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Chair’s Welcome
By Antoinette L. Laskey, MD, MPH, FAAP
Chair, Section on Young Physicians
Have you seen the new Young Physician’s Guide to the AAP? If not, what are you waiting for? The Section on Young Physicians has asked our members what they would like to see from us and we heard loud and clear. You wanted to know what the AAP has to offer people just starting out in their career. You wanted help connecting with your new Chapter when you moved to your new job. You asked for some guidance on how to make the transition from residency to the working world easier. We hope that this comprehensive guide helps with those needs. In our efforts to stay “green”, we have made the guide an interactive, online guide so we can keep the information as up to date as possible without having to have new ones printed and to make it accessible to you when you need it, where you need it: at your fingertips. Take a look; see what it has to offer you! Are there things you think we should add? Resources that you would like to know more about? Drop us a line. The Section on Young Physicians is about our members.
Are you making your travel plans for the 2008 NCE in Boston? This year promises to be full of activities suited to the YP. Friends of Children is hosting a 5K run/walk through the attractions of Bean Town. We have an exciting YP section program planned for Sunday. And following the AAP Presidential address, join us for our YP reception, Sunday, October 12, 7:00-8:00; Sheraton Boston Hotel- Liberty Room. Free food and exciting prizes and a chance to see your friends who are attending the NCE can’t be missed! And don’t forget, there is more family programming offered than ever before including a night at the Boston Library that will be sure to be a hit for everyone young and old alike. The AAP offers excellent CME programming for just about any pediatric interest; why not get all your CME needs met at a great meeting like the NCE? If you can’t make it this year, we won’t let you down for next; join us in Washington, DC on October 17-20, 2009.
Don’t forget, the Section on Young Physicians is in the connecting business. We want to connect you to the AAP so that you can get the most out of your membership. We want to help connect you to your colleagues across the country and in your area: don’t forget to register on YoungPeds Connection. We want to be your voice to the AAP so that the AAP brings you what you need at this point in your career. Have something on your mind? Drop us a line. From our home page, click on “AAP/YP Section”, then on “About SOYP” and then “Contact Your Section’s Leader”. We look forward to hearing from you!
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Editor's Note
By Graciela Wilcox, MD, FAAP
My kids love to remind me how “old” I am. (Luckily I’m still younger than many of my colleagues so I’ll take solace in that.) But I remember when I was a kid how I thought, “Wow, when I am old like my mom and dad I’ll know everything”. I find it amusing to look back to that and realize, daily, how much I still have to learn.
I admit, on a bad day I wish I just knew “it” all already. But most days I find it invigorating to have chosen a profession that offers regular challenges and learning opportunities. Regardless, in a profession such as ours in which we need to keep up with medical knowledge and work to deliver healthcare that best serves our patients’ needs, all while keeping a sense of personal perspective, I am thankful to have a strong professional organization like the AAP to support my efforts.
Being a part of the SOYP section makes the AAP even more relevant to me, and hopefully, to you as well. Dennis and I love to hear from you about patients that make you pause, or scramble to the literature or a more experienced colleague…or about those times in your personal life that somehow resonate with the professional…or about what really gets you going and how you went about getting “active” for change. Whatever you choose to write about, we learn from you and encourage you to keep the articles coming.
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AAP District Meetings
By Christina Vo, MD, FAAP
For almost one year now, the SOYP has had district representation at the level of the Executive Committee. Our executive committee members were invited to the district meetings held by the AAP over the summer. These meetings are held annually allowing the various chapters in the districts to come together with the executive committee of the national AAP (President Renee Jenkins, President-elect Dave Tayloe, and Executive Director Errol Alden). Local and district business are conducted and there is opportunity to socialize with chapter, district, and national leaders.
Young physicians had the opportunity to present at each of the district meetings. We showed the district leaders what our section has accomplished in the last year: district representation, young peds network, young peds connection , programming at the NCE scheduled for this fall, and the chapter guide to recruiting young physicians. We also discussed our goals for young physicians including recruitment, mentorship and leadership.
As many of you know, only about 80% of young physicians maintain their membership in the AAP. Recruitment is a major issue for all chapters and the national AAP. The SOYP offers recruitment and retention grants of up to $3000 to get young physicians involved in AAP activities. Talk to your chapter if you have ideas on getting young physicians involved in your area.
In terms of mentorship and leadership, Antoinette Laskey, our Executive Committee Chair presented to the Board of the AAP in May, and we relayed her presentation to the various districts. Although young physicians make up about 42% of national AAP membership, we only hold 11% of leadership positions. We asked that young physicians have a designated chair on each of the executive committees and chapter boards. We also asked that young physicians participate as speakers or co-speakers at the NCE and other conferences.
To learn more about what your district representatives spoke about and learned at the various district meetings, please select your district below. All power point presentations given during the meeting are also available on the AAP website. Don’t know what district you are in? Check the district page on young peds network.
| District II and VI |
June 5-8 |
Adam Vella and Bryan Wohlwend attended |
| District VII and X |
June 26-29 |
Nancy Harper and Cristina Pelaez attended |
| District IX |
July 17-20 |
Christina Vo attended |
| District I and IV |
August 7-10 |
Scott Shipman attended |
| District III |
August 21-24 |
Angela Allevi attended |
| District V and VIII |
September 11-14 |
Alexandra Cvijanovich attended |
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District IX Report
By Christina Vo, MD, FAAP
The District IX meeting was a success! We had excellent speakers including Anne Francis, MD, the chair of the Section on Administration and Practice Management (SOAPM) speaking on vaccine payment; Kelly Kelleher, MD speaking about the Mental Health toolkit; and Joe Dunn, CEO of the California Medical Association speaking about politics and how physicians can survive. Our district discussed the establishment of a foundation to help with grant funding and possibly with making some money for district activities in the future.
During the meeting, I gave a presentation on young physician involvement. Our district seems to be a little ahead of the game when it comes to young physicians. For example, ours is the only district who has made the SOYP Executive Committee member a voting member of the District Board; therefore, I have been participating in board meetings and decisions for the past year. In addition, every chapter in our district has a young physician at the chapter leadership level and every chapter has at least one committee chaired by a young physician. I offered the following as goals for all of California:
- Identify young physicians and young physician leaders in each chapter
- Work with the many residency programs to develop follow-up on where our residents go after training
- Continue to apply for chapter grants for recruitment and retention
- Invite young physicians to chapter and district events
- Try to specifically invite a young physician
- Develop educational programming specific to young physicians
- Develop a pool of young physician leaders
- Recruit chief residents
- Develop a young physicians' committee in each chapter
- E-mail me, Christina Vo your interest so that if a leadership opportunity comes up, I know what your interest is. For example, if there is a dental coalition, I would need to identify a young physician who might be interested in dental issues in children
- Increase young physicians' leadership roles to 30%
- Let ours be the first district to meet this goal as presented to the Board
Our district is unique in that we are only one state divided into four chapters (as opposed to each state being a chapter in a bigger district). As a single state, District IX represents AAP California in Sacramento. Here are some of the bills and upcoming ballot measures you should know about:
1. Children's Hospitals Bond Measure (Proposition 3 – Support)
Submitted by the California Children's Hospitals Association, this measure would establish The Children's Hospital Bond Act Fund, for which bonds (debt for the estate) in the amount of $980 million may be issued. The funds would be allocated in grants to children's hospitals in California, as defined, for projects of "constructing, expanding, remodeling, renovating, furnishing, equipping, financing or refinancing" the hospital. The District supports this proposition as it allocates dollars specifically for the care of children.
2. California Marriage Protection Act (Proposition 8 – Oppose)
Submitted by a coalition of groups and largely funded by "The National Organization for Marriage - California," which includes San Diego developer Terry Caster ($172,000), the San Diego-based hotel developer Manchester Financial Group ($125,000), and the Connecticut-based Knights of Columbus Headquarters ($250,000), a one-line initiative has qualified for the ballot this November:
"Only marriage between a man and a woman is valid or recognized in California."
The District opposes this proposition. The AAP-CA has clear policy supporting nondiscriminatory marriage, based on the multitude of rights conferred by the state to marriages that benefit the children in those families. That policy reads as follows:
"Respecting the Rights of the Child: The Need for Nondiscriminatory Civil Marriage"
Policy Statement of The American Academy of Pediatrics, California District
April 2005
The mission of the American Academy of Pediatrics, California District IX (AAP-CA) is to promote the health and well-being of all California's children. The physical growth, development, social and mental well-being of all children is supported by allowing parents a full range of parental legal rights, such as Social Security survivor benefits, health benefits for dependent children, and legally recognized consent for education and medical decisions. In order to protect and promote the best interests of the child, the AAP-CA supports equal access for all California children to the legal, financial and emotional protections of civil marriage for their parents, without discrimination based on family structure.
(*Note: this policy is specific to AAP-CA. The national AAP does not have an official policy on civil marriage.)
3. Parental Notification of Minor's Abortion: "Sarah's Law"(Proposition 4 – Oppose)
An initiative with the proposed title "Child and Teen Safety and Stop Predators Act: Sarah’s Law," has qualified for the November ballot. The initiative would require physicians to act as agents of the state in making the notification to parents of a minor's intent to have an abortion. If a physician performed an abortion without providing such notice, as defined, the physician would be liable for damages in a civil action brought by the minor, the parent, or a legal representative.
The District opposes this proposition. The AAP-CA has opposed similar initiatives in the past. While pediatricians clearly support communication with the parent about all significant health care decisions, including choices related to a pregnancy, this already occurs voluntarily in the vast majority of cases. A law is another matter altogether. There have been documented instances where the requirement for such notification has resulted in delayed, deferred or illegal abortions, creating a risk to the minor's health. Further, creating a new civil crime for which the physician is liable is not an appropriate structure for compliance with such regulations.
4. AB2580 Middle School Pertussis Requirement (State legislation – Support)
This bill would require the administration of the Tdap vaccine for middle school entry. The bill has stalled in the Senate Appropriations Committee (the money committee) because the committee looks at the $270,000 price tag of immunizing children with Tdap through Medi-Cal. AAP-CA is trying to educate the Appropriations Committee that the treatment of pertussis in infants runs a bill about 10 times that amount and that such a state mandate would reduce the number of deaths in infants from this disease.
Don’t forget to vote this November. Educate your families, friends, colleagues and perhaps your patients as well on these issues. Please feel free to contact me by e-mail at csvo@aap.net and please join YP Connection and sign up for the California group to get more of these legislative updates.
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District III Report
Quebec, Canada
August 21-24, 2008
By Angela Allevi, MD, FAAP
District III had a very productive meeting in beautiful Quebec City, Canada. The meeting focused on developing a strategic plan and balanced scorecard for the district, the first district to attempt to do so. Emphasis was placed on extending successful activities and endeavors that are happening at the chapter level to all those members in the district. One such program is the leadership conference in District III, which started in Maryland over a year ago. District III felt this to be such a worthwhile activity for future leaders in the district that it has decided to adopt this as an annual event in District III. Attendance is by invitation at the chapter level.
Much emphasis was placed on the importance of young physicians at the district level, and this sentiment was echoed by Dr. Renee Jenkins as well as the AAP Presidential candidates, Dr. Colleen Kraft and Dr. Judith Palfrey. District members in both state and programmatic updates (PROS, CATCH), discussed how the district could develop programs where a senior member or leader “partners” with a young physician to directly involve them in chapter or district activities, as a type of mentoring project. District leadership also supports the idea of having designated voting young physician member seats in each AAP section, council, and committee.
Over the last year District III leadership has initiated monthly conference calls with members of the resident section from District III. The District III resident coordinator said that they have a regular attendance of a handful of residents on the line at these monthly calls. District III leadership promised to continue monthly conference calls with the resident section and plans to initiate a similar monthly conference call with young physicians in the district, so that the leadership is in touch with the needs of residents as well as young physicians.
The 2009 District III/VII AAP meeting will be held June 25-28 in Philadelphia, PA.
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District II & VI Report
By J. Bryan Wohlwend, MD, FAAP & Adam Vella, MD, FAAP
This past June, Districts II and VI met in Minneapolis for a joint annual meeting. We were given the opportunity to represent the Section on Young Physicians (SOYP) for our districts and it was a great experience. It was exciting to hear everything that is happening in the chapters and to discuss and share ideas. We, along with the resident section, were given the opportunity to lead a discussion regarding young physician membership issues. The support we received from our districts was amazing! We also had the opportunity to hear both AAP presidential candidates speak and answer questions regarding young physician issues. The joint sessions also provided the opportunity to learn about quality improvement initiatives and to discuss the Healthy People 2010 agenda for 2009 which will focus on immunizations.
There is a lot happening in District VI. Iowa and Illinois won the outstanding chapter awards. Several chapters have been working diligently on oral health initiatives including Nebraska, Kansas, and Iowa. North Dakota announced that they had received a grant on medical homes. Wisconsin discussed the outcomes of their young physician CME meeting. Missouri has created a pediatric council and is working on a lot of other initiatives. Kansas announced that they had met their challenge grant for their “Turn a Page, Touch a Mind” initiative. Those are just a few of the exciting programs and announcements from District VI.
District II has also been busy. New York chapter 3 won the outstanding chapter award and have ongoing projects regarding immunizations, foster care, mental health and advocacy. New York chapter 1 is hard at work on tobacco control issues. Chapter 2 created two new committees on family violence and information technology. They also held seminars entitled “Secrets to CPT Coding” last spring. District II has been very active.
Overall it was a great meeting. It was very exciting to witness the support our district leadership has for young physicians. In addition, both districts remain legislatively active on both a local and national level. We encourage you to also make your voice heard and vote in the ongoing AAP (and national) elections.
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2008 Annual Meeting of the AMA House of Delegates
By Lloyd D. Fisher, MD, FAAP
Delegate from the AAP-YPS to the AMA-YPS
The American Medical Association House of Delegates (HOD) met in Chicago from June 14 through June 18th to debate hundreds of resolutions and reports affecting the practice of medicine. As your AMA-YPS delegate I attended the Young Physicians Assembly where YPS members representing every state and specialty meet the day prior to the HOD meeting to discuss issues specific to young physicians and also instruct the YPS delegate to the HOD how to vote on all of the resolutions. Below is a summary of just a few of the resolutions that were discussed. For complete details of the meeting and text of all of the resolutions
Click Here.
Industry Support of Medical Education - The AMA Council on Ethical and Judicial Affairs (CEJA) submitted a very controversial report which would essentially ban all industry involvement and support for any educational activity. While this may seem like an admirable proposal, there are many possible unintended consequences. Industry is a significant contributor to CME activities, which presently have no other mechanism of funding. In addition it is unclear how the CEJA proposal would affect research funding for academic institutions. Currently there are very strict guidelines by which all CME accredited activates must abide, whether they are supported by industry or not. There was a concern raised that without industry money being channeled into regulated CME activities, such money would go towards promotional activities that are far less regulated and may be more biased. Perhaps these guidelines need to be looked at and revised, but to universally ban all industry involvement in medical education was thought to be short-sighted by the House, who thought that the guidelines ignored the large and important role that for-profit corporations do play in health care. The House therefore decided to refer the report back to CEJA for further consideration and revisions. For an interesting editorial on this issue Click Here where Thomas P. Stossel, MD, physician with Harvard Medical School, shares his views.
Improving Parental Leave Policies for Residents and Fellows - This resolution aims to assist residents and fellows who have children during their training. Currently there is wide variation in how training programs handle maternity leave. The resolution, which did pass the house, asks that the ACGME require programs to grant 6 weeks of paid leave and allow an additional 6 weeks of unpaid leave. In addition, the resolution asks the ABMS to not extend the time required for certification if residents take parental leave. This is already consistent with current AAP policy which recommends 2 months of paid leave for residents with no loss in training status.
Smoking in Movies - This resolution, submitted by the AAP, asks that the AMA support a campaign to encourage the movie industry to automatically assign an R rating to any movie in which an actor smokes. Positive debate on this resolution was nearly unanimous and it easily passed.
Abstinence-only Education - This resolution attempted to ban any state or federal mandates for funding of abstinence-only sex education programs. Debate on this resolution was quite mixed with some delegates highlighting the lack of evidence for effectiveness of this type of sex-education program, while others felt there was good evidence to support the benefit of abstinence-only education. Ultimately the resolution was referred back for further study and clarification of existing data. The AMA already does have a policy supporting comprehensive family life education in lieu of abstinence-only education.
Consent for HPV Vaccination by Minors – Since policy already exists in support of legislation allowing girls 12-17 to consent for HPV vaccination on their own, this resolution was reaffirmed.
Reporting of Suspected Intentional Trauma - This resolution asks the AMA to support “comprehensive reporting and investigation of all cases of reasonably suspected child abuse.” In addition it supports the creation of a curriculum for medical students and residents on the topic. While on the surface this seems like an important resolution that should have been supported, the AAP delegation actually was opposed to it as written and was successful in its attempt to have this resolution referred back for further input. The delegation felt that it was in conflict with the AAP stance on de emphasizing reporting and improving coordination between multiple agencies. As the results of a PROS study on this issue were forthcoming in Pediatrics at the time of the meeting, the resolution was referred to the Board of Trustees for further consideration after the Pediatrics article was published. The article was an E-article published with the August, 2008 issue of Pediatrics.
Electronic Prescribing – There were three different resolutions that dealt with this very complex topic. What eventually passed after these three resolutions were combined is policy advocating that the Centers for Medicare and Medicaid Services and state Medicaid directors eliminate the barriers that currently exist to electronic prescribing (i.e. requirement that physicians write in their own handwriting, “brand medically necessary”) and that the DEA allow prescribing of schedule II drugs to be done electronically. In addition, payments to physicians for non-adoption should not be reduced, but rather there should be financial incentives to use e-prescribing.
CFC Inhalers – This resolution, which was not adopted, asks for an extension on the phase-out period of CFC inhalers until the current supply runs out. The House felt that the three year warning period was adequate. In addition, a representative from the DEA testified that they do not have the authority to change the date as it is an Environmental Protection Agency mandate and any alteration would violate both federal regulations and an international treaty.
Vaccines for Parents of High-risk Infants. - A successfully passed resolution, it asks that the AMA advocate to NICUs and newborn nurseries to make vaccines for influenza and pertussis available to parents of newborns younger than six months of age.
If you would like more information on this meeting or about AMA-HOD meetings in general, feel free to contact me at lfisher@massmed.org.
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Young Physicians and Continuing Medical Education
By J. Bryan Wohlwend, MD, FAAP
Young physicians may have interesting dilemmas when it comes to continuing medical education. The costs of attending a live CME event can be prohibitive. It can be difficult to take time off while starting a new practice, not to mention the additional time spent away from family. Live CME events may not offer topics that address the unique interests of YPs. Many of us now obtain our CME online or through journals. Unfortunately, by not attending live CME events, we are missing out on peer-to-peer interaction and networking. These interpersonal interactions can be invaluable to our careers, even in this increasingly digital age of email, listservs, blogs, and podcasts.
The Section on Young Physician (SOYP) has recognized these trends and is constantly exploring new and innovative CME options that specifically target young physicians. For instance, at the National Conference and Exhibition (NCE) this October in Boston there will be an entire educational program for young physicians. This year the topic is leadership. The program will help train us to be better leaders both in our practice and in our community. Our hope is to continue to promote YP specific content at these national conferences so that we can get “more bang for our buck”. Leadership 101: What They Forgot To Teach You In Residency, Sunday, October 12, 9:00am - 4:00pm; Sheraton Boston Hotel - Liberty Room.
Many local chapters are also working to address these concerns and are starting to offer CME activities designed specifically for young physicians! The programs present unique topics of direct relevance to physicians early in their careers. General topics have included work-life balances, coding and billing, advocacy and leadership. Often these courses are close to home which helps reduce costs and makes it easier for families to come along. Some conferences have built in time for mentoring and networking as well.
One recent example is “Not Your Dad’s CME”, a young physician CME conference hosted by the Wisconsin AAP chapter. Held in April of 2008, the conference had topics including, but not limited to, leadership, the art of negotiation, ensuring quality in practice, advocacy and re certification. They offered break-out sessions regarding obesity, mental health, autism, oral health and more. There was time for networking and it provided a great opportunity to meet current and future AAP leaders. Those who attended found it very valuable and the feedback was so good that the SOYP decided to adapt it to use as a template for the 2009 NCE curriculum. As another example, the Florida Pediatric Society just hosted “Pediatrics of Tomorrow”, a CME event targeting young physicians. Topics included work-life balance, advocacy, medical home, vaccines and more. It was be a valuable, and inexpensive, resource for Florida young physicians.
There are certainly many other chapters that have hosted or are exploring young physician CME events. I highly encourage everyone to contact their local chapter and/or YP representative to find out what they are offering. You can find your contact person in the new “Young Physician’s Guide to the AAP” located on the YoungPeds Network. If nothing is being planned, perhaps you could even be the spark that gets it started! It is certainly exciting to see more and more events geared towards the young physician. It is a testament to us as a section that our voices are being heard. Keep up the good work!
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Lessons From A Muzungu
By Michelle Fiscus, MD, FAAP
As if turning 40 isn't bad enough in its own right, it’s also marked by your official "graduation" from the SOYP. And perhaps that's one of the things that spurred my need to do something different this year. Something a little "out of my comfort zone". So, to mark this momentous occasion, I spent one of my final SOYP months in East Africa (Tanzania, specifically). I’d had the opportunity to spend 3 months of my pediatric residency in Eldoret, Kenya and have spent the last 12 years intermittently regretting passing up on that chance. So, when the opportunity came up to accompany a few friends on a mission trip to a remote area of Tanzania, I jumped. The decision was made 18 months before the trip. It wasn't until several months later that the thought occurred to me that I might be in a little over my head. After all, I'd be leaving my little two-doctor practice for a month, not to mention my 4 and 6 year old children and my husband. What do you tell a little kid when you're planning a trip away for that long? I decided "not much". Talk about Africa. Take me to the airport. Say "goodbye" (without tears preferably) and give a big hug when you get back (and presents).
I tried to avoid speculation as to what this experience would be like, but I certainly had the thought that I was going to rescue this country's people. The reality was far from that vision. What I found there was a welcoming village whose people were doing just fine for the most part. They have needs, of course, and plenty of them. But there lacked the misery I thought I'd find there. My team and I were hosted by the remote village of Pommern in the south-central part of the country. This village supports a secondary school (run by the Lutheran church) with over 900 boarding students ranging in age from 15-28 or so, all hoping for a chance at attending a university. The school has a solar powered computer lab (but a mouse is hard to come by). They teach chemistry, physics, English literature, and world history, among other subjects. They have a greater understanding of American politics than I do (and, by the way, they support Barack Obama). These students held a debate on "The Globalization and Privatization of Africa" and asked us to participate. When they found out I was from Tennessee they asked about the Tennessee Valley Authority because they have to know about it for their national examination. I couldn't tell you about the TVA and I LIVE here. These students are intelligent, social, well-spoken young adults and should be the pride of their country.
I worked with Dr. Godlove (yes, that's his real name) in his community health center. Dr. Godlove is a medical technician of sorts but does a darn good job of taking care of his community and is probably the most respected man in the village. He does remarkable work, given his limited supplies. He spent a day and a half showing me the ropes--"Give the patient a little piece of paper with their number from the register on it. Write your SOAP note on this scrap of paper. Treat everything you see with Bactrim or Cipro or Flagyl..." And so it went. The following morning he came to the mission house to tell me he was going to a funeral and would be back in a few days. I was left in charge of a third-world health center where I didn't speak the language and didn't understand most of the diseases. He was gone for a week.
The first morning on my own I was greeted by the padlocks on the clinic doors. It would seem that the female medical technicians were a little resentful of the "muzungu" (translation: "crazy white person who wanders around aimlessly", I think) woman who was left in charge. So they took their ball and went home. No translator. No drugs or supplies. A line of Swahili-speaking villagers who had walked God-knows-how-long to receive health care that day. I was helpless. I grabbed some of my fellow teammates and we decided we'd break down the door of the supply room and find our own translator when one of the techs wandered back. She was just in time to help me stitch a gaping wound on the forehead of a 6-year-old girl who had fallen on a stick. When I told her of my difficulties without her she replied "Pole, doctor". (I'm told that means "sorry", but I'm not so sure). I thought my handiwork might have won me some respect, but when I went to use the restroom after I was finished with the patient she was gone again--padlocks back on the doors. It was about that time that a teacher from the school came to ask about the condition of the unconscious student who had been in the ward since the night before. "Student?!? WHAT STUDENT?" No-one had bothered to tell be about the student who happened to be unconscious in the ward! He ended up being a psychiatric patient who was actually more "catatonic" than "unconscious", but he was the last straw on this camel's back. I told the teacher that if I didn't get some support from the clinic staff I would go to the school and teach English. It seems that the threat of losing the only trained medical person in the village until Dr. Godlove returned got some response and the techs begrudgingly returned to assist me.
The rest of the week went fairly smoothly (considering my circumstances), although I was definitely practicing out of my area of comfort. I saw all-comers--babies, children, adults, the elderly. I treated the "top ten" of Tanzanian disease--malaria, intestinal parasites, acute respiratory infection, ear infection, pneumonia, gastroenteritis, AIDS, pharyngitis, trauma, and dental caries. I saw the ill-effects of Bamboo juice--the local brew. That stuff will make you try to stab your relative to death and then allow you to walk the 25 kilometers to the nearest clinic with him to make sure he's going to be alright. I taught family planning and HIV prevention over and over and over again. I tried to dispel myths where I could ("Please don't cut your face to let the evil humors out"). What I found among the villagers there was a grateful population who was amazingly accepting of this muzungu in their midst and trusted me with their lives. They are a stoic people. They never complain. I saw a woman in the clinic who walked 5 kilometers to see me with a broken hip. How do you do THAT? And how frustrating it must be to have arthritis and only be able to receive a 5 days supply of Motrin for your chronic discomfort. Still hurting? Come back again next week for more.
So what were the lessons I learned? I'm happy to share:
- Be grateful for what you have, for many are happy with much less.
- Appreciate the beauty and convenience of (clean) running water.
- You can treat most infectious diseases with only 2 or 3 drugs
if you have to.
- People can tolerate an incredible amount of pain (but shouldn't have to).
- Shoes are critical to good health
- We rely too much on expensive test to practice the medicine we're more than capable of practicing with our minds and hands alone.
- The gift of a live chicken feels better than an MCO payment.
- We can give assistance to developing communities without dictating how things must be done.
- Turning 40 may be the best idea I've had yet.
- I'll miss my involvement in SOYP but there's a great big AAP world out there to explore.
- Get outside your comfort zone. You'll be glad you did.
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| Dr. Fiscus outside the clinic in Tanzania |
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Village girls giggling at getting their picture taken
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Look Out For Lookalikes: Criteria For Defining True Health Care Reform?
By Robert Zarr, MD, MPH, FAAP
Advocates of genuine, fundamental health care reform in the United States always have to be on their toes, particularly during an election year. Why? Because while many politicians and advocacy groups call for health care reform, and some even call for “universal health care,” not everyone interprets those words in the same way.
Case in point: A coalition called Health Care for America Now (HCAN), made up of groups like the AFL-CIO, MoveOn.org , and the Service Employees International Union®, recently announced its formation by calling for “a truly inclusive and accessible health care system in which no one is left out.” HCAN also called for everyone to have “a choice of a private insurance plan, including keeping the insurance you have if you like it, or a public insurance plan without a private insurer middleman that guarantees affordable coverage.”
Such an approach sounds reasonable to the average listener, no doubt. But advocates of genuine health reform understand that the for-profit, private insurance industry is precisely the source of our problems in U.S. health care. Our dysfunctional patchwork of over 1,200 health insurance companies, with their drive to maximize shareholder profits, their high marketing and other overhead expenses, and their exorbitant executive salaries, now consume about 31 cents of every health care dollar. No other country in the world spends as much as the US on administrative waste, and yet the WHO report card ranks the US 37th out of 191 countries for performance.
Insurance companies increase their profits by enrolling the healthy, screening out the sick, and denying claims. They are the very opposite of what insurance was originally intended to do – to protect the health and financial security of its members. So advocates of real reform can rightly ask: How is it that a group that promotes “universal health care” insists on keeping the wasteful private insurance industry at the center of our system?
For over 20 years, Physicians for a National Health Program an organization with 15,000 members, has been advocating what it believes to be the only truly universal, comprehensive health care plan: single-payer national health insurance. A single-payer plan would involve establishing a nonprofit, publicly financed system of paying for care, leaving the delivery in the hands of private docs. Single payer means free choice of providers, no premiums, and no co-pays. Single payer means that doctors and other health professionals get paid in timely fashion after submitting their bills. Single payer means global budgets for hospitals, nursing homes and other providers. Single payer means negotiating lower prices for pharmaceuticals, and finally being in a position to control costs.
A single payer plan would be financed by a small payroll and income tax, much like Medicare is financed today. A bill in Congress, the U.S. National Insurance Act (also known as the Expanded and Improved Medicare for All Act), H.R. 676, would do just that. Sponsored by Rep. John Conyers (D-Mich.), the bill now enjoys the support of over 91 members of the House, more than any other reform proposal.
WE CAN DO THIS TODAY! Taiwan was the most recent country to adopt a single payer financed health care. Since 1995, coverage has increased from 57 to 98 percent of their population, life expectancy has improved, and their total health care costs have been controlled, staying at 5 to 6 percent of the GDP (1). In contrast, the U.S. now spends 16 percent of our GDP on health care. That’s almost twice the average of 30 of the world’s richest countries. America cannot sustain these high rates for much longer while insurance companies continue to reap billions in profits. It is especially important that health care reform is on the national agenda for election year 2008, to distinguish real reform from placebo. We can’t afford to squander this opportunity for real change.
· How do we distinguish real reform from placebo?
The plan must provide health care coverage for all Americans, not just the healthy and wealthy.
· Is the coverage comprehensive?
Health insurance must provide financial security in times of illness. HR 676, when it’s passed into law, will guarantee comprehensive coverage for everyone, including all medically necessary services including mental health care, dental care, vision, maternal care, end of life care, prescription drugs, medical equipment, hospital stays, and more.
· Will the coverage be affordable to families and individuals and sustainable for the country?
U.S. health care costs have consistently increased faster than both the rate of inflation and growth in the minimum wage. This is largely due to the expense of keeping up our fragmented, for-profit health insurance system. HR 676 will remove these inefficiencies and save an estimated $350 billion in administrative waste. That would be more than enough to cover all of the uninsured and provide better care.
Incremental reform is a placebo. The only way to solve our health care crisis is by eliminating the private for-profit insurance companies. A recent poll showed 82% of Americans think the “U.S. healthcare system should be fundamentally changed or completely rebuilt.” Single payer, HR 676. Expanded and Improved Medicare For All, is the cure we need.
1. Karen Davis & Andrew T Huang. Learning from Taiwan: Experience with Universal Health Insurance. Annals of Internal Medicine. Feb 08, Vol 148 (4)
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What Really Counts As A Good Doctor?
By Christopher Romero, MD
It is Saturday evening as I settle my restless children down at the dinner table and I hope to partake in the meal while it is still somewhat warm. Then I hear the “beep” and my post-residency trained reflex places my hand at my hip; however, I soon remember I do not have the on-call pager tonight. Instead, I gently pull an insulin pump from my belt that is beeping to remind me to check my blood sugar.
I am not, in fact, a diabetic, but rather a third year pediatric endocrinology fellow who was given the opportunity by one of the pharmaceutical reps to use one of their insulin pump models over the weekend. It is a chance to briefly experience what my patients do every day. A saline solution acting as a basal rate is slowly pumping through a small catheter inserted into my belly, and I need to decide hypothetically how much more insulin I would require for my dinner. I reach for the glucometer bag, pull out the necessary supplies and check my blood sugar. I briefly reminisce on the statement I have heard a few times during my training, “don’t worry, you will get used to the finger pokes”; however, I am feeling no tickle as a tiny piercing bite jolts in my already raw fingers. And, of course, without hesitation or anxiety, I read on the meter the number 92. I look at my plate and realize I have a small challenge--carbohydrate counting! Did I serve myself two spoons of rice, or three? Will I have a slice of bread with dinner? Will I drink a glass of milk, or just water? I make my decisions and with one hand instructing the kids to continue eating, I use the other to dial a bolus of saline to mimic carbohydrate coverage. I package up my supplies, clip on the pump, tuck the tubing under my waistband (ouch! I feel a tug at the insertion site on my belly), and realize my dinner is now cold.
The “inconveniences” I experienced over that weekend are the unfortunate realities of what my diabetic patients face multiple times a day. They are part of the ritual we strictly enforce to maintain good diabetes care, but we often forget the chaotic and unpredictable path required to achieve the goal. Of course, as pediatricians we instinctively recognize children are all too often unpredictable by nature and perhaps that is where the true challenge lies as we strive for “good” diabetes care. My one weekend with an insulin pump provided me invaluable insight that no diabetes clinic could offer a trainee.
As a fellow, you are trained to calculate the proper insulin doses and, with honest intentions, repeatedly provide relentless mantras to patients such as “check more blood sugars” or “learn to carb-count better”. It is frustrating to hear parents who state they follow your instructions, only to see a hemoglobin A1C of 8.5. Each family offers its own unique situations and challenges. I faced some of those challenges this weekend, and I could not help think of how many times I may have not taken sufficient time to reflect and discuss my family’s own challenges in clinic. The breadth of child development makes parenting a challenge in itself, but now factor in a chronic illness that forces you to bleed yourself countless times each day, think twice about biting into another cookie, and finally, to muster the courage to inject yourself at least twice a day (or more) just to “stay healthy”. I wonder how often a parent of a diabetic child enjoys a peaceful hot dinner each week.
That weekend did not provide me with all the answers to keep all my diabetics’ hemoglobin A1C’s below 8, but it did make me appreciate on a different level the real challenge of forming appropriate partnerships with families that can help establish a foundation toward achieving good health. Many have told me “pediatricians who are parents make better doctors”. Perhaps I believe there is some truth in such a saying, as I have struggled with the public display of titanic tantrums and battled the iron-gate attitude of a three-year-old protest to eat. Outside of personal experience, however, I do believe there is something more important that can makes any pediatrician effective and connected with families. It is one of the fundamental principles presented to us in those first few years of medical school: take the time to listen and use what you see and hear to form the right questions.
My weekend on the insulin pump has reinforced to me once again that there is so much more to diabetes care than calculating insulin doses and clearing ketones. Most importantly, I recognize that as a member of a diabetic team I must learn to appreciate the possible challenges each family may face day to day, and with this awareness provide appropriate medical direction for the care of their child. In truth, these words of advice probably apply to any pediatric provider who cares for children with a chronic illness. This challenge is perhaps one of the main reasons I chose pediatrics and is a motivation to make myself a better doctor each day. Diabetes in a growing child seems to present endless challenges to families and providers; I marvel at how any parent is able to achieve any good blood sugars on a consistent basis. When I returned the pump the following Monday, I took a moment to be thankful for two things: I can rely on my own pancreas to do its job (much better than I), and the opportunity to provide myself with insight on what really “counts” to be a good doctor.
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Common Office Procedures: Get Paid For What You DO!
By Jill Stoller, MD, FAAP
Membership Chairperson
Section on Administration and Practice Management (SOAPM)
While it is true that Pediatrics is predominantly a cognitive specialty, there are several procedures that are commonly performed that can add significantly to the financial status of the practice. It is essential that the practice’s billing encounter form (“superbill”) have procedures listed, that the doctors remember to document performing these procedures in the medical chart, and that the billing staff knows the proper way to submit them to insurers for payment. If a procedure is performed as a service done in addition to an Evaluation and Management Service (sick or well visit) then the –25 modifier should be appended to the E/M code. You may be more likely to be paid for the procedure if a –59 modifier is appended to the procedure’s CPT code. A –59 modifier is used to signify that a distinct procedural service was performed. Below I list the common procedures performed in pediatric offices.
- Bladder catheterization (CPT 51701, RVU = 2.12). This procedure is commonly performed during the work-up of a febrile child under the age of 3 years.
- Wart removal (CPT code 17110). This CPT code signifies removal of up to 14 benign skin lesions via cryosurgery, chemosurgery or curettage)
- Removal of foreign body from ear without use of anesthesia (CPT code 69200) or foreign body removal from nose (CPT code 30300)
- Closed reduction of subluxed radial head (CPT code 26460, RVU = 3.17)
- Incision and drainage of skin abscess (CPT code 10060)
- Removal of foreign body from subcutaneous tissue, simple (CPT code 10120); Removal of foreign body from subcutaneous tissue of foot (CPT code 28190)
- Closed treatment of finger fracture - evaluation and splinting (CPT code 26750, RVU = 4.41)
- Treatment of second-degree burn with debridement and/or appropriate dressing (CPT code 16020)
Remembering to appropriately code the procedures that we provide to our patients will enhance practice revenue. Code and submit claims correctly and GET PAID FOR WHAT YOU PERFORM!
To learn more about practice management become a member of SOAPM.
For more information e-mail Heather Fitzpatrick at hfitzpatrick@aap.org
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Caught in the Crossfire? Re-thinking Youth Gun Violence
By Danica Liberman, MD
Dear parents of “Acute X,”
My name is Dr. Liberman. I took care of your son in the emergency department on September 17th, 2007. I wish I had a chance to know him. I never knew your son’s name nor heard his voice, but I want you to know that he changed the way I look at the world and the way I look at my role as a physician. On September 17th, I was working a shift at Children’s National Medical Center when I took a call from Emergency Medical Services. The paramedic team was several miles away from the hospital with a 14 year-old male who had sustained a gunshot wound to the head. Five minutes later, we were actively resuscitating him in our trauma bay. Two hours after that, the ICU team pronounced him dead.
Over the following week more pieces of the story surfaced by way of the media, my colleagues, and your family. He was a kid who had begun hanging out with the wrong crowd, breaking curfew, and skipping class, though never previously arrested or officially tied to any violent acts. On this particular night he had stolen a cop’s motorbike. When the cop found him riding the motorbike, a chase ensued, shots were fired by both sides, and your son was hit. He was in the wrong place, at the wrong time, doing the wrong thing. What happened to your son, though, was not random. Many factors, failures really, got him to where he was that night. How did he get there and why are there thousands of other kids on a similar path towards self-destruction?
Youth violence, including gun violence, is a problem we cannot ignore. The United States of America holds the tragic indignity of the highest rates of youth homicide and suicide among the 26 wealthiest nations in the world. U.S. teenagers are now more likely to die of gunshot wounds than all natural causes combined, , with one out of every four deaths in 15 to 19 year olds attributable to firearms. Gun violence among youth is a subcategory of youth violence in general and the research and public health interventions rarely distinguish between the two. With increased urgency, government and advocacy organizations are tackling the problem of youth violence. We are studying the factors that cause, permit, and perpetuate youth violence, with the ultimate goal of creating effective programs aimed at prevention, intervention, and rehabilitation. As a pediatrician I believe that prevention, if possible, is preferred over intervention or rehabilitation. This was so vividly reinforced when I met your son. Unfortunately, sometimes an opportunity at prevention is the only opportunity we get, and at the point of intervention or rehabilitation it is already too late.
Rehabilitation
During the decade between 1983 and 1993 youth violence in the United States was at record levels, causing the public to speak ominously of a nation under siege by a new generation of “superpredators.” In response, the government, both federal and state, attempted to tighten control over young people with passage of new gun control legislation, interest in alternative military-type schools, and movement of youth offenders out of the juvenile system and into adult criminal courts. The reported incidence of youth violence has decreased since its peak in 1993, largely as a result of diminished access to guns and therefore a fall in the lethality and visibility of crimes committed. Trying kids in adult court and forcing youth into alternative schools has only made matters worse. A growing body of evidence shows that youth transferred to adult criminal court have significantly higher rates of reoffending and a greater likelihood of committing subsequent felonies than youth who remain in the juvenile justice system. Other programs born of the fear generated in the 80s and 90s, such as boot camps, temporary residential programs with milieu treatment and behavioral token rewards, and “shock” programs are proving to be equally ineffective when studied methodically.
What, then, comprises a sound tertiary prevention program with the highest chance at successful rehabilitation? Previously, many argued that rehabilitating youth offenders was not possible and that they were a lost cause. Presently, however, we are beginning to realize that that is, in fact, not the case and that many of these violent youth can escape a future of destruction and crime. Recent meta-analyses reviewing existing tertiary prevention programs for violent youth conclude that comprehensive interventions with a multimodal approach, including skills training, behavioral modification, and family participation are significantly more effective than one-dimensional and unstructured programs.
Even with universal access for every youth in the justice system to the most powerful and successful rehabilitation programs, we would still come up short purely based on the capture rate. Data on youth violence is collected in two primary fashions: official reports and self-reports. When we look at data sources such as arrest reports, hospital emergency department encounters, and victimization rates we see a steady decline in youth violence following the epidemic peak in 1993.7, However, according to several national research surveys asking youths to report on their own behavior, for every youth arrested in any given year in the late 1990s, at least 10 were engaged in some form of violent behavior that could have seriously injured or killed another person. The vast majority of violent acts committed by youth are never reported, and of those reported, fewer than half will result in an arrest. If we cannot effectively identify those youth perpetrating violent acts, how can we rehabilitate them? It would be inadequate to rely heavily on youth violence rehabilitation programs, thereby missing the vast majority of violent youth.
Intervention
Over the past several decades, researchers have looked critically at youth violence to elucidate factors that make some people more vulnerable to violence. Broadly stated, risk factors for youth violence can be divided into four primary categories: individual, family, peer/social, and community. Each category contains a long list of different risk factors, with several overarching themes: poor social interaction and social rejection, limited family involvement, poor academic interest and success, and community level disorganization. Some risk factors identified are difficult or even impossible to adjust, such as IQ and parental education level; while others, like involvement with drugs and low commitment to school can be deliberately targeted and modified using specific intervention programs. Although risk factors are not necessarily causes of youth violence, it is possible to use this information to identify and refer children at risk as well as to design well-timed and effective intervention programs.
Hundreds of programs already exist, and we are only now realizing, after rigorous and methodical review, the dramatic variability in these programs’ success. Some of the more effective interventions include: comprehensive school-based programs aimed at improving social and problem-solving skills, family training programs to aid with parenting skills and family communication, and behavior modification programs using techniques of positive reinforcement and classroom management. Unfortunately, many of the programs currently funded and supported have proven ineffective. Peer-led interventions, such as peer counseling simply do not work to decrease youth violence and related risk factors, particularly when compared with similar adult-led programs. Similarly, nonpromotion to succeeding grades appears to exacerbate rejection by peers and low academic commitment. Even DARE, the most widely implemented youth drug prevention program in the nation, fails to decrease rates of drug use among students who have participated when compared to those who have not. These ineffective programs not only feed us a false sense of accomplishment, but also consume resources that can and should be used for programs that work. There was a time, several decades in the past, when implementation of youth violence intervention programs was occurring concurrently with acquisition of evaluation research, forcing us to create programs based on what we thought would work. Now, however, with quantitative data and sound research, we have a clearer idea of what works—and what does not work, and should redirect our energies.
Prevention
While the study of risk factors is relatively mature, research into the flip side—protective factors, remains in its infancy. What happens when we ask, what are the protective factors preventing kids from getting involved in youth violence? What if we could prevent the risk factors? To fairly and most sensibly address the problem of youth violence we must widen our focus to include not only the identification of risk factors and creation of intervention programs, but also the identification of protective factors and creation of prevention programs. Protective factors include aspects of an individual’s life and environment that mitigate the effect of risk. At present, we have only preliminary research of possible protective factors against youth violence. Researchers have used protective factor data gleaned from youth antisocial behavior work to evaluate possible protective factors against youth violence.
As with risk factors, protective factors can be divided into several broad categories: individual, family, school, and peer group. To date, the only two protective factors that have shown statistical significance in preliminary studies are an intolerant attitude toward deviance and a commitment to school. Identifying and understanding how protective factors buffer the risk of youth violence is as important to preventing and alleviating violence as is identifying and understanding risk factors.
Recommendation
There is no easy solution to the problem of youth violence in our country. A successful strategy must be multifactorial, generalizable, evidence based, and cost-effective. A three-pronged approach of prevention, intervention, and rehabilitation developed through sound research would be able to tackle the problem at each stage in its development. Emphasis should be placed on the front end by enhancing protective factors and reducing risk factors. Rehabilitative efforts would then be reserved for those who failed prevention and intervention.
As a young physician, I spend most of my work day taking care of individual patients and their families. It is important that I ask my patients and their families about access to guns and exposure to gun violence. I have found that this subject rarely comes up during the course of a patient encounter unless I specifically bring it up. When I identify those who are struggling with school or drugs, I must realize that this may heighten their risk of involvement with youth violence. It is crucial to empower my patients and their families to make positive changes to modifiable risk factors while concurrently reinforcing preventative factors. At the community level it is possible to affect change in youth violence through involvement with and support of local youth programs that encourage safe after-school activities. Most communities have youth injury research and prevention programs, many of which are organized through hospital-based programs. At the hospital where I work we have an Injury Research Committee, a Child Health Advocacy Institute that works on injury and violence prevention, and several experts in the field of youth violence. Finally, at the national level and for those with a dedicated interest in violence prevention a great place to start is with the American Academy of Pediatrics Committee on Injury, Violence, and Poisoning Prevention. A quick review of their policy statement on the National AAP website provides a glimpse into the magnitude of the problem of youth violence and the ideas the academy has to combat this problem.
In retrospect, there were many warning signs for your son—school failure, truancy, a troubled social network—that strongly hinted at potential involvement in high risk behavior and violence. As we continue to better understand the role of protective factors and warning signs for kids at risk, hopefully we can prevent other children from being in the wrong place, at the wrong time, doing the wrong things. Intelligently crafted, evidence-based prevention, intervention, and rehabilitation programs have the power to make a positive difference in our country’s epidemic of youth violence.
Sincerely,
Dr. Liberman
References:
Keith Alexander, “I Failed Him. I Failed My Baby,” Washington Post, 27 September 2007, page A01. accessed 7 March 2008. http://www.washingtonpost.com.
Task Force on Violence. “The Role of the Pediatrician in Youth Violence Prevention in Clinical Practice and at the Community Level.” Pediatrics 103 (January 1999): 173-181.
Committee on Injury and Poison Prevention. “Firearm-Related Injuries Affecting the Pediatric Population.” Pediatrics 105 (April 2000): 888-894.
Shay Bilchik, ed. “Reducing Youth Gun Violence: An Overview of Programs and Initiatives.” Office of Juvenile Justice and Delinquency Prevention. May 1996.
Fagan J. “Policing Guns and Youth Violence.” Future Child 12 (Summer-Fall 2002): 132-151.
“The Changing Borders of Juvenile Justice: Transfer of Adolescents to the Adult Criminal Court.” Macarthur Foundation Research Network on Adolescent Development and Juvenile Justice. accessed 7 March 2008. http://www.macfound.org/atf/cf/%7BB0386CE3-8B29-4162-8098-E466FB856794%7D/ADJJTRANSFER.PDF.
“Youth Violence: A Report of the Surgeon General.” United States Department of Health and Human Services. January 2001. accessed 7 March 2008. http://www.surgeongeneral.gov/library/youthviolence/youvioreport.htm.
National Youth Risk Behavior Survey, 1991-2005. Centers for Disease Control. accessed 7 March 2008.
http://www.cdc.gov/HealthyYouth/yrbs/pdf/trends/2005_YRBS_Violence.pdf.
“Youth Violence Prevention Scientific Information: Risk and Protective Factors.” Centers for Disease Control. accessed 7 March 2008. http://www.cdc.gov.
Bolland JM et al. “Hopelessness and Violence Among Inner-City Youths.” Maternal Child Health 5 (December 2001): 237-244.
D.C. Gottfredson et al. “Preventing Crime: What works, what doesn’t, what’s promising: A report to the United States Congress.” U.S. Department of Justice, Office of Justice Programs. 1997. 125-182.
MD Resnick, M Ireland, and I Borowsky. “Youth violence perpetration: what protects? What predicts? Findings from the National Longitudinal Study of Adolescent Health.” Journal of Adolescent Health 35 (November 2004): 424.e1-10.
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| Clinical Experience and Pearls |
An Uncommon Cause of Dysuria in a Teenager
By Alexandra Cvijanovich, MD, FAAP
Last year, I saw a fifteen-year-old female in my office, three times for dysuria, urgency, and urinary frequency. She was consistently afebrile and denied costovertebral tenderness, and when questioned alone, denied sexual activity. Her physical exam was significant only for suprapubic tenderness; her urinalyses were significant for 1+ leukocytes and microscopic hematuria with negative cultures. Finally, at the third visit, the patient admitted to being sexually active. She denied dyspareunia and vaginal discharge, and she claimed to have used condoms with each sexual encounter.
I performed a vaginal exam because of the dysuria and the possibility of a sexually transmitted disease. I immediately noticed an anterior vaginal mass. Upon further questioning, the patient said that she had first noticed this “lump” four years ago but that it seemed to have grown in the past eighteen months; she denied any pain associated with it. I sent her to the urologist for further work-up. He chose to do a urethroscopy followed by total excision and gave her a final diagnosis of distal urethral diverticulum based on pathology. The patient has been symptom-free since her surgery.
According to Dorland's Medical Dictionary, a diverticulum is defined as "a pouch or sac occurring normally or created by herniation of the lining mucous membrane through a defect in the muscular coat of a tubular organ." Specifically, a urethral diverticulum is lined by urethral mucosa and extends from the urethra into the urethrovaginal space. It is unknown how these are formed and whether they are a true herniation of urethral tissue or originate from dilated paraurethral glands or ducts. In 1890, an Englishman by the name of Routh first described what is now perhaps the most accepted theory of origin: one or more paraurethral glands become obstructed, forming a retention cyst. This cyst eventually becomes infected, forms an abscess and ruptures back into the urethral lumen, eventually becoming epithelialized into a diverticulum. This theory is supported by the anatomical location of most diverticuli, which corresponds to the region of the urethra with the highest density of paraurethral glands. Another potential cause is trauma due to childbirth, surgery, or catheterization. Incidentally, my patient had had a bad fall on a bicycle frame shortly before she first noticed her mass. However, no apparent cause can be found in approximately 15% of cases.
Urethral diverticuli are more common in females than in males, but the true frequency is difficult to estimate because of large numbers of undetected diverticuli. One series identified the disorder in 4.7% of 129 asymptomatic patients, with rates as high as 40% in women with recurrent urinary tract infections. According to a clinical series of 108 female patients at the Mayo Clinic, the age range was from 10 to 76 years, with it being most common in women aged 30 to 50.
Clinically, symptoms vary. Dysuria, frequency, and dribbling are common at the onset of the disorder when the gland is starting to become infected. Later symptoms include dyspareunia and pain as the infection becomes more chronic and inflammation increases. On exam, a mass may be palpable in the anterior vaginal wall, but there may be no detectable findings on physical exam. Hardness may be felt in the mass if there are stones present. Purulent material may be expressed from the urethra in a small percentage of cases. An anterior vaginal wall mass has a large differential, including leiomyomata, urethral carcinoma, Skene's gland abscess, Gartner duct abscess, ectopic ureter with a ureterocele, and even an endometrioma.
Workup of a urethral diverticulum includes urinalysis and urine culture as UTIs are common with this disorder, urine cytology to evaluate the possibility of a malignancy, voiding cystourethrography with an emphasis on postvoid films which may show a filled diverticulum, positive-pressure urethrography with double balloon catheter (proven to be 100% sensitive), ultrasound, magnetic resonance imaging, and when an ectopic ureter is suspected, intravenous pyelography. Urethroscopy may also be used to diagnose as well as to further define suspected diverticuli. A simple procedure that can be done in the office without special equipment is milking of the urethra from the proximal region to the distal, watching for (and obtaining cultures from) purulent material or cloudy urine. Finally, biopsy of the diverticulum and/or urethra may be indicated, as well as bladder and vaginal biopsies if malignancy is strongly suspected. Histologic examination must also be undertaken, as nephrogenic adenomas are discovered in urethral diverticuli approximately one-third of the time.
Surgical therapy continues to be the therapy of choice for symptomatic urethral diverticuli. Definitive treatment depends on the size and location of the lesion and may include either marsupialization, if located on the distal third of the urethra, or urethral diverticulectomy, if the lesion is in a region not appropriate for marsupialization. There is ongoing debate in the literature as to the most effective approach. There are procedure-specific complications associated with surgical correction of this disorder, including but not limited to recurrence, urethrovaginal and vesicovaginal fistula formation, postoperative stress incontinence, urethral stricture and urethral pain syndrome. Interestingly, these complications appear to be related to the location of the diverticulum. Recurrence alone is associated with lesions in the proximal one-third of the urethra and fistula formation. Recurrence, and stricture formation are associated with lesions in the mid-urethra. Relatively few cases of recurrence occur when the distal one-third of the urethra is involved.
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Starting in Practice Handbook: Getting Started
Joining or starting a practice is an exciting and challenging career step for pediatricians. The Starting in Practice Handbook is a practical, innovative, and evolving resource developed by a working group consisting of American Academy of Pediatrics (AAP) Practice Management Online (PMO) editorial advisory board members and representatives of the AAP Section on Resident and Section on Young Physicians.
The first section of this series is posted on PMO. Section 1 was designed to help pediatricians choose a location to practice medicine or open a practice. The following topics are addressed in this section: personal and family needs, financial considerations, assessing the community, practice types, current trends in malpractice and professional relationships and opportunities.
Check back often for updates as new content will continue to be added.
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Why Participate in PROS? Two Practitioners Tell All
By AAP Department of Research
Burlington, Mass., pediatrician Ben Scheindlin, M.D., FAAP, does it for "the fun" and enjoys the knowledge that "colleagues all over the country are collaborating on the same effort." Los Angeles pediatrician Heide Woo, M.D., FAAP, does it because it helps her provide "a higher quality of care" to her patients.
The "it" is participating in Pediatric Research in Office Settings (PROS) — the Academy's practice-based research network. Along with 1,700 of their colleagues across the nation, Dr's. Scheindlin and Woo help generate knowledge about the best pediatric care, not only for the patients in their offices, but also for those across the country.
Dr. Scheindlin joined PROS in 1995, and all of his colleagues also participate in the research network.
"The excitement of reading about and working on PROS studies spills over and constantly renews my excitement about primary care pediatric practice," he said. "I get excited every time I see our practice name listed at the end of an article in a medical journal."
Dr. Scheindlin said he has been able to use PROS research findings in his practice, including the normal time of pubertal onset in girls, the high prevalence of behavioral symptoms in young children and how to manage febrile young infants. PROS studies also have helped him rethink how he approaches well-child care and anticipatory guidance.
"As someone who has always been interested in research and attracted to academic medicine, but was called to clinical primary care practice, it's great to have readymade opportunities to contribute my small part to important research studies," Dr. Scheindlin said. "I'm proud to be part of such a high-quality group as PROS. It's a pediatric grassroots effort; it's open to anyone who wants to participate, and it makes me feel more connected to the larger AAP."
Dr. Woo practices with three colleagues, serving a diverse population in West Los Angeles. Since joining PROS in 1999, she has found that participation in studies affects her care of patients in surprising ways.
"I have been asked by parents of boys coming in for physicals about when to expect the onset of puberty," she noted. "I have been happy and gratified to tell them my part in the Secondary Sexual Characteristics in Boys study, which is designed to answer exactly that question, and that the answer will be available in the next year or two when the full study is complete."
She also sees benefits with her practice employees. "The office staff who have helped us do the PROS studies have appreciated the fact that we as an office are committed to research and, through the research, also improving the quality of care we deliver to the patients."
Both practitioners have seen their roles in PROS grow over the years. Beginning as contributing practitioners, they have gone on to become chapter representatives and members of the network's steering committee, and have participated in writing up study results (as any PROS practitioner is welcome to do).
Dr. Scheindlin co-authored a recently published paper in Clinical Pediatrics, based on the results of the violence-prevention-oriented Safety Check study. Dr. Woo co-authored a platform presentation at the 2004 Pediatric Academic Societies meeting, based on the results of the PROS Life Around Newborn Discharge study.
"In the era of evidence-based medicine," Dr. Woo said, "it is quite exciting to be able to prove the value of some of the things we do in general pediatrics, whether it is how we care for young febrile infants or the discussions we have with parents on anticipatory guidance and violence prevention."
Core funding for PROS is provided by the Health Resources and Services Administration Maternal and Child Health Bureau and the Academy. PROS seeks practitioners interested in participating in its research. For more information, see the coupon below.
PROS seeks young practitioners interested in participating in its important research. For more information, please contact PROS Central at 800/433-9016, extension 7623, or via e-mail at pros@aap.org.
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An Intensive Review of Developmental-Behavioral Pediatrics
By Pamela C. High, MD, FAAP
Chairperson, DB:PREP® Planning Group
Update on Autism, Developmental Screening, ADHD, Learning Problems, Mood Disorders, Psychopharmacology, Coding for Developmental-Behavioral Services and more...
It is not unusual for young pediatricians to complete residency training, to enthusiastically embark upon their new career and practice, and to find themselves yearning to know much more about the developmental and behavioral aspects of pediatric care. The upcoming DB:PREP® - An Intensive Review of Developmental-Behavioral Pediatrics is designed to meet this need.
The course will be held in Atlanta, December 4-7, 2009 and will be taught by a world class group of faculty in the field. This is a truly excellent course with well organized and highly useful content covering a range of DBP topics. These include autism, developmental and behavioral screening, school problems, behavioral interventions, sleep disorders, foster care, adoption, learning disabilities, ADHD and comorbidity, complementary and alternative medicine in DBP care, psychopharmacology, anxiety, depression, obesity and eating disorders, as well as coding for your services related to this care. Morning and early afternoon sessions are didactic, while later afternoon sessions are provided in a small group, interactive workshop format. Course faculty members are known to be helpful, approachable and supportive. Participants are invited to get a head start on learning by completing an optional online CME course prior to coming to
Atlanta.
For more information or to register online, visit www.pedialink.org/cmefinder or call toll-free, 866/THE-AAP1 (866/843-2271).
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