Ron Marino, DO, MPH, FAAP

“The future isn’t what it used to be.”
                                             —Yogi Berra

Medicine is a noble profession; it is a human service profession, the goals of which are to support and enhance health, cure disease and infirmity, and comfort the afflicted.  However, numerous factors have affected how medicine is taught and practiced in the 21st century.  Medicine has moved from a cottage industry to a massive medical industrial complex that constitutes an ever-increasing percentage of all economic activity in the United States.¹  The pharmaceutical industry has created markets through direct-to-consumer advertising, and it seems that both physicians and patients have come to consider drugs central to patient-physician encounters.  In my experience, patients have become consumers who have high expectations for miraculous outcomes, and attorneys are ubiquitous and willing to explore potential malpractice in almost any situation where the clinical outcome was disappointing to the patient.  Meanwhile, at the earliest steps of a medical career, education is long and expensive, leaving most young physicians in 6-digit debt by the time they graduate.^2,3  These economic realities impact young physicians’ career paths.²

I have worked as a medical educator for more than 35 years, and I see very clear changes in who physicians are, what they know and value, and how they are educated and practice medicine.  I have found that the possession of scientific knowledge has been elevated to a place of supremacy in discriminating a superior physician from an average one and has, in my opinion, wrongly become the emphasis of what we want and need in our students.  Cognitive information-based diagnostic and therapeutic approaches are important, but physicians may be losing sight of the humans who are experiencing the symptoms.  It is Sir William Osler who has been credited with saying, “It is more important to know what kind of patient has the disease than what kind of disease the patient has.”  Perhaps in the 1800s that was true.  Today, a balance seems more tenable.  Physicians must develop scientific knowledge to serve their patients’ best interests, and although knowledge and diagnostic acumen are necessary, they are insufficient qualities in excellent physicians.

Our current love affair with evidence-based medicine deifies data and minimizes the importance of relationship-based care, as well as ignores the reality that medical scientific information is merely a click away.  I have witnessed faculty clamor for more didactic time to essentially “fill the bucket” of medical students’ brains.  Meanwhile, I watch students move quickly from lecture to lecture, focusing on acquiring knowledge and passing written examinations.  I fear this misplaced emphasis will neither foster lifelong learning nor develop the ethics and values so critical to physicians.  As Albert Einstein was attributed with saying, “Not all that counts can be counted, and not all that can be counted counts.”

As physical examination skills fade into history, physicians become more dependent on high-cost, high-technology laboratory imaging and procedures to diagnose diseases and heal patients.  Yet, in my years of experience, a thoughtful conversation with a patient coupled with a skilled examination may both diagnose and heal in a cost-effective manner that is satisfying to both the patient and the physician.

Where does one learn the art of speaking with patients and using clinical examination skills?  I believe that senior physicians mentoring junior physicians through an ongoing relationship-based process models what the patient-physician relationship can be and serves as a vehicle to transmit our dying art.

Perhaps some of today’s medical students do not want an ongoing relationship with their patients; perhaps they simply want to develop a technical skill that is marketable, helps people, and affords them a nice lifestyle.  Perhaps some medical students want to practice the calling of longitudinal humanist care.  How will they know and decide what kind of physician they want or do not want to be?  Third-year medical students are asked to create their fourth-year curriculum, which sets the trajectory for graduate medical education, before they experience enough clinical rotations to have a clear sense of personal direction.  Perhaps medical schools should provide some combination of workshops, guidance counseling, and personality inventory in the first and second years to help medical students clarify their visions and values as they prepare to make choices that will have enduring significance.

The number of options available to medical school graduates boggles the mind—from administration to roles that involve technologically probing the body in so many ways, from medical physics and surgery to neuro-ophthalmology and, oh yes, primary care.  For those who are drawn to providing compassionate and ongoing care for humans, I hope there will always be a place.  I hope that the changes in the culture of medicine in our society never replace the patient-centered physician.

References

1. The Effect of Health Care Cost Growth on the U.S. Economy. Washington, DC: US Dept of Health and Human Services; 2008.  http://aspe.hhs.gov/health/reports/08/healthcarecost/report.pdf.  Accessed February 4, 2013.
2.  Research Department American Association of Colleges of Osteopathic Medicine. AACOM 2011-12 Academic Year Survey of Graduating Seniors Summary Report. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2012.  http://www.aacom.org/data/classsurveys/Documents/AACOM%202011-12%20Graduating%20Seniors%20Survey%20Summary%20Report.pdf. Accessed February 4, 2013.
3. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. Washington, DC: Association of American Medical Colleges; October 2012.  https://www.aamc.org/download/152968/data/debtfactcard.pdf.  Accessed February 4, 2013.

 (Dr. Ron Marino, DO, MPH, FAAP is a pediatrician and Associate Chairman and Director of General Pediatrics at NYU Winthrop Hospital.  He is co-chairman of the Yoga and Meditation Committee of the New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics.)

Shetal Shah, MD, FAAP

(As healthcare reform continues at a fast pace in the US Senate, Chapters have been working to highlight the impact proposals within the Better Care Reconciliation Act will have on children.  Given Medicaid’s vital role in providing health insurance to children, protecting its budget from impacting children, particularly those with disabilities, is a vital national American Academy of Pediatrics’ priority.  Here, two active AAP members from neighboring chapters, Drs. Shetal Shah and Heather Brumberg, discuss the importance of a strong Medicaid program on children in New York and children’s hospitals.  More importantly, they highlight how Medicaid reductions will result in decreased access to subspecialists for ALL children, irrespective of insurance status.  This blog post was originally published as an Opinion-Editorial piece in The Journal News, a prominent newspaper in Westchester.  It is available at: http://www.lohud.com/story/opinion/contributors/2017/06/21/medicaid-cuts-hurt-babies-lifetime-outcomes-valley-view/414018001/

MEDICAID MUST BE SAVED TO ENSURE THE HEALTH OF CHILDREN

By SHETAL SHAH MD FAAP and HEATHER BRUMBERG MD MPH FAAP

As the landscape of healthcare reform shifts rapidly, it’s clear the federal Medicaid Program – the nation’s largest insurer of children – is in jeopardy.  Over the next two weeks, the United State Senate will debate a version of the American Health Care Act, also known as the “ObamaCare Repeal,” which drastically endangers the care of children.  The House of Representatives version of this bill defunded Medicaid by $834 Billion over 10 years and President Trump’s recently released budget was even more drastic – calling for $1.3 Trillion dollars in cuts over the next decade.

As pediatricians and neonatologists, we know firsthand such measures would be devastating to the critically-ill babies we care for, over 70% of which receive Medicaid coverage.  These babies are among the most gravely-ill in New York State, often weighing less than 3 soda cans.  There are roughly 3,300 of these babies born each year in our state.  They are at risk for heart, lung, intestinal and eye disease as well as cognitive delays.  The care our team provides saves their lives and gives them the best chance at growing up to be healthy adults.  But these treatments are made possible by health insurance programs like Medicaid.

Nationally, Medicaid is fundamentally integrated into child health, covering 40% of all children, including 1.78 Million kids in New York.  In our area, more than a third of children rely on Medicaid for healthcare.  That number is expected to grow.  Data from the University of Pennsylvania suggests the combination of higher annual contributions and increased deductibles for family plans will result in even more children from working class families ($49,200 for a family of four) shifting to public insurance.

Children depend on Medicaid.  Pediatricians depend on Medicaid to ensure that every child, no matter what tax-bracket they were born into, has access to the care they need.   Without this strong child health insurance program, our babies born more than a trimester early, or born to mothers addicted to opioids won’t have access to the care they need.  Other children won’t have access the life-saving vaccinations, autism screening and other preventive healthcare.  This leaves parents dependent on the emergency room for their children’s care, increasing costs and causing unnecessary suffering for children who could have had mild conditions treated by a pediatrician before they got worse.

Even if your children’ aren’t in the program, your family will be affected.  Since Medicaid covers so many kids, local children’s hospitals, including ours, disproportionately rely on Medicaid payments.  Without those funds, hospitals will reduce personnel, which impacts all hospitalized children, regardless of insurance status.  Medicaid funds also support school nurses, and allow hospitals to afford more physicians who provide mental health care and treatment for behavioral problems – increasing the ability of all kids to see specialists.

Economically, Medicaid also covers a great share of children with special health care needs, including children with cancer, sickle-cell disease and cystic fibrosis.  It’s estimated Medicaid saves $2,800 per child annually.  Without this support, these children will receive uncompensated care by a hospital; increasing the charges for private insurers who ultimately relay those costs to their beneficiaries via increased premiums.

Reductions in Medicaid funding, often labelled as reducing “entitlements” are shortsighted and ignore the demonstrated societal cost savings of insuring children’s health.  These proposals also ignore the long-term effects of having a healthy childhood.  Healthy children become more successful adults.  Throughout childhood, kids who receive Medicaid are more likely to complete college, pay more taxes and grow to healthier adults.  Sadly, this 18 year period doesn’t coordinate well with election timelines, putting Medicaid under threat.

Children are 0% of the vote and 100% of our future.  As parents, we know there is nothing we wouldn’t do for our children.  Medicaid has been there for our poorest children, allowing them to stay healthy.  It’s time for pediatricians and parents to be there for Medicaid.

(Dr. Shetal Shah is the Legislative Secretary and Secretary for the American Academy of Pediatrics, District 2, Chapter II.  Dr. Heather Brumberg is Vice-President of the American Academy of Pediatrics, District 2, Chapter III.)

Elie Ward

(The New York American Academy of Pediatrics, Chapter 2, collaborates with the other two chapters to form a strong, expert and respected voice for children in our state capital.  As another legislative session continues until June, Elie Ward, MSW, Director of Policy and Advocacy for the New York State District of the American Academy of Pediatrics, provides an update on the status of issues for which pediatricians across the state strongly advocated.  Mrs. Ward is also Executive Director of Chapters 2 & 3.) 

Legislative Successes in New York State

There are seven weeks left for the state’s legislative session, but before we highlight what we still need to accomplish, let’s take a moment in these turbulent times and enjoy our major successes at the state level.

1. Our work over the last several years and especially this year, helped get Raise the Age passed in the state budget.  Now most young people who get involved in the justice system will have their cases heard in Family Court, or a Special Youth Court, but not in Adult Criminal Court.
2. And we can take credit, with our partners, for getting Medicaid Coverage for Donor Breast Milk for the tiniest sickest babies included in the state budget.

These are two issues that the NYS AAP has been championing for several years. Focused, consistent and strong advocacy by our members on both issues helped push them over the top this year, in an environment with multiple competing initiatives.
New State Regulations Help Adolescents

The NYS AAP also played a key role in a coalition that helped create and implement state regulations that have the potential to truly improve the lives of adolescents. New Regulations:

• Permit Adolescents to Consent to their own HPV Immunization
• Permit Adolescents to Access PREP as an HIV Preventive Service
• Allow Access to Over the Counter Emergency Contraception with no age limit

Here Is What We Still Have to Do Before June 21st

We have key sponsors for our Standing Orders for Healthy Newborns legislation.  We will need your Advocacy, once we have a bill number.

We are working with key legislative leaders to move legislation Requiring Flu Immunization for Infant and Child Care attendance, A.1230.  Call your Senator & Assemblymember and let them know this is an important goal for pediatrics to keep our youngest children safe.

We have worked on the language for the “new” Child Safe Products Act, which would remove known toxic chemicals from children’s clothing, toys, furniture and accessories. I will let you know when we have a bill number so you can add your voice to our advocacy efforts.

We have filed Memos of Support for:

• School Access to Blood Lead Levels  A.03899 / S.03941
• E Cigs covered by Clean Air Act Requirements A. 00516/S. 0254
• Prohibiting Sex Conversion Therapy  A.3977/S.26
• Banning Tobacco Sales in Pharmacies  A.6956/S.543

Your calls and visits to your Senator and Assemblymember can help move these bills forward.  For E-Cigarettes and Sex Conversion Therapy, focus needs to be on the State Senate.  The Assembly has passed both.

The NYS AAP also provided comments with input from our medical professionals on many initiatives, like Cytomegalovirus enhanced testing, telehealth in schools and child care, cross state credentialing and more.

In addition, we have worked with the state to begin the implementation of Paid Family Leave.  We encourage all members to remind their patients about the availability of Paid Family Leave should they need time to care for a family member.  The very best advice you can offer is for a working Mom and/or Dad to talk to their employer about Paid Family Leave.

Statewide advocacy, along with the hard work of our Pediatric Councils, has resulted in most insurers now paying for Maternal Depression Screening.  If you are still having a problem with payment, contact your Chapter Pediatric Council representative.

The NYS AAP works throughout the year on policy development – keeping a pediatric voice at the table in areas that can and do directly impact children’s health and well-being.  Some examples include taskforces, work groups and committees focused on Value Based Payment for Children, Advanced Primary Care Statewide Stakeholders Steering Committee, State Partnership on HPV Immunization, with SDOH, ACS, ACOG, NYCDHMU, NYSACHO, Maternal Health Partnership (focusing on pre-conception health) State Immunization Advisory Council, State Early Care and Education Advisory, SDOH Breastfeeding Partnership, SDOH Antibiotic Resistance Work Group and others.  If you have a specific interest in any of these areas and can volunteer time, please contact Elie Ward at eward@aap.net.  Our members are always welcome to participate.

Now it’s time to pick your issue or issues and begin to reach out to your state representatives.  They are home in your communities each week from Thursday – Sunday.  Call, visit, e-mail.  Let them know what is important to pediatricians and why.

Whatever happens in Washington, we have a responsibility to continue to advocate for policies and targeted investments in New York State that can and will improve the lives of all of our children.

Shetal Shah, MD, FAAP

(As healthcare reform continues at a fast pace, Chapters have been working to highlight the potential impact proposals within the American Health Care Act will have on children.  Given Medicaid’s vital role in providing health insurance to children, protecting its budget from policies that would result in restricted enrollment or decreased services has become a national American Academy of Pediatrics’ priority.  Here, two active AAP members from neighboring chapters, Drs. Shetal Shah and Heather Brumberg, outline how measures to “Block Grant” or instill “Per-Capita Caps” on the Medicaid program will affect children.  This blog post was originally published as an Opinion-Editorial piece in Tulsa World, a prominent newspaper in Oklahoma.  It is available here.)

By SHETAL SHAH MD FAAP and HEATHER BRUMBERG MD MPH FAAP

At a time when national healthcare can change with a tweet, politicians seeking to “Repeal and Replace” the Affordable Care Act (or Obamacare) are proposing to weaken our children’s healthcare safety net.  President Trump aims to convert Medicaid to a Block Grant System which gives states a fixed dollar limit to fund their entire Medicaid program.  Features of this plan also appear in House Speaker Paul Ryan’s proposal, “A Better Way.”  Auditions for potential replacements of healthcare reform have also included these provisions.

We experience the Affordable Care Act each day.  As pediatricians who care mostly for infants in the Medicaid program, this fiscal maneuver will hurt children, decreasing their access to preventive care.  It also ignores the intangible benefits children experience when they have stable health insurance.

Children in the Medicaid program receive advantages aside from better health.  Rates of child poverty are epidemic, and include 1 in 5 children.  Poverty impacts the brain development of growing children, leading to increased rates of distractibility and longer times to learn new tasks.  Studies illustrate impoverished children have differences in parts of their brain which affect emotions, decision-making, and language.  As a strategy to elevate kids out of poverty, Medicaid yields significant benefits.  Data from the Georgetown University Center for Children and Families shows children with Medicaid grow up to be healthier adults, and achieve greater economic success than if they had periodic coverage.

Medicaid is the nation’s largest child health insurance program.  Expansion of Medicaid under the Affordable Care Act means the program now covers almost 30 million children.  This has led to the lowest rate of uninsured children (4.8%) EVER.  Children are over-represented in the Medicaid program, comprising only 20% of the population but almost 50% of Medicaid beneficiaries.

Though popularly conceived as a social handout, the parents of our infant patients often work 2 jobs apiece as janitors, waiters and daycare attendants, but still can’t earn enough to phase out of the program.  Since children are healthier than adults, pediatric Medicaid recipients incur only 20% of Medicaid costs, mostly in preventive care like immunizations, lead and autism screening.

A key factor of Medicaid is its economic adaptability.  States share the costs of new enrollees with the federal government, so they are encouraged to enroll as many children as are eligible, including my newborn patients.  During the “Great Recession” 3.7 million people moved to Medicaid.

However if converted to a Block Grant system, or per-capita cap program, states will bear the costs for new enrollees or increased children’s healthcare on their own.  Unlike the federal government, 45 states have balanced budget amendments, which mean they cannot take on debt to provide children with healthcare in times of economic recession.

This backward step for children’s health insurance leads to reduced coverage, unnecessary obstacles meant to deter families from enrolling their children in Medicaid and limited physician payments – all of which reduce access to care and literally sicken a third of our nation’s kids.  Practically, that means “addicted” babies born to opiate-exposed mothers don’t get home visits by nurses to ensure they are thriving.  It means new mothers won’t see lactation consultants to support breastfeeding.  A Block Grant program would mean premature babies, at risk for cerebral palsy, won’t be able to see a neurologist.  It will mean long waits for parents of autistic children to see specialists.

Even if you don’t receive Medicaid, cuts could affect you.  The School Superintendent’s Association notes that should block grants be implemented, services benefitting all children will be cut first.  These include school-based vision and hearing screening and fewer nurses in schools.

How much funding are states expected to lose?  Block Grant programs are not new, and had those proposals been implemented, states would have had to cut $76.6 billion dollars over a 10-year span by slashing child enrollment and refusing necessary services.

Why are children especially vulnerable to Medicaid funding cuts?  Despite being the most cost-effective population to insure, children suffer excessively in times of fiscal crisis.  Since children are 0% of the vote, and their lost preventive care is less visible than reducing payments for adult acute care like health attacks and strokes, our newborn infants are the main course on the financial menu.

One night in our unit slept 2 babies.  One infant’s mother was a professional from a wealthy suburb, the other baby’s mother cleaned rooms in a local hotel and took 2 buses each night to be with her ill newborn.  A well-funded Medicaid program gives each of these babies a chance to reach their full potential.

Obamacare has flaws.  It made no improvements in malpractice reform, did not curtail the unconscionable costs of prescription drugs, fails to provide universal coverage to all children, does not substantially fund comparative outcomes research which could save billions and increased taxes in certain income brackets.  Efforts to “Repeal and Replace” would be better spent in addressing these issues instead of jeopardizing healthcare for 30 million children.

The babies need us, but are we there for them?

(Dr. Shetal Shah is the Legislative Secretary and Secretary for the American Academy of Pediatrics, District 2, Chapter II.  Dr. Heather Brumberg is Vice-President of the American Academy of Pediatrics, District 2, Chapter III.)

Jack Levine, MD, FAAP

(Recent efforts by the American Academy of Pediatrics, New York, Chapter 2, as well as other pediatric advocates, have worked to make screening for postpartum depression in the pediatric office more convenient.  Two years ago, the New York State Legislature passed a bill expanding pediatric scope of practice in the state to specifically include screening for this common condition.  However, regulation and insurance issues were interpreted as requiring a separate chart for the mother solely for this screening, which impeded many practices from implementing this important work.  Last year, your chapter worked with a coalition to ensure maternal postpartum depression can be included in the infant’s chart.  In this blog post, Dr. Jack Levine, MD FAAP, Chairman of Developmental Behavioral Pediatrics/Children with Disabilities Committee for AAP NYS Chapter 2 and an Executive Committee member of National AAP Section on Developmental Behavioral Pediatrics, provides insights into how, why and when to screen.)

2017 is the perfect time to begin screening for postpartum depression in your office!  According to the American Academy of Pediatrics, pediatricians can now use CPT code 96161 and bill with the infant’s visit.  New York State Medicaid billing guidance can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf.  Pediatricians see new mothers earlier and more frequently than other physicians, giving us multiple opportunities to assess and screen parental mental health.

Why screen?

Postpartum depression is common (8%-25%) and in some low income populations may include close to 50% of all new mothers! It is the most common cause of infant toxic stress in the United States.  There are significant and highly detrimental effects to developing infants (Table 1).  Screening helps us assess the baby’s environment and to establish a positive helpful relationship with the family.

Table 1. Effects of Postpartum Depression on Infants

What to ask at every visit?

Assessing the risk factors for postpartum depression should be part of every well visit (Table 2). Maternal history of mood disorders and/or anxiety is an important risk factor and should be carefully assessed.  Discontinuation of anti-depressant medication during pregnancy is a particularly important risk factor.

Table 2. Risk Factors for Postpartum Depression

When should I screen and what tools are available?

Depressive symptoms peak at 6 weeks, 2-3 months and 6 months.   “Baby blues” usually resolve by two weeks so that earlier screening may over identify, but post-partum depressive symptoms  can be delayed or persist for up to one year or longer!   Screen at 2 weeks, 2 months, 6 months and one year.  One month and 4 month screens can be added.  The Patient Health Questionnaire (PHQ-2, PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS) are commonly used, readily available, well researched, easy to administer, free, and have been translated into many languages (See References).

The EDPS has 10 questions and includes both anxiety and suicidal intent. The PHQ-2 is brief and contains only two questions.  The PHQ-9 (which also includes suicidal intent but not anxiety) can be given alone or with the PHQ-2 to determine the extent of depression.

Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.

What are available resources?

Treatment for postpartum depression must include both treatment for the mother and the mother-infant dyad. Reassurance and parent education can be provided along with specific referrals.  Medication is usually not needed but can be provided by obstetricians, internists or psychiatric providers.  A pediatric office should have plans available for the rare event of emergency referral (911) or in case of safety issues. Resources and guidance for both providers and parents are available through the Postpartum Resource Center of NY www.postpartumny.org and Postpartum Support International www.postpartum.net. Programs are available at most local hospitals in the Chapter 2 area.   Resource material should be available for immediate referrals (See Figure).  Appointments should be confirmed in the pediatric office and frequent follow-up provided. Early treatment results in the best outcomes for mother and baby and should be obtained as quickly as possible (within a day or two).

Identifying and treating postpartum depression are effective ways to ensure optimal early infant brain development – which is after all, why we all do what we do!!!

References:

1. Earls, M et al. Clinical Report: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Pediatrics. 2010;126(5):1032–1039. Reaffirmed December 2014)
2. PHQ-2 download: http://health.utah.gov/mihp/pdf/PHQ-9%20two%20question.pdf
3. PHQ-9 download: https://www.cappcny.org/home/media/phq9_adult.pdf
4. Edinburgh Postnatal Depression Scale download: https://www.cappcny.org/home/media/Edinburgh_Postnatal_Depression_Scale.pdf

Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and practices Developmental -Behavioral Pediatrics at Nassau University Medical Center.  He is Chairman of the AAP Chapter 2 Developmental Behavioral Pediatrics/Children with Disabilities Committee and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics.  Follow him on Twitter: @doctoj

Nina Suresh, MD

“Minor Consent for Human Papillomavirus Vaccination”

(The local AAP Chapter is heavily involved with advocacy efforts in Albany, over the past several years, our voice has been critical in expanding paid family leave, ensuring parents are offered Tetanus, Diphtheria and Acellular Pertussis vaccine, and combating exemptions to vaccination prior to school entry [to name a few].  This month’s blog post outlines the case for supporting a proposal to allow minors to consent for Human Papilloma Virus Vaccination.  Last year, the bill was referenced as “New York State Bill S.2712/A.1528,” and though it did not pass, it is expected to be re-introduced when the legislature convenes next January).

by Nina Suresh, MD

This year alone, almost 300 women in New York State will die from cervical cancer (1).  On average, 2,400 New York State residents are diagnosed with cancers associated with human papillomavirus (HPV) each year[1]. Virtually every single sexually active person will become infected with the virus at some point during his or her lifetime, and HPV causes almost all cases of cervical cancer, over 80% of anal cancers, and over 50% of vaginal, penile, and oropharyngeal cancers (2).

Fortunately, acquisition of the most virulent strains of HPV can be prevented with the HPV vaccine, recommended by the CDC for both boys and girls ages 9 to 26 years.

As pediatricians in New York City, we frequently see young patients who are delayed in receiving the HPV vaccine because they cannot legally consent for vaccination. We treat teenagers for sexually transmitted infections each day in our clinics. Current New York State legislation allows qualified health care professionals to provide treatment for sexually transmitted infections to minors without parental knowledge or consent. However, these same minors do not have the right, under interpretation of our current legislation, to consent for HPV vaccination, an unfortunate missed opportunity to provide them protection from both sexually transmitted infection and certain cancers.  This is particularly dangerous since the vaccine is most effective when given to children as young as 9 years old, prior to the onset of sexual activity.

Bill S.2712/A.1528, introduced by New York State Representative Amy Paulin and Senator Liz Krueger will expand a health care professionals’ scope of practice beyond treatment for sexually transmitted infection to preventative care as well, including the administration of HPV vaccine to minors with their consent alone.

HPV vaccine is effective.  In 2013, the Centers for Disease Control (CDC) showed that that since the vaccine was introduced in 2006, rates of HPV have decreased 56 percent among female teenagers 14-19 years of age.  But vaccination rates are still low.  The U.S. rates of HPV vaccination in teenage girls are lower than vaccination rates in Rwanda.  The CDC estimates that 50,000 lives could be saved if HPV immunization rates reached 80%.  Allowing minors to consent for vaccination, in the same way they consent for treatment of sexually transmitted infections, will help increase vaccination rates and provide pediatricians a teachable moment in sexual health and prevention.

As pediatricians, we strive to protect the health and welfare of our patients through effective counseling and anticipatory guidance, as well as effective preventive measures and treatment. Without all of these aspects of care, we miss significant opportunities to protect our patients. For these reasons, I support Bill S.2712/A.1528 to enable us to provide not only treatment for minors, but also safe and effective preventive care that will protect them against this deadly, cancer-causing virus.

(Nina Suresh, MD is a resident in pediatrics at NewYork-Presbyterian/ Weill Cornell Medical Center.)

REFERENCES:

1. https://www.health.ny.gov/statistics/cancer/docs/hpv_related_cancers_and_vaccination_rates_2015.pdf
2. National Cancer Institute at the National Institutes of Health, “HPV and Cancer,” March 2012, http://www.cancer.gov/cancertopics/factsheet/Risk/HPV

Lucy Weinstein, MD, FAAP

“Love us and Leaf us Alone!”

Led by Environmental Health Committee Co-Chair, Dr. Lucy Weinstein, MD, MPH FAAP, New York Chapter 2 of  the American Academy of Pediatrics has made significant strides in reducing noise pollution across our region.  Dr. Weinstein has worked with the committee to help enact bans on gasoline leaf blowers, often going community-to-community to meet with local and state legislators and neighborhood groups.  Here she recounts her experiences and success in reducing the environmental imprint of gasoline leaf blowers – a timely topic now that fall is here and many of us will be bagging up leaves. 

You can hear them from many blocks away. Gasoline leaf blowers are relentless and go from morning till night, seven days a week, in many of our Long Island neighborhoods.  As annoying as the sound can be, there are major health and environmental concerns associated with these devices.  Fortunately, with the help of AAP Chapter2 and other partners, our local Environmental Health Committee has worked to restrict their use in some communities in our chapter and is working to ban or reduce their use in others.

Gas leaf blowers are among the worst offenders in our garages.  Their inefficient 2- stroke engines burn an oil-gas mixture that generates high levels of toxic chemicals, and they churn up fine particulate matter at ground level, where they are easily inhaled.

Up to 30% of its gasoline is discharged unburned.  The exhaust from gasoline leaf blowers combines with sunlight to produce ground level ozone which can cause immediate respiratory symptoms and may exacerbate long-term lung disease.

Other pollutants caused by gasoline leaf blowers read like a “Who’s Who” of toxins which adversely affects health, particularly for the young and elderly. These include:

• Volatile organic compounds (VOCs) – including known carcinogens such as
  • Benzene
  • 1,3 butadiene
  • Acetaldehyde
  • Formaldehyde
• Carbon monoxide
• Nitrogen oxides
• Particulate matter – including mold, fungal spores, insect eggs, fertilizer, heavy metals and rodent feces
  • Fine particulates which are inhaled deep into lungs, damage lung tissue, and increase the risk of cancer and premature death.
• Carbon dioxide
• Other hydrocarbons

According to an Environmental Protection Agency study, small lawn and garden engines account for 5%–10% of total US emissions of carbon monoxide, carbon dioxide, nitrogen oxides, hydrocarbons, and fine particulate matter. The hydrocarbon emissions from 30 minutes of running a 2-stroke leaf blower equals those produced in a 3,900-mile drive in a Ford Raptor!

Children are particularly vulnerable to these toxins because their organs are still developing, and they breathe more air per pound of body weight than adults. They are also lower to the ground and therefore inhale more pollutants released into the air by this equipment and spend more time outside. Gasoline leaf blowers are linked to asthma exacerbation, pulmonary disease, various cancers, heart attack, strokes, congestive heart failure, and increased overall mortality.

These devices are also significant causes of noise pollution, which is why you can hear them six streets over in our neighborhoods.  The ears of young children are particularly susceptible to the damaging effects of the intense, high-frequency noise that gasoline leaf blowers generate. Noise has been shown to negatively affect blood pressure, to increase stress, impair communication, reduce school performance, and diminish the accuracy of complex tasks.

Gasoline leaf blowers also harm gardens and landscapes via loss of top soil and of beneficial soil microbes. They also disturb habitats of small mammals, birds and insects. It’s better for the environment to allow some leaves to remain under bushes and trees.

What are the alternatives?

Banning gasoline leaf blowers does not mean losing this landscaping tool to maintain our yards, parks and community gardens.  Today we have commercial-grade Lithium Ion battery blowers. They are a much better alternative.  Newer commercial-grade lithium battery blowers do not pollute, do not cause ground level ozone, eliminate solid waste byproducts and are much quieter.  These and manual equipment (think rakes and brooms) have been shown to be equally or nearly equally efficient and effective, and are cost-efficient. Landscapers and homeowners actually save money.  (In a test in California, a Grandma was nearly as fast and was more effective in cleaning a yard than a leaf blower!!!)
As we all become more aware of the accumulated impact of toxins in our environment and of the specific vulnerability of our children to pollutants, our committee has been working to have this equipment eliminated from local use.  Over 400 municipalities across the US have restricted or banned gasoline leaf blowers, including 16 in Westchester.

However, “Lawn Guy-land” has been slow to adopt healthier alternatives.

The Environmental Health Committee for New York Chapter 2 has been actively working to improve our region’s environmental health.  Our list of accomplishments related to reducing gasoline powered leaf blowers includes:

• We’ve written letters of support and testified before New York City Council’s Committee on Environmental Protection in favor of legislation sponsored by a Queens city council member that would restrict the use and sale of gas lawn equipment.
• A medical summary I wrote assisted the Medical Society of the State of NY in developing a resolution regarding the dangers of gasoline leaf blowers; the resolution passed and will be presented at the next national American Medical Association meeting. Adoption of this resolution would strengthen our cause to enact a ban of these devices across our region.
• Brookhaven National Laboratory has agreed to consider “greener” landscape practices as a result of a presentation we gave – along with Huntington CALM (Citizens Advocating for Leafblower Moderation – to their landscape maintenance division.
• Huntington and Stony Brook University Hospitals have agreed to restrict their use of gasoline leaf blowers based on information we provided. Northwell Health (formerly North Shore-LIJ) will have in their fall newsletter an article about the health risks of gasoline leaf blowers.
• I’ve joined with partners such as the Environmental Health Section of the American Public Health Association to publicize this issue and am hoping to recruit more pediatricians interested in this issue to engage other community elected officials after the election.

Our Academy’s goal is “Dedicated to the Health of All Children.” This includes making changes across our local communities that positively influence child health.  In ways big and small, making sure our communities make choices that put the health and well-being of children at their forefront — and bringing information to them about the dangers of pollutants — is the core mission of our committee.  We will next bring our cause to local town councils across Long Island to further spread the word about the dangers of gasoline leaf blowers on child health.

For more information:

• Steele NLC, Rowland S, Carter M et al. A report to the California legislature on the potential health and environmental impacts of leaf blowers.  California: California Air Resources Board; Feb 2000.
• 68 p. California Environmental Protection Agency.  Accessed Jan 6, 2015: http://www.arb.ca.gov/msprog/mailouts/msc0005/msc0005.pdf
• https://www.quietcommunities.org/wp-content/uploads/2014/11/Scientific-statements-on-Noise.pdf

(Dr. Lucy Weinstein, MD, MPH, FAAP is Co-Chair of the New York, Chapter 2 Environmental Health Committee, Assistant Clinical Professor of Preventive Medicine at SUNY/Stony Brook, and consultant speaker for the Child Welfare Training Program of the Dept. of Social Welfare of SUNY/Stony Brook)

Khalida Itriyeva, MD

Conducting Concussion Research with the Help of New York AAP Chapter 2: A Model of Partnership

Dr. Khalida Itriyeva, MD FAAP

(New York Chapter 2 of the American Academy of Pediatrics includes several medical centers with training programs.  In addition to co-sponsoring residency research presentations through our affiliated Brooklyn, Queens and Nassau Pediatric Societies, our chapter can be utilized as a resource to aid members interested in research.  Here Dr. Khalida Itriyeva, MD FAAP discusses how she partnered with NY AAP Chapter 2 to conduct a research project on the management of concussions in primary care which was subsequently presented at a national meeting.)

Concussions, a form of mild traumatic brain injury, are a “hot topic” in sports and medicine, with current studies focusing on the link of repeated concussions on the development of chronic traumatic encephalopathy and other long-term sequelae.  Mild concussions are common in young athletes, and pediatricians see many of these patients in their practices.  Guidelines and recommendations on diagnosis and management of concussion are constantly evolving and come from multiple organizations, resulting in varying practices among providers.

The Committee on Youth and Adolescence (COYA) of New York AAP Chapter 2 sought to survey local primary care pediatricians on their attitudes and practices regarding concussion after reviewing an article by Zonfrillo et al¹ in the December 2012 issue of Pediatrics.  Sampling pediatricians in the Philadelphia area, the authors found a majority of providers were referring concussion patients to specialists for reasons such as inadequate time or resources, comfort level, and setting.  They also found that providers had barriers in providing neurocognitive assessments, most notably due to inadequate time and training.

Were the issues and barriers in treating concussions in the primary care setting similar in our area?

The COYA conducted a survey of pediatricians in AAP Chapter 2 to determine whether our pediatricians would present with similar responses.  The COYA membership worked to modify and adapt the same survey used in the original article.  Partnering with AAP New York Chapter 2, we were able to disseminate our questionnaire electronically to all members on their chapter membership email list serve.

We found that most pediatricians were seeing patients with concussion and the majority of providers did feel comfortable educating families about the diagnosis of concussion and recommending the appropriate time to resume school and activities. A little over half (57.4%) of respondents were familiar with the New York State Education Department concussion guidelines.

Yet despite this familiarity with concussion, its symptoms and recommendations from the New York State Education Department (NYSED), most providers were referring some or all of their concussion patients to specialists, most commonly neurologists.  Reasons for referral included lack of comfort with management of concussion, lack of time or resources, and inappropriate setting for follow-up.  The majority of providers (87.1%) also identified completing a neurocognitive assessment as a barrier, most commonly secondary to lack of training.

Most respondents (84.3%) also answered that they would be interested in a webinar for CME credit focused on concussions.

Concussion Poster

The abstract for our study was accepted for poster presentation at the Society for Adolescent Health and Medicine 2016 Annual Meeting in Washington, D.C. in March.  Our poster also won 2^nd place in the Educational Outcomes Research category at the Northwell Health 2016 Academic Awards Day at the Feinstein Institute in June.  In the future, we hope to develop a webinar for CME credit on concussion diagnosis and management for primary care pediatricians.

A link to NYSED “Guidelines for Concussion Management in the School Setting” is listed in the references below.  The guidelines state that any student suspected of having sustained a concussion must be taken out of the physical activity immediately, and cannot return to physical activities until he/she has been symptom free for a minimum of 24 hours and cleared by a medical provider to initiate a gradual return to play.

The SCAT3^TM is a standardized tool that pediatricians can use in their practices to evaluate a patient who has suffered a concussion.  This tool may aid the pediatrician in determining whether an athlete is ready to begin a gradual return to physical activities.

Partnering with our local AAP Chapter was crucial to conducting this work.  Without their input, we would not have been able to send the survey to as many pediatricians and wouldn’t have adequately assessed the local practices regarding concussion management.  Further the Chapter benefitted by allowing us to identify a knowledge gap in the local pediatric community – a gap we hope to address in the creation of our webinar.  We hope this description of how we worked with the local AAP chapter will convince other academic programs to reach out to their local chapters to engage them in mutually-beneficial scholarly work.

References

1. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion.  Pediatrics.  2012 Dec;130(6):1120-5. doi: 10.1542/peds.2012-1431.
2. http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservices/ConcussionManageGuidelines.pdf
3. http://bjsm.bmj.com/content/47/5/250/T1.expansion.html

Elie Ward – Director of Policy and Advocacy for the New York State District of the American Academy of Pediatrics and Executive Director of Chapters 2 & 3

(The New York American Academy of Pediatrics, Chapter 2, collaborates with the other two chapters to form a strong, expert and respected voice for children in our state capital.  As another legislative session ended this June, Elie Ward, MSW, Director of Policy and Advocacy for the New York State District of the American Academy of Pediatrics, provides an update on the status of issues for which pediatricians across the state strongly advocated.  Mrs. Ward is also Executive Director of Chapters 2 & 3.) 

Your hard work of visits, calls and e-mails to our state leaders did make life better for children and families across New York State this year.

Two major wins that will have a positive impact on the lives of millions of children across the state are:

1.  Increase in Minimum Wage
   This year, working in coalition with many organizations across the state, we can claim victory on passing one of the largest increases in the Minimum Wage in the country.  Increasing the Minimum Wage is the most direct and effective way to address child poverty.  Here in New York State we took a giant step this year with minimum wage moving to $15 downstate and incrementally from $12.50 to $15 dollars upstate as the economy allows.  This legislated increase will do more the address child poverty across our state than any other option available to our state government.  Our voices, which focused on the direct positive impact on children across the state, made a difference in this campaign.
   
2. Paid Family Leave
   Again, working in a large coalition, we were able to get a generous and real Paid Family Leave program passed in NYS.  Families will now be able to take care of family needs at challenging times, birth, adoption, serious illness, and not worry about losing their jobs or losing all of their income.  Paid Family Leave is a crucial family support service that is important to all families as they struggle with balancing the complex needs of financial support for families to keep stable and the emotional social needs of taking care and building strong bonds to keep families together.  Paid Family Leave is a pro-family initiative that has finally come to NYS. Again, our voices, which focused on the impact on early brain and child development and early bonding strengthened the arguments in favor of Paid Family Leave.

Other legislative victories include passage of:

Insurance Coverage of Donor Breast Milk for high risk premature babies weighing less than 3.5 lbs, whose Moms for various reasons cannot breastfeed, or supply their own milk.

Minor’s Consent to HPV Immunization addresses conflict between Minor’s Consent Law and Immunization Law.  Passage of this legislation bridges the conflict and allows Minors to Consent to their own HPV immunizations.

Crib Safety and Safe Sleep This legislation requires the State Department of Health and the State Department of Consumer Affairs to clearly inform parents about the dangers of drop side cribs, recalls of unsafe cribs and provide information about safe sleep options for newborns and infants.  Implementation of the legislation will create more voices talking to parents about the importance of safe sleep, amplifying pediatric counseling at well baby visits.

We also were able to secure Executive Orders to Raise the Age of Criminality in NYS to 18 and to deny any coverage for Conversion Therapy in NYS.   Although we are appreciative of the Executive Orders on these two issues, we will continue to advocate for legislation, so the protections afforded cannot be challenged.

In addition, although we did not get our legislative fix for the Maternal Depression Screening payment challenge, we are being advised that the Department of Health will be coming out with a regulatory fix that will allow pediatricians to bill the screening to the child.   It is anticipated that we will see this fix before Labor Day.

Key Legislative Initiatives That Did Not Become Law This Year Include:

• E-Cigarettes Added to the Indoor Clean Air Act
• Child Safe Products Act
• Gun Safe Storage
• Collective Bargaining Rights for Physicians

But we will be back next year and will fight again for budget and legislative protections for the children and families of New York.   As you all know, advocacy is a long term process, what we don’t get one year, we can and will get the next year or the year after that.

Our goal, to improve the health and well being of all the children in New York motivates us to be consistent and strong in raising our voices for children.  When we win we celebrate.  When we lose, we take a breath and then plan how to come back and win.  That’s Advocacy!!!

Sam Bangug MD FAAP

     The American Academy of Pediatrics’ Motto is “Dedicated to the Health of ALL Children,” — not just those in the United States.  Locally, our international health committee works to help represent global childhood health issues across Long Island.  Working with multiple Filipino organizations and partially sponsored by New York Chapter 2 of the American Academy of Pediatrics, Dr. Sam Bangug MD FAAP organized and participated last spring in a 3-day international medical mission in his home country of the Phillipines. 

     Here he recounts his experiences leading a team of physicians in a provincial hospital in Isabela a province located 200 miles north of Manila, and a place where the majority of patients live below the poverty line. 

The Philippine Islands are well known for their natural beauty and friendly people.  However, despite hosting the fastest growing economy in Asia, access to healthcare can be difficult in more remote regions of the country.

Drawing on resources from the Association of Philippine Physicians of New York, the local chapter of the American Academy of Pediatrics, the Isabela National High School Alumni International group as well as other ethic organizations — Dr. Jose Quiwa and I organized our third annual medical mission to Ilagan Isabela, a province with high rates of poverty and poor access to healthcare.

This is where I was born and how I “give back” to those in my home country.

The medical mission catered to all dental, medical, and surgical needs, including free cataract surgeries. Dr. Jose Quiwa, Secretary of the Queens Pediatric Society and another AAP NY Chapter 2 member led the pediatric contingent.  Other volunteers include internal medicine physicians and ophthalmologists, four nurses and 25 volunteers.  We were also assisted by both local doctors and dentists and a pharmacist.

As a pediatrician, it was especially fulfilling to care for the children and to provide services which families had often been waiting months for.  Over the three days, a total of 2,200 patients were seen, 782 were pediatric.  Common medical problems encountered included anemia, malnutrition, pneumonia, diarrheal disease and dental carries.  Our surgeons repaired several hernias and operated on a patient with a thyroglossal duct cyst.

Patients wait to see a physician the Filipino clinic.

Among the many patients was a 9 month old named Mark with hydrocephalus whose family had been waiting for over three months to get an appointment at the Children’s Hospital in Manila.  One of the mission physicians, a retired neurosurgeon from California was able to schedule surgery for the patient a week after he presented to the mission clinical staff. By the time volunteers returned to New York, we heard Mark’s surgery was a complete success.

Despite the issues we often face navigating the medical bureaucracy for our patient here, there are so many aspects of care we take for granted.   Here, however, these practical issues add multiple layers of complexity which make providing care difficult.  A patient with a hernia was initially unable to receive surgery because expense anesthetic medications must be paid for in advance and his family could not afford it.  Our organization, partially funded by the NY Chapter 2, was able to underwrite the expense so the boy could be operated on while the surgeon was in the region, less he had to wait another year for his repair.

Another woman whose infant had diarrheal illness held her child’s intravenous (IV) fluid bottle in her hands for her baby’s entire hospitalization because the hospital ran out of IV poles.

New York AAP Chapter 2 members, Dr. Jose Quiwa MD FAAP (R) and Dr. Sam Bangug MD FAAP (L)

The number of patients seen and the timeliness of care given made the mission successful.  It could not have been achieved without the support of the generous donors and volunteers who selflessly provided their time and services. Queens based Physicians and American Academy of Pediatrics Chapter 2 International Committee Co Chairs Drs G. Sabogal and S. Patel help approach the Chapter about use of funds to support the mission and AAP Chapter 2 President Dr. J Abularrage authorized funding for the project as part of Chapter’s mission to uplift the health and conditions of ALL children.

Plans are underway for a fourth mission in February of 2017 and volunteers are currently being actively sought.