or practice may have life insurance offered as part of your benefits package. This is typically a term life insurance policy. If you decide to purchase life insurance individually, it is worth considering a permanent life insurance policy (also known as whole life insurance), which can be sustained over your entire life. Over a period of years, such a policy will slowly accumulate cash value in addition to its face value, thus it can be regarded as an investment. Insurance companies are usually very conservative with their investments, so the returns will usually be in the single digit percentage range. However, over time, the policy may accrue significant value, which you may borrow from, or use as collateral for loans. The premiums for a permanent life insurance policy are significantly higher than those for a term life insurance policy, so this should be considered only when you have enough cash flow to make a long term commitment to the premium payments. It is worth including an umbrella policy with your homeowner’s/renter’s/auto insurance, which will give you extra personal liability protection.
Investments:
Investment strategies are tricky to discuss as they are dependent on many variables, including investment goals, tolerance for risk, and cash flow. Investing in individual stocks and bonds makes sense only for those who have time to read and study annual reports in detail. Most young physicians do not have that kind of time. Mutual funds and exchange traded funds (ETFs) are sensible choices for most young physicians. The safest strategy is to invest a large chunk in one or more equity index funds, and smaller amounts in other types of funds such as bond funds, real estate funds, and commodities funds. Most types of investments have international options also, which are worth considering. It is important to pay attention to annual fees for all types of funds, loads (sales charges for purchase of shares) for mutual funds, and brokerage fees when purchasing or selling ETFs, as these can put a significant dent in any return on your investment. Many mutuals funds have no loads, thus it is perfectly reasonable to consider only those. A mutual fund can be purchased directly from the firm or often through a brokerage account. An ETF can only be purchased through a brokerage account. The best bargains are usually no-load index mutual funds with annual fees around 0.20% or less.
Asset protection:
Unfortunately, a number of physicians will be subject to malpractice lawsuits during their careers. In most cases, the physician’s liability insurance will cover any damages from a settlement or court verdict. However, in rare instances, a physician’s assets may be vulnerable, including bank accounts, investment accounts, and even real estate. However, certain assets may be protected from such claims. Retirement accounts, permanent life insurance policy balances, and primary homes owned jointly by a physician and spouse may be protected, depending on the laws of a particular state. This issue may be worth considering as you decide how to distribute your personal assets over your career.
Getting advice:
A financial planner can be a valuable resource in making major financial decisions. It is best to use a financial planner who charges an hourly fee, rather than one who charges a commission, as the latter has a vested interest in convincing you to purchase securities and other financial products through his or her office, and may be not be an objective advisor. Depending on the complexity of your financial situation, it may be worth retaining an accountant to sort out your tax returns and other filings. Filling out tax returns yourself, either by hand or by using a software program, is of course the most cost-effective approach, but both can be time-consuming, and if you are not familiar with specific deductions and other tax issues, you may miss out on refunds that would more than pay for the accountant’s fees.
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Community Pediatrician's Guide to Supporting Military Children During Wartime
CPT Bonnie Geneman MD - Resident Pediatrician
Maj. Keith M. Lemmon MD, FAAP
AAP Uniformed Services West Chapter Vice President, Adolescent Medicine SpecialistMadigan Army Medical Center – Department of Pediatrics, Ft. Lewis, WA
In today’s fast paced military environment and the era of multiple deployments, there is an entire generation of military children affected by the absence of one or both parents. Recognizing that a military member’s deployment has a variety of impacts on his or her family, the military is making an effort to reach out to children and provide them with the tools to cope with this unique military family stressor.
Many parents notice behavioral changes in their children before, during or after parental deployments. This is not unusual and is most appropriately addressed through meaningful discussion. Parents may hesitate to talk about their children’s behavioral changes or other family challenges, feeling that they need to maintain a strong front in support of the deployed family member. In actuality, discussing the emotions, stressors and changes in the family dynamic can be helpful for all family members.
Younger children and toddlers often do not understand the concept of deployment or even conceptualize long absences. They may, however, notice that a beloved parent is not there to tuck them in at night or read them a story. Developmental regression (i.e. bedwetting, return of separation anxiety, baby talk) is a common phenomenon seen with young children who experience a big change or life stressor. With increased age comes increased understanding, and with increased understanding may come fear. Fears that a parent may forget about a child, become injured or fail to return from deployment are all too common. Additionally, many older children face increased responsibilities at home, which helps fill the void left behind by the deployed parent. Some adolescents feel bitter or angry, some feel depressed, others are consumed by fear, and yet others channel their emotions via rebellious and troublesome behavior. If these behavior changes are anticipated and addressed proactively, military youth can be expected to tolerate military deployment stress well and even thrive if they are actively engaged by their community and family.
Many families are beginning to learn that there are a variety of resources available that are specifically focused on military children and adolescents. Such resources include the Military Youth Deployment Support Video Program, Operation Purple Camps, Zero to Three – Coming Together Around Military Families, Military One Source, and the Army Behavioral Health Website. Families may not realize the valuable resources their pediatrician can provide during such stressful times. Pediatricians offer credible developmental and behavioral expertise to families while being intimately aware of the importance that cultural issues, such as belonging to the military, play in overall family well-being.
Military Youth Deployment Support Video Program
In August 2006, the Sesame Street Workshop partnered with Wal-Mart to create “Talk, Listen, Connect: Helping Families During Military Deployment,” a preschool aged movie featuring Elmo and Elmo’s Daddy. In the movie, Elmo’s Daddy explains how he has to go away for a long time to do important work. He tells Elmo about all the people who will help care for Elmo, and he helps Elmo make a plan to stay connected while he is gone. This short film helps toddlers and preschoolers relate to a familiar icon (Elmo) as he goes through a similar situation (a long term parental absence). The movie is free and comes with supplemental reading material for parents when ordered online at www.sesameworkshop.org/tlc/.
Realizing that children older than six may be less interested in Elmo and will likely have a deeper understanding of parental absence during deployment, military pediatricians, in conjunction with the American Academy of Pediatrics (AAP), created an animated feature for elementary-aged children to give older children something they can relate to and use as a starting point for discussion. “Mr. Poe and Friends Discuss Reunion after Deployment” is a dynamic cartoon that provides young children with interesting characters and stories to relate to as they think about their own feelings in relation to deployment. It covers maternal and paternal deployment as well as single parent deployment. The cartoon also highlights some of the unique challenges that reunion after deployment poses and helps normalize many of the emotions that a child can wrestle with during these challenging times. The video is available at www.aap.org/sections/unifserv/deployment/index.html.
Also included in this uniquely targeted video support program, is “Military Youth Coping with Separation: When Family Members Deploy.” Created by a military adolescent medicine specialist, military pediatricians and the AAP, this video is specifically made for older children and adolescents. It features interviews with real teens going through family member deployments and it touches on a broad range of emotions and fears that an older child or teen may face. Adolescence can be challenging enough without the additional stress of a parent’s deployment. It is a time where many older children and teens do not feel comfortable sharing their emotions, or they may feel that their emotions are wrong or abnormal. This video strives to show that any emotion is normal and acceptable and that there are other kids going through the same thing at the same time. A great supplement to this video is the accompanying Interactive Military Youth Stress Management Plan, an interactive tool developed to walk teens through the process of identifying their specific stressors and developing effective methods to cope with them effectively. The stress management plan was developed in conjunction with Dr. Ken Ginsburg, an adolescent medicine specialist and a pioneer in operationalizing child and adolescent resilience concepts into usable formats. The Video and Stress Management Plan is available at www.aap.org/sections/unifserv/deployment/index.html.
All of the videos mentioned above are available free of charge and can be ordered or watched online. It is recommended that a caregiver (parent, teacher, grandparent) watch the selected video with the child or adolescent and spend time afterward discussing the feelings experienced during the video. This is an excellent way to open up lines of communication regarding potentially uncomfortable feelings. Watching the videos with other children experiencing parental deployment can also be helpful. The intent is that each child will gain a better understanding of his or her own emotional reactions to deployment while learning positive ways to cope with these reactions.
In addition to video media as a form of support, there are other excellent military child and youth resources available to parents and youth serving professionals.
Operation Purple Camp
Operation Purple Camp, a program sponsored by the National Military Family Association (NMFA), is designed to bring children of deployed service members together for a fun-filled summer camp. Camps are located throughout the country and are available for any military child, with preference given to those who have a deployed parent. Operation Purple camps are free and offer camaraderie between military youth as they share experiences with one another. Information regarding the 2008 Summer Camps can be found on the NFMA website at www.nmfa.org/site/PageServer?pagename=op_default.
Zero to Three: Coming Together Around Military Families
Zero to Three has created a helpful resource for military families and youth “aimed at strengthening the resilience of young children and their families who are experiencing deployment and separation.” Coming Together Around Military Families (CTAF) has a downloadable activity book for toddlers entitled “Over There,” and downloadable pamphlets teaching parents how to be supportive of their children during deployment. Other features on this website include audio resources and helpful advice for making it through the holidays while a family member is deployed. These resources are all available online at www.zerotothree.org/site/PageServer?pagename=key_military.
There are many resources and supportive organizations available for families and military youth during this time of lengthy and recurrent deployments. Please become familiar with these resources and provide information and support to military children and youth when they visit your practice.
| Military Child and Adolescent Support Web Sites |
AAP Deployment Support Website |
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Zero to Three - CTAMF |
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Military One Source |
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Army Behavioral Health |
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Army Reserve Child and Youth Services |
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Operation Military Kids |
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Our Military Kids –Activity tuition assistance for children of deployed Reserve/NG members |
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| Clinical Experience and Pearls |
How I Got Over My Fear of Testifying and Actually Do Not Mind…Anymore
Leena S. Dev MD
Yes or no doctor. Just answer the question. DOCTOR! YES OR NO!” the lawyer screams at me in the courtroom where there is standing room only. I wake up in a sweat with my heart racing, like some cliché scene in a bad movie. I cannot remember, was I wearing my suit or was that a different dream where I forgot my clothes? Okay, so except for the clothes part, I have had plenty of those dreams. Why? I should explain.
I am a child abuse physician and Medical Director of our hospital Child Protection Team. I conduct medical examinations on children who are alleged victims of sexual abuse, physical abuse and medical abuse (aka Munchausen Syndrome by Proxy). I consult throughout the hospital on cases of suspicious bruises, burns, fractures, head trauma, neglect and medical abuse. It is my career and it is fascinating to try to understand what has happened to a particular child. But after the medical work-up has been completed by the appropriate teams and consults, and I have completed my assessment and plan, inevitably, these cases go to court. In fact, they can often go to both family court and criminal court since there are often guardianship concerns as well as a possible crime. But it is part of the job for me and after doing this for so many years, I actually find it quite interesting.
My first case was probably the most nerve-wracking and best learning experience for me. It was a high profile abusive head trauma case, and when I testified in the preliminary hearing, there was a camera just 4 feet from my face. The prosecutor first attempted to qualify me as an expert in child abuse pediatrics. The defense asked me, “Doctor, how many cases of abuse had you seen prior to this one?” I reply, “Um, including residency and 4 years of general practice, probably about 10 or so.” He then asked, “Doctor, how many cases of abuse have you testified in?” I broke out in a cold sweat. “This is the first one.” I could hear the people sitting in their living rooms snickering with the laugh track on their television sets while eating TV dinners (not sure why I imagined a family from the 1950’s on checkered plastic-covered couches). Qualifying me as an expert went on and on. Eventually, the judge qualified me as an expert since I was employed to do these examinations at a reputable hospital. But I learned that I needed to keep track of all the kids I see and for whatever reason, whether it is physical abuse, sexual abuse, neglect, etc. I also had to keep track of everywhere I testified and where I was qualified as an expert. I have now testified over 30 times and have examined over 300 victims of alleged abuse.
A few other lessons I have learned are important for anyone who is a physician. Any physician - period. Of course, this is in non-malpractice cases I am referring to since that is my experience:
First, it is every physician’s obligation to testify if she or he receives a subpoena. As hard as it is to leave a busy practice, it is an important part of your job. In pediatrics, this is often in cases of abuse or neglect which makes it especially important. If you get a subpoena, be proactive, find out why you are an important witness, what the person calling you plans on asking you, and what to expect from the other side.
Second, lawyers are not (fill in expletive)(fill in derogatory noun). They are simply trying to get to the truth and/or trying to get a fair trial for their client. Talk to the person who has subpoenaed you and see why you are important to the case.
Third, know your case inside and out. As an expert, I have to render an opinion and study the whole case, so I make a timeline for myself and commit to memory when a child was admitted, what procedures occurred when, which specialists consulted on the case, etc. Most people who get a subpoena for a case will serve as a fact witness instead of an expert. This is usually good news because there is less to study. If you are called as a fact witness, you simply have to state the facts (as recorded in your note, hopefully). Make sure you know your notes and why you wrote what you wrote. And remember, if you are asked to give an opinion, it’s easy to say, while keeping your ego intact, “I am not an expert in that area so I do not feel qualified to give such an opinion.” Hopefully there is an objection in there somewhere and you do not have to give an answer since other parties know you are not the expert, but if you get no objection, then tell the court you are not an expert so cannot render an opinion and can only state the facts as you know them. That should work.
Fourth, make your handwriting legible at all times. Some practitioners think that if their writing is not legible or their signature is not legible, people will not question their work or send a subpoena. WRONG. If anything, it looks bad in court when your handwriting is so bad that you are called into court to read your handwriting because no one else can, and it’s even more embarrassing when you cannot read your own handwriting…in court! I once testified in a case where the handwriting was so bad I could not tell if the pediatrician saw bruises, asked for a skeletal survey, or what. I had to say, “I’m not sure what the clinic note says, I cannot read it. You will have to ask that particular physician.” If you have bad handwriting, it is not an excuse. Find a solution. There are plenty around including dictating, EMR, templates or find a creative solution of your own. Also, provide good details in your notes so your note can stand on its own. Isn’t that what we learned in medical school? It’s quite interesting after students and residents spend time with me on the Child Protection Team. Their notes change to, “Mother stated….father states …..according to grandmother…we met with mother the morning of…..source of information: mother, father, EMR” etc. Of course that is more detailed than the average clinic or hospital note but something to keep in mind. And when the students and residents see me testify in court, their notes get even better!
Next, if you are subpoenaed, have a CV ready to present in court. Personally, I recommend keeping a separate CV for court purposes that does not have your personal address on it or the fact that you volunteer in your child’s school or for her soccer team. This is because the CV becomes part of the public record and I (particularly in my line of work) do not want people to know where I live or where my kids go to school.
Finally, once I have gotten over the fact that I have a subpoena, reviewed and re-reviewed my note, read the chart, gone over the questions the prosecutor has prepared me with, gone over definitions I want to review and handed in my updated court CV, it’s time to testify. Thankfully, I do not wake up in a cold sweat anymore. I have prepared to the best of my ability. Then comes the actual court date. Of course now that I’m completely prepared and have experience to testify with some confidence, there is no camera to record this! No Court TV! While on the stand I try to understand the various perspectives of each side. I answer the questions to the best of my ability. I take care to look at the appropriate person whether it is the prosecutor, the defense attorney, the judge or jury. It’s hard to be asked a question by the lawyer and answer facing the jury, but some say it adds to your testimony if you look at the jurors. As long as jurors are not uncomfortable with it, I try to make eye contact. I just try my best to present myself properly from attire, to language, to the confidence (not arrogance) I say it with. And when there is an objection, I listen and try to understand the point of the argument. Remember, the objection is not about you it is about the case. Each side is trying to prove his or her case and disprove the other; and why there is an objection to something I have said is intellectually stimulating to me and I do not take it personally. Students and residents that join us on the Child Protection Team often go to the law school classes and they tell me that it is such a different discipline from medicine. It is about fairness and evidence and the law. It is not personal. And the more I do it, the more I appreciate it and the more it fascinates me. A lawyer friend recently told me, a witness starts off with 100% credibility and it is a matter of maintaining that credibility or chipping away that credibility via etiquette, knowledge, presentation and what is asked and said. The goal for each witness is to maintain one’s credibility to the best of one’s ability.
That said, I have now testified in over 30 cases in family and criminal court. Some cases have gone the way of the prosecution with verdicts of criminal sexual conduct, child abuse in the first or second degree. There have been some murder convictions and some manslaughter convictions. There have also been some acquittals if the prosecutor was not able to present the case “beyond a reasonable doubt.” There have been terminations and reunifications. In the end, I do not make or break a case. I am just a small part of the puzzle for the lawyers to put together. I accept that position and enjoy what I do and do not mind testifying as it is my duty as a pediatrician. Hopefully after reading this, you too will not break out in a cold sweat when you get your subpoena!
Leena S. Dev, MD, Clinical Assistant Professor, University of Michigan, School of Medicine
Medical Director, Child Protection Team, Dept of Pediatrics
University of Michigan, Ann Arbor, MI
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Spontaneous Pneumothorax
Shanthi Thomas MD, FAAP
A 15 year old male presents to the Pediatric ER with chest pain that started one day prior to arrival. He describes the pain as sharp and constant, primarily on the left side. Currently he rates the pain as 3/10, but at its maximum intensity was 8/10. There is radiation at times to the left shoulder. The pain is exacerbated by taking deep breaths and lying down. Nothing seems to alleviate it, including Tylenol.Review of Systems: no fever, no URI symptoms, no history of trauma, no nausea, vomiting or diarrhea, no rashes, no diaphoresis, no numbness or tingling in any extremitiesPast Medical History: no hospitalizations or surgeries, currently on no medications, immunizations are up to date Social History: smokes 4 cigarettes a day for the past 3-4 years and smokes marijuana on weekends, denies alcohol useFamily History: mother with lupus, sister with Guillain-Barre Syndrome, no history of sudden death or heart attack prior to the age of 40Physical Exam (pertinent positives and negatives):
- Vital signs stable, pulse oximetry 99% (room air)
- Gen: a tall, thin male in no acute distress
- CV: regular rate and rhythm without murmurs, strong central and peripheral pulses
- Lungs: Decreased breath sounds on the left- primarily in the left upper to middle lobes, no crackles, no wheezes, has difficulty taking deep breaths but is not tachypneic
- Abd: soft, non-tender, non-distended, normal bowel sounds, no HSM
ER Course:
- EKG was found to be within normal limits.
- CXR was significant for a left apical lateral pneumothorax approximately 25%-30%.
General Surgery was consulted and a pigtail catheter was placed. The patient was admitted to the floor and discharged in 2 days after resolution of the pneumothorax.
Note: Since this patient was stable and not hypoxemic, he was able to go to the floor. However if a patient is hypoxemic and tachypneic, this would warrant admission to an intensive or intermediate care unit. The surgeons usually are primarily responsible for chest tube or pigtail catheter placements, however, ICU fellows or attendings can also place these if a surgeon is not readily available.
The differential diagnosis of chest pain is extensive. Major categories include musculoskeletal, tracheobronchial, pleural, esophageal, traumatic, and psychiatric (anxiety). As pediatricians, we usually tend to see chest pain associated with costochondritis, asthma, and GERD. It is important, however, to be keen to chest pain associated with an acute process such as a pneumothorax, since a patient such as this could also come for evaluation to his regular pediatrician.
Pneumothorax is defined as a collection of air between the visceral and parietal pleura of the lung. It can either be traumatic or spontaneous. The patient described had a primary spontaneous pneumothorax (PSP) since he had no underlying lung disease. Secondary spontaneous pneumothorax occurs when there is a pathologic lung process, such as cystic fibrosis.
The annual incidence of PSP in the general population is about 5-10 per 100,000 and usually occurs between the ages of 16-24. It is more common in males than females and those with a tall, thin body habitus are more affected. Smoking significantly increases the risk of PSP. Also, marijuana smoking and cocaine inhalation are risk factors.
The diagnosis is established by chest x-ray. The usual finding is air in the pleural space outlining the visceral pleura (pleural line) and hyperlucency. Atelectasis with flattening of the diaphragm can sometimes be seen, as well as tracheal deviation away from the pneumothorax. If there is underlying lung disease, chest CT scan may be more helpful to identify a pneumothorax. An arterial blood gas should be obtained if a patient is in respiratory distress.
The management of pneumothorax remains controversial and furthermore, not much direct data is present for the pediatric population. A conservative approach involves observation, supplemental oxygen, and analgesics. This is applied to those who have a PSP less than 25% that is not enlarging. Supplemental 100% oxygen increases the rate of resorption dramatically. The mechanism is through increased alveolar oxygen tension creating a steep gradient between the partial pressures of nitrogen in the pleural gas collection and capillaries.
Simple aspiration can be done percutaneously using a large-bore intravenous catheter connected to a large syringe so air is withdrawn manually. A CXR should be obtained after 4 hours. If re-expansion has occurred, the catheter can be removed and children should be observed for 24 hours with repeat CXR obtained prior to discharge. Simple aspiration has a recurrence risk of 20 to 50% so frequent follow-up is essential.
Patients who fail aspiration treatment or who have recurrent pneumothorax should be managed with a thoracostomy tube, which involves a waterseal device to prevent re-accumulation of air. Surgical intervention is recommended for an air leak that fails to resolve and video-assisted thoracoscopic surgery (VATS) is usually what is used for pediatric cases. Surgery involves stapling ruptured blebs or tears in the visceral pleura and resection of abnormal lung tissue (if present).
The majority of recurrences occur within one year of the initial event. Activities such as deep sea diving or flying in small, unpressurized aircrafts are associated with an increased risk of recurrence.
In conclusion, spontaneous pneumothorax should always be on our differential of chest pain, particularly for adolescents. It is also important to ask about smoking and marijuana use as this increases the risk. One also has to remember that a patient will not always be in respiratory distress since this depends on the size of the pneumothorax, so paying careful attention to the lung exam is essential.
References
Choudhary, AK, Sellars, ME, Wallis, C, et al. Primary spontaneous pneumothorax in children: the role of CT in guiding management. Clin Radiol 2005; 60:508.
Baumann, MH, Strange, C, Heffner, JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590.
Fleisher, G., Ludwig, S. Synopsis of Pediatric Emergency Medicine. Lippincott Williams and Wilkins. 2002. pp. 179-183.
Wong, KS, Liu, HP, Yeow, KM. Spontaneous pneumothorax in children. Acta Paediatr Taiwan 2000; 41:263.
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PRESIDENT-ELECT CANDIDATES 2008
To review question & answer forums from the candidates please check out the AAP
Members Only Center.
Colleen A. Kraft MD, FAAP
Richmond, VA
Colleen A. Kraft is the President of the Virginia Chapter of the American Academy of Pediatrics. In her private practice with Pediatric and Adolescent Health Partners in Richmond, Virginia she develops innovative ways to address morbidities new to the practice of pediatrics. In her previous practice, she served as Managing Partner. She also teaches in the Division of Community Pediatrics at Virginia Commonwealth University, and is Medical Director of Medical Home Plus, Inc., a non-profit that complements the Medical Home by connecting families and physicians with community resources.
Born in Akron, Ohio, Dr. Kraft was in an inaugural Head Start class in 1965. She received her B.A. from Virginia Tech, her M.D. from the Medical College of Virginia, and completed pediatric training at the Medical College of Virginia Hospitals. For the past 20 years, she has taught medical students and residents in classroom and clinical settings here and abroad.
As President of the Virginia Chapter, Dr. Kraft is often quoted in media and print about the excellent return on public investments in children’s health. She is well known to the Governor’s staff, State and Federal legislators, insurance companies as well as Medicaid and health department officials. Dr. Kraft has spoken nationally and internationally on numerous pediatric topics, serves on the Executive Committee of the Council on Community Pediatrics, and writes for the Section on International Child Health Newsletter.
Dr. Kraft enjoys music and travel with her three children, ages 22, 20, and 18.
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Judith S. Palfrey MD, FAAP
Boston, MA
Judy Palfrey is a general pediatrician and child advocate. She has developed widely accepted medical home approaches that address health inequities and provide guidance for practices and school systems on the comprehensive care for children with special health care needs. She has advocated for SCHIP, improved school health services and payment to pediatricians for developmental screening and coordination of care.
She has served as AAP Section Chair of Developmental and Behavioral Pediatrics, President of the APA, Director of Building Bright Futures, and National Program Director of the Dyson Community Pediatrics Initiative.
Born in El Paso, Texas, Judy grew up in Baltimore, Maryland. After receiving her AB from Harvard and MD from Columbia, she trained at Jacobi Hospital in New York. She joined Children’s Hospital, Boston, serving as General Pediatrics Division Chief (1986-2008). She fostered the division’s growth to 90 faculty members, 25 fellows, nearly 100,000 annual patient visits. She has written five books including Community Child Health and Child Health in America, over 100 articles and chapters dealing with improving child health systems. She has mentored 100s of medical students, residents, and fellows.
Judy is the T. Berry Brazelton Professor of Pediatrics, Harvard Medical School. She directs the Children’s International Pediatric Center, Children’s Hospital, Boston. She is Master of Adams House at Harvard College along with her husband, Sean, is the former President of the Massachusetts AAP. They have three children and two grandchildren. Judy enjoys messing around in boats, clamming and tennis.
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“Frontiers in Pediatric Hospital Medicine Symposium” 3rd annual symposium
Sponsored by Pediatric Hospitalist Division Physician Foundation at California Pacific Medical Center. San Francisco, CA.
The Grand Hyatt Hotel, September 11th and September 12th, 2008
Our symposium will focus on a variety of clinical subjects that pediatric hospitalists encounter on a daily basis. Medical experts from California Pacific Medical Center, the surrounding Bay Area and nationwide will discuss topics including but not limited to: pediatric surgical emergencies, neonatal emergencies, sedation, pediatric nutrition and shock. We hope that this symposium will serve to both broaden your knowledge of current pediatric inpatient medicine and highlight the excellent patient care received from pediatric hospitalists at CPMC and across the country. Price: $ 175 for two days, $100 for one day, and $50 for residents/fellows
CME credit: 14 AMA PRA Category 1 credits To register, go to our website: www.cpmc.org/frontiers or contact Beverly Hoover at 415-600-6484 or e-mail HooverB@sutterhealth.org
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Practical Pediatrics CME Courses are Practical for You
Patricia A. Treadwell MD, FAAD, FAAP
Chairperson, Practical Pediatrics Course Planning Group
It’s ironic, really. As a young physician, one of the first things you learn when you’re done with your formal education is that you’re not done learning – you’re never done learning. Black-box warnings have you questioning which treatments are best for ADHD and depression, you’re not sure which sports injuries you can treat and which you should refer, and your patients are presenting with rashes you don’t recognize and fevers you can’t explain. And then there are all those questions from parents about poop.
AAP Practical Pediatrics CME courses (PPCs) are just right for you. With the emphasis on “practical,” these courses offer answers to the kinds of issues all of us face in our daily practice. Each course features six expert faculty discussing both the common problems and hot topics that challenge all of us, and each course provides general session lectures and breakout seminars to ensure you have direct access to the course faculty and their expertise.
Practical Pediatrics CME courses also offer a practical way for you to combine CME with R&R. Scheduled with half-day sessions over three to four days in vacation destinations, PPCs are designed to give you the best and most practical pediatric CME while also providing you and your family with a relaxing getaway. Whether you enjoy the beach, the ski slopes, theme parks, historic landmarks, or world-class cities, there’s a PPC course to meet your educational and recreational needs.
But don’t just take my word for it. See what your colleagues had to say about our most recent PPCs.
“The course was a concise update of some of the most recent changes in standards of care…a must for a busy practitioner. The scheduling allowed free time to refuel both professionally and personally.” Damea Bourne Benton, MD; Hattiesburg, MS.
“The instructors were all excellent and entertaining. I always leave with pearls and improvements to my practices. I am always ‘better’ when I leave.” Lucille E. Kanjer Larson, MD; Clinton, MA.
“The name says it all – practical pediatrics. Knowledge gained can be used in daily practice.” Parimal Parekh, MD; Freeport, IL
.“A wonderful way to combine great CME with family-inclusive fun.” Michael Jaczko, DO; Carlton, OR.
So whether you’re looking to fill gaps in your training or learn about emerging issues, PPCs are the practical choice for your continuing medical education. I encourage you to attend a PPC course or two in 2008 and 2009.
Remember to register early to lock in early bird registration rates for any of the following outstanding course locations:
Hilton Head, SC
May 22-24, 2008
Portland, OR
May 23-25, 2008
PPC Sports Medicine Course
Vancouver, BC, Canada .
June 19-22, 2008
Chicago, IL
August 29-31, 2008
Amelia Island, FL
November 6-8, 2008
PPC Focus on Obesity
Williamsburg, VA
December 11-13, 2008
Lake Tahoe, CA
January 29-February 1, 2009
Orlando, FL
March 19-21, 2009
Providence, RI
April 2-4, 2009
Seattle, WA
May 14-16, 2009
Hilton Head, SC
May 21-23, 2009
You can find more information and register online at www.pedialink.org/cmefinder. Registrations for the 2009 PPC courses will open this fall. We look forward to seeing you soon.
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AAP Section on International Child Health
Cliff O'Callahan MD,PhD,FAAP
Our earth, when viewed from the space shuttle, is a small globe with little to no perceptible borders between regions other than bodies of water. With that view in mind it is easier to grasp the flattening of commerce and disease between the created boundaries, and the homogenization of the peoples on those landmasses. Organisms and climate are but a few of the issues that unite us all in a complex web of interconnections. It is this sense of global smallness and increasing connectivity that brings us together in the AAP’s Section on International Child Health (SOICH). I am certain that this feeling is shared by many other members of the Academy, and in particular to members of this Section, and for this reason I am writing this brief introduction to our activities.
The Section was formed in 1996 and has grown steadily. There are over 1000 members, including approximately 300 colleagues from other countries. Our mission statement states: “The Section on International Child Health is committed to improving the health and well-being of the world’s children.”
The seemingly boundless energy and idealism of our members is recounted in our newsletters through their stories. Organizationally we channel our SOICH activities through our four strategic goal areas of Education, Service, Advocacy, and Partnership/Diplomacy. Some of the regular activities include:
- Conducting educational programs for the AAP NCE every Fall
- Nominating the speaker for the annual Christopherson Lectureship
- Awarding several international travel grants each year that enable pediatric residents to pursue an elective abroad
- Maintaining a Book Repository Program which distributes medical texts to individuals and programs in developing countries
- Awarding I-CATCH grants to pediatricians in developing countries for programs that will improve the lives of children in their communities
- Developing partnerships and collaborations with pediatricians who work in the developing world: we have chosen to specifically work closely with the Haitian Pediatric Society over the last four years, and maintain a communication with many other societies.
- Supporting conferences in developing countries concerning advocacy, environmental hazards, and humanitarian disasters
- Working with the AAP International Office to help coordinate some of the international activities of the AAP
- Serving as liaisons to other AAP Committees and to other international organizations such as Health Volunteers Overseas, WHO, International Rescue Committee, and others
- Creating four newsletters a year, two of which are devoted to summaries of some of the best articles on international child health
- Maintaining an up to date Directory of Overseas Opportunities
- Fostering an active listserv
Take a look at our website www.aap.org/sections/ich for more details about these and other programs. There is a lot for all of us to do. SOICH members help children and our colleagues who live and work in difficult circumstances. Participation in SOICH does not have to involve even leaving home!As a pediatrician and member of the Section on Young Physicians, you share our mission to make the world a better place for all children. If our work appeals to you we would welcome your membership and the sharing of your concerns, experiences, and ideas on behalf of children and those who serve them on this tiny globe.
Be well.
Cliff
Cliff O’Callahan MD,PhD,FAAP
Chair, Section on International Child Health
cmocallahan@aap.net
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 Did You Know?The Academy Travel Office is here to serve your travel needs Monday thru Friday from 8:00 am to 4:30 pm, CST. Receive air discounts to AAP meetings and car discounts through Avis and Hertz. We also offer reservations through RESX on line, for those who prefer to book their own travel. If taking a vacation is what you’re looking for then contact Elizabeth Harrison for air, cruises or land packages. Our toll free number is 888-227-1772.
Happy Travels!
Deborah M. George
Director, Division of Travel Service
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