March 28, 2017

Doctors and Oversharing

Jaime Friedman MD FAAP
San Diego CA
drjaimefriedman.com
@drjaimefriedman  Facebook and Twitter

In medical school budding doctors are typically taught not to share personal information with their patients.  Doctors should be neutral professionals, so their patients feel comfortable without feeling judged.    Furthermore, the visit is 100% about the patient, not the physician.

However, we aren’t robots.  We want so much for doctors to be seen and treated as humans with human emotions and flaws.  When we aren’t available one day, it’s OK that we need to stay home with a sick child, attend a continuing education course or just take a much needed vacation.  If we are a bit irritated by the late patient at 5:00, it’s because we may be missing Back To School night or an important soccer game. It’s OK for us to be sad when we give bad news or to have happy tears when we give reassuring news.  Doctors are people too.  We have families and personal needs that are often overlooked, as the demands of medicine pull us in many directions.  Our needs get sacrificed.

So where is the balance?  How do we relate to our patients on a human level without ever sharing any information about ourselves that make us more human?  In my opinion, it can’t be done.  Now before everyone freaks out, remember I am a pediatrician.  The majority of my discussions take place with parents, not patients.  Furthermore, my own experiences as a parent have made me a better pediatrician, and I want to be able to share the wealth.  Imagine how empowering it is for parents (who feel like they always need to be perfect) to know that their own pediatrician isn’t a perfect parent. 

Imagine getting advice from a million different sources on a variety of topics; it might carry more weight hearing what actually worked for their child’s doctor.  I think being able to share my own sleep, feeding, and behavior successes and failures not only makes me more human but also helps my patients and their parents.  And sometimes it’s just plain fun to talk to my young patients about my favorite ice cream flavor, or a good movie they may like, or what my Halloween costume will be this year.

Many times parents ask me, “What would you do if it were your child?”. They want to know, when they are hesitant,  if my child had their shots.  They ask how old my kids are and when I let them stay home alone.  They want advice on everything from book ideas for the kids who aren’t excited about reading, to ideas about potty training, to ideas for behavior modification.

As a human being, I learn and grow from my patients as well.  We bond and build our relationship by sharing with each other.  I get, as well as give, book ideas from my teens.  I get vacation ideas from parents.  I even learn about therapists or other health professionals that parents have liked or haven’t liked.  One of my favorite parts of a visit is “schmoozing” with a family about their summer, or school, or a new pet, or an upcoming holiday…the list goes on.

I do think it’s important to know when it is appropriate to share and when it isn’t.  There are way more times that I’ve held back from sharing personal information than I have actually chimed in.  But when I think it’s helpful or might make a mom feel better that I have been in her shoes, I choose to share.


February 26, 2017

Clearing the Air

Yolanda (Linda) Reid Chassiakos, MD, FAAP 
Director and Medical Chief of Staff
Klotz Student Health Center
California State University Northridge  
Clinical Assistant Professor, Pediatrics
David Geffen School of Medicine, UCLA. 


The CDC reports, “If smoking continues at the current rate among youth in this country, 5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness. That’s about 1 of every 13 Americans aged 17 years or younger alive today.” 

Most new smokers start smoking as teens.  Per the CDC, “Nearly 9 out of 10 cigarette smokers first tried smoking by age 18, and 99% first tried smoking by age 26.

 My university, California State University Northridge in northern Los Angeles, wanted to “clear the air” - for non-smokers, as well as potential smokers - and promote a smoke-free, tobacco-free environment on campus.  Over 80% of our students, faculty, and staff supported a transition to a non-smoking policy.  So, working in partnership with the non-profit California Youth Advocacy Network and our sister campuses in the 23 campus CSU system, we developed a smoke-free, tobacco-free policy and implementation plan for a one year transition to clean air.  Our goals included reducing the effects of second-hand smoke, as well as limiting opportunities for youth to be “introduced” to cigarettes, tobacco, and e-cigarettes at school.

The phases of implementation were identified for our campus community and local neighbors as information, education, resources and support, and, finally, enforcement, as a last resort.  As a mediatrician serving as co-chair of the CSUN Becoming a Smoke Free Task Force and Implementation Committees, I recognized the critical importance of working with our communications department to develop messages that would reach our target audience; 

- social media posts on Facebook and Twitter, 
- public service announcements on our rock radio station, 
- text announcements to students,  
- videos on the campus website

all to complement an informative webpage with in-depth facts about the upcoming policy adoption and available resources for smoking cessation.
Our core website and the video can be viewed at http://www.csun.edu/clear-the-air 

This multifaceted digital media approach allowed us to reach a wide audience and direct those with questions and concerns, or who needed assistance with cessation or FDA approved nicotine replacement options, to the appropriated resources.  Additional steps included catalog revisions, website revisions, signage changes, removal of ashtrays, and smoke-free peer advocate outreach.  

But the media “push” helped us achieve our goals.  Our first year and a half of being smoke-free has demonstrated a compliance rate of over 95%.  

Mediatricians can serve as excellent guides to improve the public health not only for your practice, but for your local communities.  By using your skills and expertise in developing and sharing healthy messages, you can have a broad impact on the health and wellness of children, youth, and families beyond your office doors.


January 27, 2017

Are Your Children Fit For Life?


Paul Smolen MD FAAP

Carolinas Medical Center, Charlotte NC

Creator of the blog, Portable Practical PediatricsAuthor of Can Doesn't Mean Should-Essential Knowledge for 21st Century Parents
Adjunct Professor of Pediatrics, University of North Carolina School of Medicine

Post originally published in slightly different form at www.docsmo.com September 12, 2016


So here is something you and your children should think about.  Unless they develop a major illness, each and every morning your children get up out of bed, they are a little stronger, a little faster, and a little smarter than they were the day before.  During the previous day, their little bodies had a chance to grow new cells in all of their organs. Compared to the day before, their hearts got a little bigger as did their lungs, kidneys, and brains.  And of course, you are not paying attention if you don't notice the tremendous increase in their cognitive abilities - they get smarter every day as well.  There is this steady march of growth and increase in organ function all during childhood that halts sometime between 20 and 30 years of age.  Today, we are going to explore these phenomena in a little more detail and talk about why this aging/organ function curve has tremendous relevance for your children.  

Childhood is about growth and change:

Do you remember how thrilling it was, as a child, to acquire new skills?  I remember how excited I was when I learned to swim and dive, ride a bike, hit a jump shot from 15 feet, or hit a twist serve on a tennis court.  I could literally feel my body getting stronger, faster, and more agile by the day.  My growth and development physically seemed to increase until my 20’s, and then the party was over.  Yes, I continued to get more knowledgeable well into adulthood, but my physical growth and agility began to decline. Research supports these facts.  Current evidence confirms that humans reach their peak physical capacities between 20 and 30 years of age.  Peak cognitive ability comes a little later, about age 30 to 40.  

What this means is that, until the physical peak, each day your child is a little stronger, a little faster, able to burn more oxygen, and do more physical work.  After that peak day, no matter how much we wish it weren't so, there is a very slow but steady decline in our physical prowess. It doesn’t matter how many yoga classes we go to, how many weights we lift, or how many miles we run a week, the decline still occurs.  The rate of decline is biologic and predetermined. 

So here is the big take home point we all need to understand that is relevant for your children - Since physical decline is inevitable in adult life, it is vital that children maximize their peak physical abilities when they are young.  The higher a child's physical capacity is during their childhood, the longer and healthier a life they can have.  

Obviously, the children with the highest functional capacity as they enter adulthood are likely to be the ones who reach the disability threshold last.
By exercising, breathing hard, sweating, chasing other children, climbing trees, eating good food, getting enough quality sleep, and expanding and challenging their cognitive abilities, a child’s organs develop a higher peak capacity than if they sit playing video games, eat low quality processed food, or get low quality sleep while watching TV and texting late into the night.

Parents need to take action:

Here is the great news - kids, your kids, can improve their long-term health.  Good health as an adult is, to some degree, a choice.  Make sure your kids know that!  You and your child need to understand the graph of physical capacity versus age, and think about it as you make decisions about your child's activities, diet, and sleep habits.

We have all heard the expression, "use it or lose it"Well, it is extremely true - a fundamental truth of childhood.  Pack that little truism into little Johnny or Janie's head before they leave your care.  Maybe they will see why you are so interested in getting them to turn off the TV and video games and get outside to play.  Physical activity that your children experience will give them health they will carry their entire adult life. 

Here is a Doc Smo pearl for you to remember:  It's a terrible mistake for parents to underestimate their influence on their kids - or its corollary - Wisdom kept to oneself is wisdom wasted. Make sure you take a few minutes regularly to share your life wisdoms with your children. You will both benefit from the effort.

This is your host, Doc Smo, asking you to remind your children that they will never become fit, if all they do is sit. Until next time.

Smo Notes:

  1. Rate of decline of physical functioning in Women
  1. Age of Peak Cognitive ability

November 21, 2016

Saying Grace and Then Demonstrating Grace at Thanksgiving

Don Shifrin MD FAAP 
Bellevue, WA

As parents, we encounter “teachable moments” every day. There is an old saying about children that they have small heads but big ears. It is unlikely and impossible to ignore that they have not seen or heard, media portrayals of both presidential candidates this year that were (OK, perhaps not unjustifiably) significantly negative. And certainly, vitriolic rhetoric from the candidates and media pundits as well. We have seen and heard hateful remarks on all media venues and our children have been watching. We have not seen many role models of civility.
America has concluded a contentious election, and now there is a significant winner/loser mentality among at least half the population, again not unjustifiable based on previous statements by both candidates, especially from our new president-elect. 
Regardless of what we are experiencing we do have a president-elect. And as parents we need to model respect for the office. Yes, we can comment that politicians can be flawed, but accusations of racism, sexism, and classism are going to stay in children’s minds a long time. 
So how should we to speak to children and families about the results, how to help families cope with disturbing rhetoric, and how to explain news reports of increasing numbers of protests? 
It is vitally important that we calmly reassure all children  so they feel safe and protected in their day-to-day lives.
Explain clearly that the way democracy works is that we vote to elect who will oversee our government. This is a good opportunity to invoke what Abraham Lincoln (our 16th president) meant (in his Gettysburg address in Nov. 1863 - 153 years ago) when he said  “government of the people ( coming from the people), by the people, and for the people.” 
Do find out what your children and teens have heard and what they understand. Teens may be very passionate when expressing their opinions about the election. 
Listen!  Try not to quickly interrupt. Allow your child to express what he or she is feeling, including fear, anxiety, or anger.  Do not minimize or dismiss their concerns. As you listen, note any misconceptions, misinformation, or anxieties. 
Every child is different. Their age and individual anxiety level will determine how much and what information you may wish to share. Try to separate fact from fiction. Put provocative statements (i.e. building a wall - deporting all ‘illegals’ - putting Ms. Clinton in jail.) in the  context of our democratic system.  
Because we live in a media saturated world, pay attention to what your children watch on screens. Try, if possible, to watch with them and use those ‘teachable moments’ to help them digest what is being discussed. Be careful not to verbally provide aggressive, dismissive, discriminatory, or inflammatory color commentary about topics being discussed. Children are not politically savvy and are unfamiliar with the checks and balances of the US Government. 
We are all American citizens. You now have a continuing opportunity to be a positive and reassuring role model for your family. When you share your feelings about new information, do so in a respectful manner. The teachable moment emphasizes that respect and kindness are important values for families, even if they have significant disagreements with someone. If we see or hear that some adults do not understand or demonstrate  disrespect by using shouts or threats, we will still value these attributes and proclaim them. Avoid generalizations about gender, race, or culture. And note that a strong democracy is designed to protect all Americans.
How can we act if we disagree? We have legislators we can petition, op-eds we can write. And we can recognize and provide commentary on incendiary and offensive words and actions. Your child is always watching, and you are the door they walk through on their way into the world. Your calm reassurance (we will be OK) and ability to promote wellbeing is  the most empowering part of parenting.
So this Thanksgiving please pay attention when political commentary (if you even agree to discuss politics) becomes inflammatory or overwhelming to children that are present. Focus on what is positive is your lives, that our Republic has survived almost 250 years and will indeed survive this administration. If adults will not cease angry or fiery words, you can gently point out to the children that is not the kind of talk that you endorse. “Our thanksgiving table is a place where we model love and value acceptance, tolerance…. and thanks.”
Finally - Always encourage your child to tell you or a teacher if he/she feels threatened or bullied,  and to speak up when they see or hear something inappropriate. 

J. M Barrie (Peter Pan) “Always be a little kinder than necessary.”
Warren Buffet, (a vocal Clinton advocate) stated, “I support any President of the United states. It’s very important that the American people coalesce behind the President. That does not mean we cannot criticize him or disagree with what he is doing. But we need a country unified. He (the president) deserves our respect.” 



October 30, 2016

New Media Plan Toolkit Available for Parents on HealthyChildren.org


Corinn Cross, MD FAAP
Pacific Palisades, CA
Council on Communications and Media Executive Committee

The AAP’s Council on Communications and Media has two new policy statements, Media and Young Minds and Media Use in School-Aged Children and Adolescents” as well as a corresponding Technical Report, Children and Adolescents and Digital Media,” out in the November issue of PEDIATRICS. These statements outline the changing relationship children and teens have with media. While the policy statements allow for us to discuss what we know and map out what still needs to be researched, the toolkit on HealthyChildren.org gives pediatricians and families the guidance and tools they need to parent, now.

Media has become ubiquitous in our daily lives. For children and adolescents, this includes school time, free time and homework time. Media is used for communication, education and recreation. The policy statements and technical report outline something that many parents have realized -- the 2 hour limit just isn’t enough advice. Screen use is so nuanced and weaved into our day that parents need more guidance. 

As busy pediatricians, we don’t often have the time to delve into media use in our office visits but recommending parents visit the website and create a Family Media Use Plan is something we can find the time to do. Creating a Family Media Use Plan is an important step in helping parents realize that they can, and should, still “parent” their children’s online life and be aware of, and hopefully approve of, their online and media choices.  The toolkit discusses screen free zones and times, device curfews and where devices should charge overnight. It talks about displacement and the need to maintain a healthy balance, which includes an appropriate number of hours of sleep for age as well as 1 hour of physical activity a day. Parents are encouraged to co-play, and co-view media with their children and to research apps and shows through sites like Common Sense Media so that they can be aware of content and age appropriateness. The toolkit introduces the ideas of diversifying media experiences and encourages parents to think about what their family’s values are and to ensure that their child or adolescent’s media experiences are inline with those values. 


Many parents feel overwhelmed when it comes to parenting, device use and media choices. The online resource gives parents concrete tools to navigate this new area of parenting. 

September 29, 2016

Stress and Teens: Does Media Play a Role?

Hansa Bhargava MD FAAP
Staff Physician, Children's Healthcare of Atlanta
Medical Editor, WebMD



Pediatricians are seeing more and more teens suffering from stress. Whether they are complaining of it or having somatic symptoms such as headaches and stomach aches, it seems that stress and anxiety are on the rise. We know that over scheduling, homework, and the pressures of getting into college can contribute to this. But can media also affect it? Is screen time and media a stressor or a remedy for stress?
In a recent WebMD survey published in their Teens and Stress report, 54% of teens were stressed according to parents. Interestingly, 40% of parents turned to the screen  for family stress relief while 58% of teens did. Social media and texting was used as stress relief by almost half the teens. This is on the heels of the Common Sense Media survey reporting that US teens were using media for 9 hours a day. Other recent reports have shown that 94% of teens with mobile devices are online daily with many online constantly.
So it seems that stress is on the rise and media use is on the rise. Although there may not be a direct relationship, some real issues impact stress and anxiety. Consider this: 23 % of teens report cyberbullying, especially girls. There have been reports of “Facebook depression” and loneliness, as kids who aren’t in social media conversations may feel left out. Other negative consequences can also have an impact: many teens are in front of a screen late at night or ‘sleep text’, both of which can contribute to lack of sleep, which in turn can decrease focus and potentially cause irritability and depression. And last but certainly not least, what about the time media consumes? 
Time spent on media is time often not spent communicating with family. Lately, when I’ve gone into a restaurant, I’ve observed that as soon as a family sits down, everyone pulls out a mobile device. No one is really talking. So even the short amount of time not doing homework, playing soccer, or at school is being compromised. Psychologists, community leaders and experts have long reported that family time can contribute to less depression, less anxiety, better academic performance and generally happier kids. But what if that family time is on media?? 
As the AAP reviews our screen time recommendations,  I feel that we, as pediatricians should continue to advise parents about basic principles. 

Parents need to lay down some parameters about when and how media is used. Media is a centerpiece of teens’ lives and is not going away, but just as we don’t give our kids a set of keys to our car and say “just drive”, we need to enforce appropriate media use. And  good modeling is also critical: parents need to put down their mobile devices and simply communicate with their kids. Old fashioned parenting and just talking to your kids can build the foundation to a less stressful childhood and hopefully a happier life. 





August 29, 2016

What’s New and Next? Applying Past and Present Principles of Professionalism for Posting



Terry Kind, MD, MPH
Associate Professor of Pediatrics
The George Washington University / Children’s National

From the latest way to share information, to dire concerns about career-ending posts, to the next new thing, where have we been and where are we going?  Guidelines are essentially meant as a starting point [Kind in AMA J Ethics 2015], to encourage thoughtful posting.  The same principles to guide your professional behavior in real life remain applicable in the online arena as well, but with additional considerations.  Your personal and professional might blend.  The voice you project --and the images you share-- are augmented. And, depending on the context, your post may be ephemeral or everlasting.  Social media has transformed our communication options, and has great potential to improve healthcare, communication, and information sharing. It allows us to innovatively reach out and engage.  And to listen.  

We’ve crafted tips for using social media in clinical care drawing upon ethical and professional principles [Chretien and Kind in Circulation 2013] and tips for use in medical education [Kind, Patel, Lie in Pediatrics 2013 and Kind, Patel, Lie, Chretien in Med Teacher 2014].   When considering new platforms of communication, think about who you are online and offline, who is or may be reading and engaging with what you post, and what are your goals?  Essentially, be a good and thoughtful citizen and share well.  

What does sharing well actually mean?  Just like in pediatrics where we aim to “catch a toddler being good” my colleagues and I sought to explore how medical students are using Twitter in “good” ways, such as for their professional development.  Do they, and if so how?  In this digital ethnographic study, we found that they do use Twitter to supplement their traditional medical school experience. It provides them with access and voice.  Access, to experts and various perspectives, and to communities of support.  Voice, for advocacy, and to craft their own digital identity, and to level the playing field among the various medical hierarchies.   [Chretien, Tuck, Simon, Singh, Kind in JGIM 2015].  

What do you need in order to post well, in addition to Wifi and a charger?  We propose that in the health professions, your posting rests on a platform of public trust [Chretien and Kind in Acad Med 2014]..  Consider security, that is, what online behaviors could jeopardize patient privacy and/or impact your own career security.  Resting on that secure base, then reflect on your own online identity and the relationships you navigate.  This sets you up to discover ways to use social media to improve health, enhance career paths (self and others) and innovate.  Throughout your journey, maintain an awareness of potential challenges and opportunities. 

Ultimately, you should draw upon the same principles of professionalism that you’d employ offline, as online.   I shall leave you with this tweet-sized tip I once shared a few years back.

T is it thoughtful
W is it wise?
E is it educational?
E is if evidence-based?
T is it tweet-worthy?

References/Resources: