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Chair’s Welcome
By Antoinette L. Laskey, MD, MPH, FAAP
Chair, Section on Young Physicians
Have you had a chance to connect to your local AAP Chapter? Your Chapter may be looking for someone exactly like you! Chapters across the country are actively looking for ways to engage Young Physicians in their activities. They often ask, “How do we increase Young Physician involvement?” One of the best ways to make a difference for our patients and our practices is through our Chapters. They are the grassroots connections to our communities. They serve as legislative resources, advocacy resources and information resources for your specific location. Opportunities for leadership and involvement are extensive. Some Chapters have specific programs or ideas for YPs; others are open to suggestions on how you can get involved. All have something unique to offer those who want to participate. Many Chapters have applied for YP grants in order to increase involvement. Was your Chapter one of those? If so, there may be some new opportunities on the horizon. The Section on Young Physicians has put together a guide for Chapters to understand the needs of YPs better: the YP Guide for AAP Chapters.
Want to learn more about your Chapter and who to contact to get involved? Go to http://www.aap.org/sections/ypn/yp/getting_involved/aap_chapter.html to find your Chapter information. Contact your Chapter directly to begin your involvement. They are waiting to hear from you.
Remember, YPs are the future of the AAP. Take the opportunity to shape the future by getting involved locally.
Enjoy the summer months. We look forward to seeing you at the NCE (the AAP’s National Conference and Exhibition) in the fall. Don’t forget to visit the YP web site often as new information frequently gets posted: www.aap.org/ypn.
Antoinette L. Laskey, MD, MPH, FAAP
Chair, Section on Young Physicians
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Editor's Note
By Graciela Wilcox, MD, FAAP
Welcome to another newsletter that has taken shape in unique SOYP fashion. With your article submissions, we have a forum to share ideas, call for change, update on professional activities, or even just reflect. As school winds down and the throngs of patients slow a bit, I find that this time of year is good to look to the future and decide where my energy will be well spent in the upcoming months (besides on a beach for that coveted vacation). I will guess that many of you are doing the same and with health care reform on the table, a novel flu virus, the recession making it harder for our patients and their families to access needed care, and the countless other issues we’re facing, we’ve got our work cut out for us. So if you’re busy learning, advocating and organizing, Dennis and I can’t wait to read all about it and look forward to seeing your articles, thoughts and ideas.
Speaking of Dennis, I am sad to say he will be leaving as co-editor of this newsletter in the near future. I will certainly miss working with him as he has been an insightful mentor since I joined and an absolute pleasure to work with. We will be posting a job description for another co-editor on the listserv in the near future. Keep an eye out if you enjoy reading this publication and would like to be an active part of its production.
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California District IX Report
By Christina Vo, MD, FAAP
Last quarter I described the district’s strategic plan. Check out the California Pediatrician to read more from about it from our District Chair, Dr. Myles Abbott and Vice Chair, Dr. Richard Pan. One of the ways that strategic plan is put into action is through support of legislation in Sacramento. The following are some bills to follow this year:
AB 1201 (Perez) Adequate Vaccine Reimbursement
AAP-CA, the California Medical Association (CMA), and the California Academy of Family Practitioners (CAFP) are co-sponsors of this bill which will require health plans and insurers to fully reimburse physicians for the direct and indirect costs to acquire and administer recommended vaccines that are already required to be covered; prohibit health plans and insurers from charging co-payments, deductibles, or other out-of-pocket expenses that deter patients from immunizing their children; and prohibit health plans and insurers from including the cost of immunizations in a policy’s dollar limit provision. This bill is so exciting for AAP-CA because so many pediatricians are struggling to keep up with vaccine costs and poor reimbursement. The state already requires health plans and insurers to provide or offer coverage for recommended immunizations. This bill would require those health plans to cover a minimum amount for those vaccines and their administration: the actual cost of the vaccine plus staff time for ordering and inventory, shipping and handling, insurance in case of loss, refrigeration and storage, staff time to prepare vaccines and prep patients for administration, supplies such as alcohol, gloves, swabs, information sheets, syringes, and physician time to discuss vaccines with parents. Bill language is available at http://www.leginfo.ca.gov/pub/09-10/bill/asm/ab_1201-1250/ab_1201_bill_20090601_status.html .
Proposition 1D Children’s Service Funding
By the time this newsletter is published, it is likely that the May 19 Special Election will have come and gone. AAP-CA opposes Prop 1D because it redirects over half the money designated for California First Five programs to the General Fund for 5 years. Local programs created by the voter designated First Five Commissions include preschools for the under served, diagnosis and treatment of developmental disabilities and enrolling children in health care. We hope you were able to get to the polls and vote NO on Prop 1D. More information is available on the Vote No on 1D web site.
SB 1 (Steinberg) Expand Children’s Health Coverage
AAP-CA continues to support this bill which would expand health care coverage to include all 800,000 uninsured children under Medi-Cal or Health Families. Bill language is available at http://www.leginfo.ca.gov/pub/09-10/bill/sen/sb_0001-0050/sb_1_bill_20090212_amended_sen_v97.html
SB 810 (Leno) Single Payer Health Coverage
AAP-CA has remained neutral on single payer bills because members do not agree on whether a single payer system is the best way to expand coverage in California.
AB 473 (Portentino) Foster Care Siblings
AAP-CA supports this bill which would ensure that more children in the child welfare system are placed with – and stay with – their siblings while in foster care by requiring that, absent an emergency, the siblings' attorneys are to be notified of a planned change of placement or separation of siblings ten days before the actual change occurs so that the attorney, as the child's advocate, can work to keep the siblings together. AB 743 would also bring California in compliance with the federal mandate of "Fostering Connections to Success" (P.L. 110-351) with regard to the requirement to make reasonable efforts to place siblings together at the outset of the case. In addition to the obvious contribution to the overall well-being of these children that staying with siblings can provide, such placement would also simplify accessing needed health care and developmental monitoring for families of sibling children in foster care.
AB 513 and AB514 (de Leon) Breastfeeding
AAP-CA supports these two bills which were initially sponsored by the California WIC program. AB513 would ensure that HMOs and Insurers Provide Coverage for Certified Lactation Consultants (IBCLC’s) to help facilitate the breastfeeding process. AB 513 will also ensure that HMOs and Insurers cover the cost of breast-pump rentals to help mothers who choose to continue breastfeeding after returning to work. AB514 supports breastfeeding in the workplace by guaranteeing breastfeeding mothers who have returned to work a 30-minute break every 4 hours, in order to express milk. As Assembly Member de León stated at his press conference: “Mothers should not have to decide between breastfeeding their child and earning an income for their families.”
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AAP Grand Rounds Contributing Section Editor for SOYP
By Andi L. Shane MD, MPH, FAAP
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/.
I was pleased that a review of the effectiveness of maternal influenza immunization in mothers and infants was selected as the leading review for the January 2009 edition of AAP Grand Rounds. This was a wonderful honor for our section. A review of vitamin and mineral supplementation use among children in the United States is scheduled to be published in the May 2009 edition of AAP Grand Rounds.
Please feel free to contact me at your convenience to share ideas, articles, or suggestions via email andishane@pol.net. I look forward to continuing to represent the SOYP in this endeavor.
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Breastfeeding Guidelines With Some Empathy and Advocacy on the Side
By Peggy Chen, MD
By Lara W Johnson, MD
Robert Wood Johnson Clinical Scholars Program
Yale University School of Medicine
Recently, the public has been inundated with a backlash against breastfeeding. In an article published in The Atlantic in April 2009, Hanna Rosin discussed her perception of the overblown benefits of breastfeeding and made a purportedly “feminist” case against breastfeeding by comparing the breast pump to the Hoover vacuum cleaner of the 1950s as a means to “keep women down”. The American Academy of Pediatrics sent a response to the Atlantic that focused on a defense of the science of breastfeeding and a reiteration of the recommendations from the academy regarding breastfeeding practices. Meanwhile, a New York Times columnist wrote about breast pumping as “grotesque” and bemoaned the pressures placed on mothers to continue breastfeeding after returning to work.
After careful review of the articles, the television appearances, and the posted responses, we feel that there is a great deal of work yet to be done on both sides. Certainly, at least some mothers with significant educational and economic resources find breastfeeding too demanding to fit into their lives. Many women voiced satisfaction with Ms. Rosin’s approach and her perspective that breastfeeding is often just too hard and shouldn't be expected. Many on the other side expressed their vision of a breastfeeding America where babies will never know a silicone nipple or pacifier. Perhaps neither of these visions is ideal.
How did breastfeeding become so disconnected from motherhood as to be a separate issue altogether? Isn’t breastfeeding one of the most awe-inspiring biological abilities that women have? Aren’t babies born to breastfeed? And how did the method or mode that one chooses to feed one’s child become such a focus of judgment, guilt and oppression? More importantly, the “plight” of the privileged, well-educated mother being pressured by similarly fortunate peers to breastfeed may not speak to the experience of the typical American mother, much less the women least likely to initiate and maintain breastfeeding: those from minority groups, those with less education, those with fewer economic resources.
The Healthy People 2010 goal is breastfeeding initiation for 75% of infants with breastfeeding at six months and one year for 50% and 25% respectively. These are modest goals compared to recommended practice, and yet only eight states (Alaska, California, Hawaii, Idaho, Oregon, Utah, Vermont, and Washington) have met the targets thus far. For mothers without significant educational and economic resources, breastfeeding exclusively is an impossible goal with no paid maternity leave and few employers that support breastfeeding mothers.
Breastfeeding is not easy, particularly in the beginning. But the science behind its recommendations is sound – we all know that. The traction gained by recent publications against breastfeeding demonstrates that, as a profession, we risk becoming like the mythical Cassandra: ignored and perhaps ridiculed, even while speaking the truth. Perhaps the reason for this is that the contrarian opinion is humanistic, telling women: I understand what you’re going through and I don’t judge you for it, and in fact, I validate your experience. Meanwhile, the official stance of the medical profession remains a cold statement of facts and guidelines. Graduate medical education in the area of breastfeeding is spotty, and residents are not usually equipped with the tools they need to ensure successful breastfeeding in their patient populations which, coincidentally, are often made up of the most vulnerable populations.
As young pediatricians we are in a unique position to make our voices heard in this area. Many of us are trying to balance work and home responsibilities ourselves. We care for families in similar circumstances. We all know the science and the recommendations. Hopefully we know the nuts and bolts of breastfeeding counseling and support and are familiar with local resources for breastfeeding mothers. How many of us speak out publicly in support of breastfeeding? How many of us support parental leave practices conducive to breastfeeding in our institutions and in the communities where we live? How many of us know where the nearest lactation room is located? How well do we educate ourselves, our peers, our families, our office and hospital staff regarding the benefits and the practice of breastfeeding?
The most eloquent and passionate people writing and talking about breastfeeding are not speaking out in favor of current recommendations; they are calling for a revolt against them. At the same time, the official message broadcasted by our profession is an ideal, which is for all intents and purposes, impossible to achieve for the vast majority of Americans. We cannot recommend the near impossible without simultaneously and vociferously advocating for enabling structures and systems that would allow for this to become the reality for all women. We must take it upon ourselves to lead the way in the development of structures and practices to allow women of all classes to achieve the ideal of exclusive breastfeeding.
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Confessions of a Secret Pediatrician
By Sara Connolly, MD, FAAP
I have a confession to make. My baby’s doctor has no idea that I am a physician, never mind a pediatrician. My girlfriends think this is hilarious. They think I’m a spy, watching the doctor’s every move. After each visit, they inquire, “Does he know yet?” My husband loves it. He thinks it allows us to ask obvious questions without looking stupid. I, on the other hand, feel like a liar. I replay scenarios in my head in which my secret identity is discovered and I am promptly escorted out of the office. In another, the doctor looks quizzically at me as if to say, “Geez, you’re pretty stupid for a pediatrician”.
Here’s the thing…I didn’t specifically not tell him that I’m a doctor. During my first visit, cradling my three day old, my ABP credentials were far from my mind. Exhausted, in that moment, I was just a super-vulnerable new mom without a clue and scared to death. I simply allowed him to go through his newborn drill, asking questions, doling out advice, checking my little one for jaundice. It felt good to just be a mom and the reassurance was wonderful. Colin was healthy, my husband’s questions were answered and off we went. No chit-chat about careers or anything else for that matter.
We’re now 9 months into this secret. Again, hilarious to the girlfriends. It’s not that I’m spying or trying to catch him unfamiliar with the new Vitamin D recommendations. “It just hasn't come up,” I sheepishly say. My mom cracks up, “You’re a pediatrician!” When I call her for advice she laughs, “What would you tell one of your patients?” It’s true. For years I’ve given the same advice to my patients’ parents that my pediatrician now gives me. In fact, now that I’m “at home”, I give it daily for free on the playground, in playgroup, or over the phone: “Yes, insist that your toddler wear his helmet on the bike. No, don’t feed your infant peanut butter.” I’m full of this stuff! Now, however, a new worry pops into my head when I’m considering my own child: Doubt. What if, evidence-based medicine aside, I’ve been wrong all these years? What if this advice is impractical, unhealthy, impossible for parents to implement, or only adds to mommy guilt without really helping a child? Or, what if I’m just wrong?
Today, for example, Colin and I were in for his nine-month Well Baby Check. He’d had a rash on his little booty for a few weeks. Last night, I explained to my husband that while red, I didn’t believe it was candida. I spouted off about friction, emollients, blah blah blah, but reassured him I would ask “the doctor” about it today. No sooner was my little boy naked that our very nice nurse declared his rash “yeasty”. I’m pretty sure I blushed. “Yeast! Of course! I’m such an idiot,” I thought. I couldn’t even correctly diagnose a diaper rash. Ugh! Dr. Pediatrician walks in and peeks at the rash. “Is it candida?” I ask. “Oh no!” replies my son’s doctor, who then goes on to spout off about friction, emollients, blah blah blah.
Turns out, I really just need to be a mom when it comes to my son. I need a different good doctor to objectively look at the little one I adore. I need to feel that he’s not skipping over the important stuff because he thinks I know it all. I also need that magical test question answer: Reassurance. To a first time mom, it’s really important. I’ve spent nine months feeling guilty that I need this validation after all these years of training, but I’m letting that go. It’s okay that I feel panicky while waiting for my baby’s test results or tearful when he gets shots. It’s okay that I stress so much over what he does or does not eat. I’m a pediatrician. I hope a good one, but it doesn’t make me immune to worry. So, sorry, Dr. Pediatrician. I promise I’m not judging or spying. Just listening with open ears and grateful for your good care!
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Serving the Poor in Nicaragua
By Beatriz Juncadella, MD, FAAP
Are you looking for an opportunity to serve the under-privileged? Would you like to make an impact in this world? If you do, then I invite you to come to Empalme de Boaco, Nicaragua.
Empalme de Boaco is a rural community in Nicaragua, the second poorest country in the Western Hemisphere. Empalme means “meeting point or cross roads.” This small community is at the intersection of two main roads of Nicaragua and it serves as the focal point to several other communities. Most of the people of Empalme and the surrounding area live in extreme poverty. Even pets in the US have better housing and higher standard of living than the average person in Empalme. Entire families live in one-room homes made with branches and mud. They spend the six months of the rainy season under a leaky roof made out of scraps of metal, cardboard and plastic, praying for the rain to stop as they curl in a corner trying to stay dry.
For the past two years, I have been committed to help this community improve their health and quality of life. My family and I joined with my local church in Charlotte, NC, to start a community health clinic in Empalme that provides basic health care, free of charge. After receiving an anonymous donation to build the clinic and fund the operations for the first year, this vision has taken off to a good start. We completed and inaugurated a new clinic building in April of 2009, and we are open to the community five days a week. Thus far, we have been able to fund raise the money to pay a full time physician and clinic administrator to run the clinic year round.
Since September of 2007, I have been taking mission teams to Empalme de Boaco, Nicaragua every six months. Our teams hold medical/dental clinics for the community and provide care and the needed medications free of charge. On our last visit to Empalme, our team was able to provide care to 535 patients. Each patient received treatment with albendazole to eradicate parasites, a month supply of multivitamins and the medication needed to treat their illnesses such as bronchiolitis, asthma, and dysentery. All children received dental fluoride treatments for the prevention of caries.
We find that many patients walk miles and wait hours to be seen, rain or shine, without complaint. Some wait all day and come back the next day and wait some more to have the opportunity to be seen. The people are so thankful; their smiles, and sometimes tears, convey the depth of their gratitude.
There is something different about caring for the most needy.
The satisfaction you feel can’t be explained with words, it has to be experienced. You reconnect again with the passion that drove you to study medicine in the first place. You feel that you have made such a difference in the life of the people there that it drives you to continue coming back.
Our next trip will be in October 2009. You do not need to speak Spanish but if you do it is helpful. The trip is for a week and the cost is around $1,000/person. If you are interested in joining us, I invite you to go to our web site www.nicaraguaclinic.org to learn more about this opportunity and how you can be involved.
Contact Information:
Beatriz Juncadella
Email: mosensito@hotmail.com
Phone: 336-689-3145
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Keeping the Passion
By Carol D. Berkowitz, MD, FAAP
Past President, American Academy of Pediatrics
An article prepared for the Section on Young Physicians
Imagine that it’s 35 years into the future and the joy of being a pediatrician is no less today than it was when you entered your practice. Many of your medical school classmates who entered other disciplines have since retired but that doesn’t seem appealing to you right now. Is this an unrealistic scenario, a rare pediatric event? I don’t believe so. So how do you craft your life so that the satisfaction associated with a career in pediatrics lasts throughout your lifetime? Go back to the core reasons for which you entered pediatrics and let those be your guide.
For me, professional satisfaction has stemmed from 2 areas: teaching and patient care. Nurturing medical students and pediatric residents serves as a constant source of professional renewal; I have countless examples. Most recently I spoke to two pediatric interns each taking on an advocacy project of different size and proportions. One intern has been involved since he was a high school student with a program to improve the education and care of individuals with diabetes in Ecuador. He has helped develop the program and now encourages others to travel to South America and become involved in the process. The other intern heard me speak about my experience as an attending on the ward and having 2 different youngsters admitted because they were each struck by an auto while purchasing ice cream from an ice cream truck. Why, I asked, weren’t there flashing lights on the back of the truck mandating that all cars stop as they do for stopped school buses? This other intern was equally outraged and is now involved in researching about and advocating for such a law. How energizing it is to continue to interact with others who are so close to the seeds of their desire to become a pediatrician! My advice is to mentor others – their energy and enthusiasm will energize you. It may be hard to continue to feel inspired to make the world a better place when you are busy putting out fires on a day to day basis – fighting for adequate reimbursement or answering denials for care that you feel is critical to your patient’s well-being. In the midst of the fires always ask yourself: “What’s in the best interest of the child?” It will always get you to the right response.
And children are the right answer. I have been involved in the area of child abuse for nearly 30 years. I am frequently asked: “How do you continue to do it? It’s so depressing seeing children who have been injured and neglected.” But my ability to intervene and make a difference is what matters. I remember a number of years ago examining a 9 year old girl who had been molested by her uncle. She was ordered by the court to see me for a forensic examination. She had never seen me before, yet was to reveal both her secrets and her body to a total stranger. At the end of the visit she said,” That wasn’t so bad. Could I come back and see you again?” Comments like that are renewing. I was there for her, and she helped reinforce for me that what I did, hard as it might seem to others, conferred on me an incredible feeling of making a difference. There is no better reciprocity in a relationship. Socrates said, “An unexamined life is not worth living.”
Making a difference is at the core of pediatrics and at the core of having a meaningful life. One doesn’t need as dramatic an example to understand the unique benefits of being a pediatrician. Having a patient make you a picture, or take your hand as you walk together to the examining room is reward enough. I remember another experience that a resident shared during our annual pediatric house staff retreat. She was talking about working in the pediatric emergency department and it had been a particularly hectic shift without a break for dinner. She had just taken out her stethoscope and leaned forward to listen to the chest of a coughing 3 year old, when the little girl leaned forward and kissed her. Her fatigue vanished as though she had slept 10 hours!! Patients are a constant source of renewal.
So it’s 35 years from now and you are in your office. A mom comes in with her 5 year old and 3 year old for their routine exams. And you can’t believe it since it seems like only yesterday that you saw the mom when she turned 5 and was about to enter kindergarten. Grandpatients – almost as good as your own grandchildren – and certainly a validation of the good that you do and the esteem in which you are held by the children you have cared for.
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Duh'ZZs and PayTients – hOur Duty:More on the IOM Report on Resident Work Hours
By Eric Horowitz, MD, FAAP
Duke University Medical Center
Melissa Murray-Lestini, MD, FAAP
Children's Hospital of Philadelphia
Clara Song, MD, FAAP
University of Southern California Medical Center
Claudia Florez, MD, FAAP
Children's Hospital at Vanderbilt
The practice of medicine is ever evolving. Improving how we care for our patients and educate the next generation of physicians is a core value of modern medicine. In this pursuit, a concern regarding supervision, fatigue and medical errors has arisen. In 1984, the death of 18-year-old Libby Zion brought great attention to this issue. To help address the concerns that this tragedy brought to light, New York State formed the Bell Commission and issued guidelines regulating resident supervision and duty hours. In 2003, under growing congressional pressure, the Accreditation Council for Graduate Medical Education (ACGME) issued nationwide regulations regarding resident duty hours. Since their inception, many people have examined the impact of these rules by the Bell Commission and the ACGME on resident oversight, fatigue, and patient safety1-14. At the request of Congress and under contract of the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine (IOM) formed a consensus committee to “1) synthesize current evidence on medical resident schedules and healthcare safety, and 2) develop strategies to enable optimization of work schedules to improve safety in the healthcare work environment. The strategies recommended will take into account the learning and experience that residents must achieve during their training. The recommendations will be structured to optimize both the quality of care and the educational objectives.”15.
In summary, the IOM consensus committee now recommends the following:
- Maximum duty hours of 80 hours a week averaged over 4 weeks;
- No shift longer than 30 hours (direct patient care for up to 16 hours, plus protected sleep period of 5 hours with remaining time for transition and education);
- Maximum call schedule of every third night (no averaging);
- Minimum time off between shifts of 10 hours after a day shift, 12 hours after a night shift, and 14 hours after an extended duty shift;
- Maximum of 4 consecutive in-hospital night shifts;
- Mandatory 5 days off per month with 1 day off per week (no averaging) and one 48 hour period off each month;
- All moonlighting counts toward the work hour limits and is restricted to above duty hour guidelines.
In response to these recommendations, we ask that you consider the phrase “Duh'ZZs and PayTients – hOur Duty.”
Duh'
It is a given that graduate medical education needs to adapt, but consideration of the latest recommendations by the IOM should make one take pause. The IOM recognizes that any change made needs to be well thought out. To accomplish this the IOM has reviewed countless studies and interviews assessing the effectiveness of the first 5 years of the ACGME duty hour guidelines. Many of these findings are limited by poor study design and small sample size in an environment that penalized accurate documentation of violations of duty hours3-4, 6-14, 16-24. In their 480 page consensus statement, the IOM acknowledges the following concerns: that the ACGME reports at least 8.8% of programs were non-compliant; there are 26 types of residency specialties with different needs; some training programs may need to lengthen residency training to become compliant with duty hour guidelines; resident caseload has increased; the cost of implementing their guidelines could cost approximately $1.7 billion; and there has been a lack of any comprehensive attempt to document changes in residency programs and their impact on educational outcomes and patient safety since the implementation of the ACGME duty hour rules15.
ZZ's
The implementation of the 80-hour work rules by the state of New York in 1989 sought to optimize patient care and supervision of residents. Their initial focus was not on duty hours, but instead on supervision. Since that time an intense debate has developed over the efficacy of duty hour regulations. The IOM has now issued further recommendations augmenting the current 80-hour duty rules. This decision by the IOM seems to be narrowly focused on studies that have demonstrated the real dangers posed by a fatigued physician or trainee who is not functioning at their best. But what about factors other than fatigue? Do we know what effect reduced duty hours will have on physician workload, distractions, shortcuts, and medical errors? Is a better-rested physician with high workload better than a physician who has worked longer hours with the support of more colleagues? It can be argued that we do not know that answer. Just as a fatigued or drunk driver is a hazard, it is doubtful that a driver distracted with text messaging while eating their breakfast would be any safer.
Disease
Graduate medical education, at its core, is little more than a clinical apprenticeship. It is through constant contact with patient care, under a master’s supervision, that the next generation of physicians learns their craft10, 16, 17, 21, 23, 25. If we arbitrarily and uniformly limit the hours that a trainee can experience this mentoring, then will we have to prolong the duration of residency or require new fellowships for general practice? Already we see the emergence of general academic fellowships and hospitalist fellowships. These fellowships may be a response to the concern that recent residency graduates have reduced clinical skill sets. All medical trainees are adult learners, and as such have varied learning styles. Therefore it is likely that some trainees learn better by doing, listening, viewing, or reading. Some learn faster, and some learn more slowly. Is it then ideal to mandate limits on the hours one can spend learning? Are these limits appropriate for all levels of trainees in all specialties at all times during their training? Would it be better to allow for some flexibility in the system for trainees to select the programs that are best suited to them, and for programs to adjust their teaching styles and clinical demands to best meet the needs of their learners and their patients? Even though we do not know the answers, yet, is it not worth asking the questions and seeking the answers before we act?
Pay
For good or bad, most everything in our society comes down to money. If the IOM mandates that their current recommendations be implemented, the financial burden could be staggering. A report by Iglehart suggested that compliance with these recommendations would require the addition of up to 5984 mid-level providers, 5001 attendings, or 8247 additional residents4. By the IOM’s calculations, these costs could be as high as 1.7 billion dollars. Even if we were not in the midst of this current fiscal crisis, it is doubtful that our health care system could support such an additional obligation. If we cannot afford this cost, would we then be forced to close down certain training programs and put the populations that they serve at unintended risk? Or would our trainees, who are already saddled with over $150,000 of education debt26, likely be required to take a reduction in compensation for services as an attending? How would this increased financial burden affect those considering medicine as a profession? Or would these expenses just be passed on to our patients?
Patients
What about our patients? The IOM’s goal with their recommendations is to provide patients with better care through improved training and performance of physicians. But will these rules achieve this goal? Currently, there are no duty hour limitations for an attending, only trainees. Does this mean that attendings are as infallible as most trainees believe them to be? But what if becoming an attending does not make a physician infallible? What lessons are we teaching the next generation about professionalism and work ethic by imposing arbitrary hourly limitations? The IOM duty hour guidelines may create an increased tendency for physicians to expect to work according to a schedule rather than to a patient’s needs. Currently, those disciplines that do revolve around a shift schedule still have providers who will stay the extra time to assure their patient’s needs are met and who are not penalized for caring about them. Will this be so in the future? Creating more shift-like schedules increases the number of physician hand-offs and limits the continuity of care. In addition, further limitation of duty hours is bound to affect outpatient clinic schedules; shifting patients from those with whom they have a bond, to someone new. Could this reduction of direct patient knowledge and continuity of care lead to sub-optimal treatment of the patient? Shouldn’t we take the time to find out?
Patience
The IOM’s recommendations may be the best plan to improve our medical training system, but they may have looked only narrowly at the identified problems, and failed to give additional thought to the problems that could arise from these changes. For a new drug to come to the market it needs extensive testing, and even with that testing harm from its use can still occur. Take Vioxx, as just one example. Have the recommendations of the IOM gone through sufficient testing to be broadly and uniformly applied to all trainees, training programs, disciplines, and their patients? To develop potential recommendations we need to foster creativity, structure independence, and secure funding to find the answers. Would not a prospective study of multiple strategies seem a more prudent approach to accommodate the varied nature of medicine and medical education before making a decision based on somewhat inconsistent data? The use of the scientific method to examine the issues of sleep versus workload and education versus apprenticeship would minimize initial costs and generate a better set of data with which to make a more informed decision. Those in decision-making positions should exercise patience, seek answers, and utilize better data to help us to develop the best healthcare system in the world.
Our Duty
The issue of duty hour regulations in medical training has strong opinions on both sides. The improvement of physician education and clinical performance requires the practice of evidence-based medicine. Therefore, it is our duty to think about these issues, review the literature, contact our former training programs, and share our opinion with our state medical board, specialty board, local congressmen, federal legislators, and the ACGME.
The ACGME can be contacted at the following address:
Resident Services
ACGME
515 North State Street, Suite 2000
Chicago, Illinois 60654
Simply stated, this is a huge issue. The IOM, with its new duty hour recommendations, is trying to make positive changes in the training of medical professionals and in assuring patient safety. As medical professionals, in training or recently trained, we have unique insight into how we perceive our graduate medical education, how it will or has prepared us for our careers and how this process could be changed for the better. Thus, we are, in part, responsible for assuring that further changes to this system truly produce a positive impact on education and patient care. The more people that reflect on strategies to improve this educational process and provide constructive comments, the more likely our medical system will evolve in a positive direction towards improving patient care and optimizing medical education.
Further Reading:
References:
1. Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg 2003, 237: 449-455.
2. Holzman IR, Barnett SH. The Bell Commission: ethical implications for the training of physicians. Mt Sinai J Med 2000, 67: 136-139.
3. Brion LP, Neu J, Adamkin D, Bancalari E, Cummings J, Guttentag S, et al. Resident duty hour restrictions: is less really more? J Pediatr 2009, 154: 631-632 e631.
4. Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med 2008, 359: 2633-2635.
5. Schulman M, Lucchese KR, Sullivan AC. Transition from housestaff to nonphysicians as neonatal intensive care providers: cost, impact on revenue, and quality of care. Am J Perinatol 1995, 12: 442-446.
6. Woodrow SI, Segouin C, Armbruster J, Hamstra SJ, Hodges B. Duty hours reforms in the United States, France, and Canada: is it time to refocus our attention on education? Acad Med 2006, 81: 1045-1051.
7. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005, 28: 1392-1402.
8. Stickgold R. Sleep-dependent memory consolidation. Nature 2005, 437: 1272-1278.
9. Jagsi R, Weinstein DF, Shapiro J, Kitch BT, Dorer D, Weissman JS. The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety. A study of resident experiences and perceptions before and after hours reductions. Arch Intern Med 2008, 168: 493-500.
10. Jagsi R, Shapiro J, Weissman JS, Dorer DJ, Weinstein DF. The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study. Acad Med 2006, 81: 1059-1068.
11. Fletcher KE, Underwood W, 3rd, Davis SQ, Mangrulkar RS, McMahon LF, Jr., Saint S. Effects of work hour reduction on residents' lives: a systematic review. JAMA 2005, 294: 1088-1100.
12. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Jr., Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004, 141: 851-857.
13. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004, 351: 1838-1848.
14. Meltzer DO, Arora VM. Evaluating resident duty hour reforms: more work to do. JAMA 2007, 298: 1055-1057.
15. Cheryl Ulmer DMW, Michael M.E. Johns. Residency Duty Hours: Enhamcing Sleep, Supervision, and Safety. Institute of Medicine of the National Academies: Washington, DC, 2008.
16. Gaies MG, Landrigan CP, Hafler JP, Sandora TJ. Assessing procedural skills training in pediatric residency programs. Pediatrics 2007, 120: 715-722.
17. Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr 2005, 146: 638-641.
18. Steinbrook R. Medical student debt--is there a limit? N Engl J Med 2008, 359: 2629-2632.
19. Gitterman DP, Hay WW, Jr. That sinking feeling, again? The state of National Institutes of Health pediatric research funding, fiscal year 1992-2010. Pediatr Res 2008, 64: 462-469.
20. Landrigan CP, Fahrenkopf AM, Lewin D, Sharek PJ, Barger LK, Eisner M, et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 2008, 122: 250-258.
21. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? J Am Coll Surg 2008, 206: 804-811; discussion 811-803.
22. Shin S, Britt R, Britt LD. Effect of the 80-hour work week on resident case coverage: corrected article. J Am Coll Surg 2008, 207: 148-150.
23. McElearney ST, Saalwachter AR, Hedrick TL, Pruett TL, Sanfey HA, Sawyer RG. Effect of the 80-hour work week on cases performed by general surgery residents. Am Surg 2005, 71: 552-555; discussion 555-556.
24. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA 2006, 296: 1063-1070.
25. Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics 2003, 112: 1242-1247.
26. Harris S. Graduates Report Higher Debt, Primary Care Interest. AAMC Reporter 2008.
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Reflections From My ‘Half-Way’ Point
By Dianna Tolen, MD, FAAP
One early morning, while typing some responses to the SOAPM list serve at 4 am after waking up for a “mommy call” and not being able to fall back asleep, I started to think about the last 10 years of practice I had weathered. I realized there were certain developmental stages that I had been through just like my patients, and wondered if others had gone through the same ‘Ages and Stages’. So I wrote the following post:
What do you think the stages are in maturing through a practice? How do you feel you have changed and what stages do we need to go through in our doctoring careers to be called a successful physician? Here's my path as I reflect.
Year 1-2 – I feel empowered and ‘god-like’ at being in charge and in control of a practice and finally being a REAL doctor in solo practice. After residency, I stayed on as a Chief Resident for one final year to study for boards (which I pass the first time much to my true surprise). In my practice, I learn how to do payroll, write policy manuals, become OSHA compliant, negotiate every item I buy, and unplug toilets and sinks. I write monthly checks for vaccines that are more than my salary. I spend my nights moonlighting in the urgent care and local ERs, which supports my feeling of omnipotence. During the night I save babies from death, sew up wounds by mastering the power of distraction and kids’ songs, and fix parents’ fears that the ‘bronchitis’ their child has is not going to kill him tonight. By day however, I am frustrated with having parents frequent my new practice for antibiotics for their child’s cough, or to escape the bill from their past physician that I am not aware of, or just not believing what I'm telling them. After all, when did they go to medical school?
Most of my parents are older than me, and they are always asking me if I'm even old enough to be a doctor. I feel like a Doogie Howser, ending each episode with a resolution but not realizing that treating the constipation doesn’t always treat the child.
Year 3-4 – I’m feeling absolutely stupid and overwhelmed at the mistakes I now realize I’ve made in both business and medicine. I wonder if I will ever be able to make it work, not to mention sitting on the bankruptcy fence every darn day… I have my own first child 4 weeks early a week before Christmas and go into the office on the way home from 24-hour discharge from the hospital to do the payroll that my staff is counting on before the holiday. I take calls from home for 2 weeks and start working again the day after New Year’s. When you are in a town with multiple solo practices all in competition, there is no one to cover without the threat that you will lose patients to the convenience of being seen now.
I start to realize that I have a lot to learn from parents who do trust me, in regards to how to approach their concerns. Now I know I need to listen to more than just WHAT they say. My first horrible letter comes in the mail from a parent who felt that I was such a bad and uncaring physician that I should not be able to take care of her children let alone anyone else’s. This letter and other patient transfers out of my practice bring me down a notch, make me irate and depressed at the same time, and I start to wonder if this is really the profession I should be in. After 12 years of schooling after high school to get to this point, years of loans, months of studying, and now sleepless nights not only from call but also from my newborn, I wonder if this is really my calling. Maybe I should just chuck it all and start over. What would I do though? Business? Computers? Teaching?
Year 5-7 –Things are riding smoother now that I’ve got some experience and learning out of the way, which helps with not making the same mistakes twice. Now I am humbled at how little my caring and time with patients really mean when they find something better around the corner. The antibiotic that won’t get called in, the fact that I can’t see them today for the stomachache that has been happening for the last two months, or because I start to expect co-pays to be paid TODAY and not when they remember to send the check in. I feel overwhelmed by how many choices I still have to learn about when I want to change things or do something new. What EMR company should I change to? How do I want to change the schedule around to fit all these patients in? What vaccine company and schedule should I really use this year. I am managing being a parent and a full-time physician and feeling that constant exhaustion that goes with it.
Year 8-9 – I am now enjoying seeing many patients grow to teens, and actually have my first child of a patient who I have seen since residency come to be my patient. (Am I actually that old now?) I find myself looking back on how the office has changed, how many employees we've supported, how much business I’ve learned and how medicine has changed in only a few short years. I actually start feeling somewhat experienced when teaching students after realizing that I graduated almost 15 years ago from the same school. I start looking ahead at the next phase of my career and wonder if I can continue to learn and be sharp but not forget the empathy that I have gained since raising my own kids. Looking at how different I am now than I was in the beginning, and laughing with parents and staff about how they "trained me" over the years.
Year 10 – We switch EMRs and I now have the daunting task of cleaning out every chart I own in preparation for scanning. I find photos, obituaries, letters and hand drawn pictures that I have saved. I laugh and cry and sometimes remember the pain that a family caused in my own psyche. I remember my mistakes, thanking the powers that guided me that I had a good enough relationship with the parents and thankfully didn’t do anything that called for being served with a malpractice suit. I remember the phone calls to hold a parent’s hand through cancers, deaths, and emotional times. I remember the kids that made me laugh when I was feeling down myself. I have seen our office morph into something to be proud of. We now are computerized, have a web site, and policies and guidelines to help parents and patients. We passed our state vaccine audit with a 99% and are surprisingly the ‘go to’ practice for other offices to call for billing questions, borrow supplies or ask advice.
I start being more active on the political side of pediatrics. I get 150 e-mails per day from various list serves on which I lurk. I start posting more, going to more AAP sponsored events and actually think about going higher up in committees or running for an office to get started. Isn’t this actually the part of pediatrics I said I would neverget involved in when I was a resident? Now it intrigues me. I feel that I might be able to be influential with the same type of drive and determination for a cause that got me through medical school in the first place 15 years ago.
My patients are fun. I look forward to the days at work again. I leave feeling content and satisfied, and actually like those extra moments answering (for the 1001st time in my career) a parent’s concern, which makes them take that big sigh of relief. And how ironic, I never get asked if I'm 'old enough' to be a doctor anymore. Maybe now I wouldn’t mind so much…
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A Tremendous Educational Opportunity Awaits You!
By Rich Kaplan, MD, FAAP
Planning Group Chairman, PREP:CAP, Associate Professor of Pediatrics and Medical Director, Center for Safe and Healthy Children, University of Minnesota Medical School
When all the forms of child maltreatment are combined, they account for more morbidity and mortality then all of the childhood cancers. Whether you plan on entering primary or subspecialty care, as a pediatrician you will inevitably encounter a variety of forms of child maltreatment. Your ability to recognize and appropriately respond to child abuse will have a profound effect on the well being of your patient and his or her family.
Because Child Abuse Pediatrics has emerged as a subspecialty, a tremendous opportunity awaits you:PREP:CAP - An Intensive Review and Update of Child Abuse Pediatrics. This is being offered as a preparatory course for those who will be taking their Boards, but also as an excellent and high-quality review for all pediatric providers regardless of their area of practice.
We will review, in-depth, areas of child physical abuse including abusive head trauma, fractures and cutaneous injuries; child sexual abuse; various forms of child neglect with an emphasis on emotional consequences; as well as epidemiology and prevention efforts.
We have brought together a wonderful faculty and will be presenting this material in a beautiful setting in Portland, Oregon on July 22-26, 2009. This course represents not only an excellent learning opportunity, but also an exciting and pleasurable networking opportunity with a variety of pediatric specialists and subspecialists from around the country.
I urge you to consider this as a critical step in the enhancement of your pediatric practice. For further details or to register, visit www.pedialink.org/cmefinder or call toll-free, 866/THE-AAP1 (866/843-2271).
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2008 Program and Legislative Results Build Strong Value for AAP Membership
The mission of the American Academy of Pediatrics (AAP) is to attain optimal health and well being for all infants, children, adolescents and young adults. This mission can only be accomplished through the ongoing efforts of the 60,000+ members of the AAP. To this end, the elected and appointed leadership, as well as professional staff, are very focused on serving AAP members-positioning each member to practice the highest quality health care as well as achieve professional and personal satisfaction in their practice of pediatrics.
The breadth and scope of the AAP’s reach is enormous. At any given time the AAP is actively working on hundreds of issues with a focus on driving toward desired results that move the mission forward and deliver value to members. Due to the nature and scope of the issues progress is often incremental rather than immediate, however important, concrete, results are delivered each year and we are pleased to report some of the key results achieved on behalf of children and our members in 2007-2008:
Legislative Victories:
- Pediatric Drugs-The Best Pharmaceuticals for Children Act (BPCA) and Pediatric Research Equity Act (PREA) were both reauthorized for an additional 5 years, strengthening the programs and ensuring continued study of drugs used to treat children.
- Medical Devices-Pediatric Medical Device Safety and Improvement Act passed with an initial $2 million appropriation to encourage development of pediatric medical devices.
- Safety of Children’s Toys and Products-New law virtually eliminates all lead in toys and children’s products and established pre-market testing and certification.
- Genetic Nondiscrimination-Genetic Information Nondiscrimination Act is passed, a bill that will protect all Americans against discrimination in health care or employment on the basis of predictive genetic information.
- Foster Care-Fostering Connections to Success and Improving Adoptions Act passed with AAP drafted legislative language that require States to examine their systems and ensure health care services are coordinated for children in foster care.
- Mental Health Parity-Working as part of an alliance achieved passage of mental health parity legislation included in the $700 Billion financial rescue bill signed by the President.
- Global AIDS-Working as part of an alliance achieved $48 billion reauthorization of the global AIDS program with new focus on pediatric AIDS care and treatment.
Improving Practice:
- Completed Socioeconomic Survey of Pediatric Practices-A comprehensive assessment of the “state of pediatric practice”. The data will be shared in the coming months through AAP News and other venues.
- Launched/enhanced Practice Management Online Web site
- Published and Delivered Pediatric Nutrition Handbook, 6th Edition as a member benefit.
- Launched Pediatric Care Online Web site - A point of care electronic resource to meet the everyday clinical reference needs of primary care pediatricians.
- Launched Redesigned Children and Disasters Web Site
- A number of practical toolkits designed to improve practice were completed in 2008:
- Protecting Children from Secondhand Smoke & Tobacco
- Culturally Effective Pediatric Care
- Preventing Sexual Violence: An Educational Toolkit for Healthcare Professionals
- Safe and Healthy Beginnings: A Resource Toolkit for Hospitals and Physicians Offices
- Payment for Telephone Care Toolkit
- Payment
- Achieved significant increase in payment for vaccine administration through the Centers for Medicare and Medicaid Services (CMS) 2009 Resource-Based Relative Value Scale (RBRVS). Now includes clinical staff time, registry input, refrigerator/freezer temperature log and alarm monitoring, and documentation as “direct” expenses rather than “indirect” overhead.
- 40 Chapter Pediatric Councils have been established and are actively working on payment issues in their states.
Programs/Milestones:
- Established and led Immunization Alliance-A consortium of health organization leaders combining resources and talent to advance and promote the importance of immunizations to the public. Accomplishments to date include actress Amanda Peet’s television and radio public service announcements, and development of print public service announcements.
- Convened and led conference entitled: “Starting Early: A Life Course Perspective on Child Health Disparities”, which established a research action agenda to reduce disparities among children.
- 15th Anniversary of the CATCH program-over 1,000 grants awarded to stimulate and solidify community pediatrics projects.
- Launched Chapter Asthma Quality Improvement (CAQI) Project-Four AAP chapters selected to launch and lead a quality improvement (QI) effort on asthma.
- Launched the Native American/Alaska Reach Out and Read Program.
- Convened and led first of its kind conference with the China Ministry of Health entitled “Child Mental Health Recovery in Disasters” in Hangzhou, China.
- Completed development of Professional Liability Insurance Program for AAP Members-Program launch scheduled for April 1, 2009.
- Established new Provisional Section on Hospice and Palliative Care Medicine.
- 15 AAP publications were honored this year with publishing industry awards.
- Sold/distributed over 1.5 million of the AAP’s parenting books.
- Reached 2 million parents with a parent resource guide developed in partnership with Babies R Us.
- 2008 NCE in Boston broke all previous attendance records, including record international attendance.
- 60th Anniversary of the AAP Section on Surgery.
- 98% of all residents are members of the AAP thanks to support by their residency training programs.
These results, delivered on behalf of children and members, are a source of great pride and value to all AAP members. The AAP deeply values your membership and support and continually strives to deliver for you every year. On to 2009!
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North American Society for Pediatric and Adolescent Gynecology
www.NASPAG.org
North American Society for Pediatric and Adolescent Gynecology (NASPAG) is a voluntary, non-profit organization devoted to conducting, encouraging and supporting programs of medical education and professional training in the field of pediatric and adolescent gynecology. We provide leadership while serving as a forum for research and promoting communication and collaboration among health care professionals on issues related to pediatric and adolescent gynecology.
NASPAG members reside in all 50 of the United States and Canada and in countries abroad. The Society is multidisciplinary, with members including obstetricians, gynecologists, urologists, reproductive endocrinologists, mental health professionals, internists, nurses, practice administrators, laboratory technicians, pediatricians, and research scientists.
As a member of NASPAG, you will be able to take advantage of many opportunities available to you:
- Reduced rates for NASPAG’s Annual Meeting
- Subscription to Journal of Pediatric and Adolescent Gynecology that includes:
- Recent Research
- Mini-Reviews & Clinical Updates
- Resident Education
- Topics for the Allied HCP
- Challenging Cases & Book Reviews
- Medical and Surgical Aspects of PAG
- Opinions and Controversies
- Access to PAG Educational Materials
- Access to Clinical Expertise & Consultation
- Develop a Clinical Niche
• Enhance your Academic Profile
- Opportunities for Research
- Be a Part of an Incredible Network
NASPAG members are its greatest asset. Members report camaraderie & friendship.
Attention Residents & Fellows: The North American Society of Pediatric & Adolescent Gynecology (NASPAG) offers reduced membership rates to trainees and to those in their first year of practice. Visit our web site for more details, for information about the society and for information about our Annual Clinical Meetings held in the spring at: www.NASPAG.org.
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“Frontiers in Pediatric Hospital Medicine Symposium”
4th annual symposium
Sponsored by Pediatric Hospital Medicine Division
Physician Foundation at California Pacific Medical Center.
San Francisco, CA
The Grand Hyatt Hotel
October 8th and October 9th, 2009
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: oncologic emergencies, acute abdomen, imaging of the abdomen and chest, pediatric palliative care, and much, much more. 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: $ 200 for two days, $125 for one day, and $50 for residents/fellows
CME credit: 14 AMA PRA Category 1 credits
To register: go to our web site: www.cpmc.org/frontiers or contact Beverly Hoover at: 415-600-6484 or e-mail HooverB@sutterhealth.org.
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