Once Again

Don Shifrin MD, FAAP

In a week where we saw tragedy followed by the automatic parsing of rhetoric by almost everyone in the viewing public, a James Baldwin quotation comes to mind. "Not everything that is faced can be changed. But nothing can be changed until it is faced."

OK, first let’s chat about we are not facing. After Aurora came the liberal, centrist, and conservative commentaries about whether more deaths should or even could be attributed to the availability of guns. With 30,000 firearm deaths a year in the US (half suicides), is it not common sense to ask ourselves why we are not facing this? Each new episode brings us back to this déjà vu discussion: how could another Columbine, Virginia Tech, and now Aurora be prevented? Debate points include outlawing purchases of higher capacity magazine clips, renewing assault weapons bans, better background checks, limiting assault weapon ammunition purchases, taxing hollow point bullets, flagging new orders for multiple assault weapons, yada yada yada.

OK, here’s where any logic goes off the rails: background checks for gun purchases in Colorado spiked 41 per cent in the four days following Aurora. After the Gabby Giffords’ shooting, gun sales in Arizona spiked 60 per cent for "self-protection" handguns and military style weapons. As Dave Workman, editor of TheGunMag.com stated, "distance does not matter when people are concerned about personal protection."

Validating Mr. Workman, several media sources reported that, once again, gun owners are convinced that if they were there - and armed - Mr. Holmes would have been stopped before his rampage became more deadly. With all that smoke and chaos I can only shudder at the collateral damage that would have ensued.

I, perhaps I alone, am mystified as to how this latest round of gun purchases, and the media attention focusing on gun violence, is being translated in the minds of our children and teens.

Media researchers have tried for years to have the public accept that viewing media violence will engender three responses:

- violence is an acceptable and even necessary solution.

- viewed violence produces desensitization to actual real life violence.

and proven by the spike in gun sales

- viewed violence produces the belief that we live in a mean and dangerous world.

F Scott Fitzgerald was quoted stating that the test of a first rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function. So Americans, can you ‘intelligently’ explain to your children that you apparently abhor violence, but then tolerate it by not creating societal or legal barriers?

It is commonly accepted that you will violate your first amendment's right to free speech by yelling "fire" in a crowded theater. So why is it legally acceptable for the second amendment to prohibit you from purchasing fully automatic weapons, but still allow you to amass an arsenal of semi-automatic weapons and ammunition that could create even more

carnage than your voice?

OK, TV networks, cable, print media, radio, and maybe even schools.  I am putting you on notice. Other than the usual volley of op-eds, who wants to take a crack at explaining that our nation’s children?

My Video Game Confession

Hugo Scornik, M.D., F.A.A.P.

            Let me start this post with an introduction. I am an overworked general pediatrician practicing in Conyers, Georgia and by no means do I consider myself a child media expert.

            And now the confession:  a few years ago, after hearing months of pleading and begging from my boys, ages ten and eight at the time, I let them purchase Call of Duty, the wildly popular, yet violent, video game. The game is rated Mature, for ages 17 and up, with “blood and gore, intense violence, and strong language” according to the label.

            When my kids brought the game home, I was surprised to learn that they already knew how to play since they had been surreptitiously playing at their friends’ house. Their eyes lit up as they blasted their way through the various levels.  In one particularly vicious scene, the player is asked to sneak up behind an enemy soldier and choke him with a chain. My young kids howled with delight. I observed them and wondered to myself, “What have I done?”

            But after a couple of months, a curious thing happened. My kids gradually lost interest in Call of Duty. They moved on, now more obsessed with playing basketball outside. While I realize that buying the game may not have been my best parenting moment, it seems that no permanent damage was done. My kids were no more violent. Their grades never slipped. They still enjoyed plenty of outside time and activities with their friends. In fact, I felt a bond develop between my kids and me as they implicitly thanked me for trusting them with the game.

            How can this be? Why do some children (and adults) become obsessed with video games while others easily maintain a healthy balance? Why are some not able to properly separate fantasy and reality while others seem not to be affected at all? I was curious enough to conduct a literature search but could find no clear answers. On the one hand, habitual video game play has been shown to increase short term aggression in children (Anderson et al, Pediatrics, 2008) and can become so excessive in some as to be described as “pathological” (Gentile et al, Pediatrics 2011). On the other hand, I could find no definite cause and effect between criminality and video game playing. It’s also interesting to note that according to FBI crime statistics, violent crime among youths has hit historic lows at the same time that video game popularity has soared.

            As pediatricians grapple with the impact of video games on children, it’s easy to state that no child should ever be exposed to these games. But this may be too simplistic; remember that long before there were X-Boxes, the corruption of our youth had been blamed on everything from comic books to rock and roll music. Furthermore, other exposures may have a much larger impact. Exposure to a dysfunctional family, to a violent neighborhood, or a mental health disorder is far more likely to create a violent individual.

            So in my clinic, I do ask about video game play but I also attempt to put this habit in the larger context of the world in which the child is living. I often fall back on common sense and experience when crafting my advice knowing that being overly dogmatic usually doesn’t work. As a parent, I try to strike this same balance, even if it means occasionally trusting my children’s instincts over my own. 

The Search for Google (Mount Rushmore Road Show)

Vandana Y. Bhide, MD, FAAP

Ever notice how pervasive the internet is in our daily lives? “What do you think about dressing up as Abraham Lincoln for Halloween?” I asked my son. I thought I would dress up as George Washington, his friends could dress up as Thomas Jefferson and Teddy Roosevelt and we could start a Mount Rushmore Road Show.

My son rolled his eyes and said nothing. I was worried he might be on Facebook “unfriending” me or placing an ad on Craig’s List: “For Sale, Lame Mom. Uses whole sentences to text. Takes notes at Parent -Teacher conferences. No, It’s NOT ok to contact me with other services or commercial interests.”

Maybe his mind, like the American advertising community, had already moved past Halloween onto the critical Christmas shopping season, which starts directly after Back to School shopping season. (I am still trying to figure what to do with those ten protractors for $20* I bought in the Back to School Specials frenzy).

But no, he texted me, “i want 2 dress up as google toolbar.”

Naturally we started our Google costume search on Wikipedia. When I moved to the United States from India at age five, one of my most prized possessions was a complete set of the Encyclopedia Britannica. It took my parents a long time to save up enough money to buy me a set. In fact, I have kept the 1978 edition until this very day to peruse on those late nights when I don’t get 30 junk emails (Note: place Unsubscribe in subject line), 20 email newsletters from Mailchimp or a notice urging me, “Vandana, read LinkedIn’s update about Dr. Extraordinarily Smarter and More Accomplished than You and on the verge of winning a Nobel prize.” 

Next we searched Google for Google (my son on an iPad, me on my iPhone).  Apparently I wasn’t feeling lucky because the search yielded only sponsored sites selling skull and crossbones ice cube trays, toxic waste candy, zombie blood energy drinks, and ketchup/mustard packet baby costumes.

 We moved on to eBay. No Google toolbar costumes but we were able to bid on some Angry Birds Halloween costumes and Albert Einstein wigs.  We also auctioned off 10 protractors, shipping included anywhere in the continental United States.

I figured some industrious and creative Mom had already thought of the Google costume and posted a How To video on Youtube, but no such luck.

Finally I went Amazon.com because one can buy ANYTHING on Amazon. I didn’t find a Google toolbar but I did find a couple of protractors (on sale for a mere 10 for $5 with $4.95  shipping!) to put on my Wish List. Those helpful folks at Amazon were kind enough to make some shopping suggestions based on items bought by people who also searched for protractors.

I clicked a flashing advertisement with the enticing tagline, “Come on over to the dark side with dark chocolate mini candy bars.” We learned there was 1 gram of fiber per 5 mini chocolate bars. So we only have to eat 150 candy bars to get the recommended daily intake of fiber.  My son thought the candy bars were practically a health food and plans on substituting them for broccoli.

Of course I had to pin the picture of fiber-full dark chocolate bars on Pinterest and then on my Facebook wall so that everyone interested could “Like” the Dark Side! I couldn’t leave Facebook (keep me logged on this computer, Check) without contacting the 5 friends with birthdays this month, see status updates on 22 friends, no lie, play a couple of games of word scramble, print out coupons for more protractors, check out friends tagged on photos, say “Maybe” to the 18 events to which I was invited by people I’m not sure I know,  “Like” the 400^th “Baby’s first steps” pictures of someone I don’t recognize and whew, I am exhausted!

I told my son we absolutely had to get off the internet because we had exceeded the two hour screen time limit recommended by the American Academy of Pediatrics.

Let’s see what Mayo Clinic Center for Social Media, KevinMD and Dr. Oz are tweeting about (dark chocolate) and we’ll call it a night!

Ultimately, my son nixed the Mount Rushmore Road Show mother-son bonding idea (South Dakota or bust!) as well as the Google toolbar costume. I tweeted to the world @VeeMD “My son is dressing up as a Mad Scientist for Halloween and I am dressing up as a Petri dish.” (Less than140 characters.)

*when bought with qualifying $50 minimum purchase

No More Sting

Jeanine M. Swenson, MD, FAAP, FACC, LMFT

Pediatrician, Pediatric Cardiologist, and Family and Systems Psychotherapist

This parenting journey is certainly an interesting series of changes for both children and parents.  One of the more nerve-wracking transitions for parents as children grow and approach the teenage years can be the area of relationships.  Even mentioning “birds & bees” can make many parents sweat.  Naturally we want to make sure that our teenagers enter the real world with the “big present of love” – information and lessons regarding health, safety, respect, nonviolent conflict resolution, emotional intelligence, relationships, and their bodies.  One of the harder parts of this mission is imparting this message gradually when teens are developmentally ready and in the best place to hear our caring and concern.  Rather than a single event where we sit down and give kids “the talk,” a series of discussions, when kids are ready, may be a more fruitful and rewarding process.  Our schools do a fine job of teaching the facts about sexual education. However, one extra needed ingredient may be the connection of all of this information with patience, your knowledge of your child, and our guiding beam of family values.  

For many parents, the world today seems very different and scary from the one we inhabited when growing up in the twentieth century.  Media and screen time fills more space for our children and youth, and much of this entertainment contains more sexualized and violent content.  Esteemed family therapist Dr. David Walsh calls it a culture of “yes,” where parents are given the difficult task of saying “no” – the job of balancing instant gratification with lessons about hard work, safety, consequences, and the real world.  Sadly, it seems like an unbalanced tug of war as media companies have billions of dollars and we are short on time and energy these days.   There seem to be so many forces out there pushing our children to grow up quickly.  We really want to be helpful, but may have few examples or models to turn to when it comes to these personal conversations. 

A new school year often brings a unique opportunity for families. We may find renewed energy to think about where we all stand in our family life.  This thoughtfulness allows us to take stock of current family needs and choose the family life that we want to live. 

Many good families are trying to do their best, but different times may call for different and new strategies.  As the experts on our kids, we hold the secret when it comes to understanding their personality, learning style, temperament, and the ways that they are motivated.  This relationship and our bond with our children has proven in countless research studies to be the most important factor in long-term success. However, we may need new information in this new century to combat the growing influence of media in our children’s education in many areas.  I encourage you to cultivate this rich soil. 

EMR: Communication and Patients

Nancy M. Silva, MD, FAAP

Our office went “live” with Electronic Medical Records (EMR) in March of this year.  This was and still is a difficult change to master.  EMR is supposed to streamline the work process, improve healthcare, and improve communication with our patients.  But does it really?

In the beginning, it felt as if all communication between everyone within the office and with our patients had been altered and damaged forever.  So, no, initially, EMR didn’t help or improve anything.  Frankly, it hurt a lot. 

First, everyone in the entire office needed to learn the new system.  This made wait times unbearably long.  Why?  Think of every step that an office visit entails.  There’s the phone call to make an appointment.  The front desk staff has to learn a new way of doing that.  There is new paperwork for a patient to fill out.  There’s a new registration process, which now includes capturing a photo.  There is the nurse’s and the doctor’s assessment.  There may also be office lab tests.  Lastly, and most importantly, were all the apologies given to the patient that included explaining the new process and why EMR would eventually be better for everyone.  The growing pains were excruciating.  Throughout the process, we learned that constant communication with our patients and their families was crucial.

It has been difficult to communicate in the exam room with a computer in the room.  It is literally a physical barrier.  Neither the patients nor I liked it.  That is until I figured out how to still be human with a computer in the room.  Mostly, I divide myself in two.  I explain that first we’re going to get through all the “virtual paperwork.”  Then, I’ll be hands on and have time for questions.  That divide is necessary in order to meet the EMR requirements while still being a caring doctor.  Since creating the division, the parents seem happier.   They know the course of the visit.  They know what to expect.  And they know their doctor is not just going to be looking at the computer screen the entire time.  There is still time for humanity; communication up front is the key.

On the flip side, there is an aspect of EMR that the patients and I do enjoy.  Improved communication! 

So, what has improved with regards to communication?  Parents have more options.  Now patients can call or email questions.  Parents receive more information, more quickly, and more efficiently with less errors.  The pharmacy can email prescription refill requests directly to the doctor.  Laboratory results are received more quickly.  Hence, I can give parents their results more quickly as well.  Any day parents receive an answer more quickly regarding their child’s health is a great day.  Responses to phone calls are also quicker.  In addition, they are now more accurate.  Now, there is no misunderstanding as to what advice I gave the nurse to discuss with the parents.  Everything is written in the EMR.  Messages aren’t getting forgotten or lost, as there is an electronic trail.  In addition, we can look back at every piece of advice ever given.  This is helpful with a prolonged or complicated illness.  I also enjoy showing parents their child’s growth charts on the screen.  The parents seem to understand the visual much better. Lastly, at the end of the visit, most parents receive an educational handout, either specific to that well child age and visit or to their child’s current illness.  Parents are happy to review what you just discussed, as opposed to relying solely on their memory.

So, three months later, I would say, the answer is yes.  The work process has become more efficient, healthcare has improved, and communication has eventually improved as well.  Mind you, there are still growing pains.  Updates in the electronic world are frequent.  Adjustments occur daily and are both inevitable and necessary. 

Everything seems to have changed with the introduction of the EMR.  However, communication is still paramount.  I still maintain a personal human touch, just with more options on how to do so.