Minnesota Chapter of the American Academy of Pediatrics

Michael Severson, MD, FAAP

<a href="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/08/MikeSeverson.jpg"><img decoding="async" class=" wp-image-484 alignleft" style="margin: 5px;" alt="MikeSeverson" src="http://mnaap.org/newsletter/wp-lib/wp-content/uploads/2015/08/MikeSeverson.jpg" width="115" /></a>By Michael Severson, MD, FAAP; Susan Schloff, MD, FAAP; Faith Kidder, APRN, CPNP, MS, PHN, Minnesota Department of Health
The Minnesota Department of Health (MDH) recently updated its vision screening guidelines and best practices in a succinct, easy-to-access document for providers who do not have the time nor the need to scan a procedure manual.
Developed by a cross section of screening entities and professional organizations, including Dr. Mike Severson representing the Minnesota Chapter of the American Academy of Pediatrics, the document provides at-a-glance information about recommended vision screening procedures for children post newborn through age 20.
In Minnesota, the number of kids who receive vision screening is above the national average. Still, many kids pass when they need further testing. The new guidelines direct practices, schools and early childhood programs to use correct methods to ensure accurate, reliable results.

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Overview of changes to MDH guidelines:
• Adds AAP risk factors requiring referral rather than screening 
• Suggests different eye occlusion strategies &#8212; because kids peek! 
• Changes the screening distance for all children to 10 feet per AAP recommendations 
• Updates pass criteria for 3-year-olds 
• Allows 3 to 5-year-olds to miss one of any HOTV or Lea symbols 
• Replaces Snellen chart for older children with Sloan Letters chart. 
• Adds screener qualifications for each procedure (this is mostly for screening programs to follow; provider would still be required by Child and Teen Checkups to do a complete eye exam). 
• Replaces the cross cover screening for screening programs with the uncover screening. 
• Adds recommendations for instrument-based vision screening.
The U.S. Preventive Services Task Force recommends vision screening for all children ages 3 to 5 years to find conditions such as strabismus or refractive error that contribute to the development of amblyopia. Amblyopia can only be treated effectively if caught early.
Impaired vision in children can contribute to the development of learning problems which may be prevented or alleviated through early identification and intervention. Amblyopia, for example, is impossible for parents or providers to detect by casual observation. A careful vision screen allows early treatment—the best option for complete cure.
With prompt referral and follow-up, Minnesota children have an opportunity to receive appropriate and timely care and services which lead to better health and educational outcomes.
Be sure you and your team check out the new guidelines (due to be posted by 8/31/2015) at <a href="www.health.state.mn.us/divs/cfh/topic/visionscreening/" target="_blank" rel="noopener">www.health.state.mn.us/divs/cfh/topic/visionscreening/</a> 
For more information, please contact the Minnesota Department of Health Child and Teen Checkups program at health.childandteencheckups@state.mn.us or call (651) 201-3650.

Open Your Eyes: MDH Releases New Vision Screening Guidelines

In St. Cloud, pediatricians are flown in on a regular basis to help staff the local PICU. In Mankato, about one quarter of hospitalists are residents of Wisconsin or communities outside the city. Locum tenens are plugged in at hospitals and clinics all over the state.
Recruiting and retaining full-time primary care providers at various stages of their careers isn’t easy, especially in rural Minnesota. And the problem could get worse in the coming years.

Recently AAP’s Committee on Pediatric Workforce said it expects increased demand for general pediatricians in the near future and confirms there is a shortage of pediatric subspecialists and surgical specialists across the country. At the same time, the prevalence of chronic diseases in children is one the rise. About 27 percent of children have a chronic health condition, such as asthma, obesity, diabetes or a mental health disorder, that needs to be managed by a primary care team.
A variety of factors contribute to the shortage, irrespective of geographic area, such as higher rates of health insurance, fewer residency program vacancies available to medical students, and an increasing number of physicians seeking part-time work.
The biggest factor, however, may be physician age. More than one-third of the state’s 15,000 primary care doctors are over 55, and roughly 20 percent intend to work less than five years more, according to a 2013 report from the Minnesota Department of Health (MDH).
MDH estimates Minnesota will have a shortage of between 1,000 and 2,000 primary care providers by the early 2020s, according to Mark Schoenbaum, director of the Office of Rural Health and Primary Care at the Minnesota Department of Health, who was quoted in a 2013 article by the Associated Press.
Currently there are about 1,200 board-certified pediatricians in Minnesota. Assuming 20 percent intend to stop working in the next 5 years, 240 will need to replaced by 2019. However, Minnesota’s residency programs have been graduating between 33 and 37 pediatricians per year since 2006. At this pace, they will produce at most 185 pediatricians to fill the gap, forcing Minnesota to hire pediatricians from other states.
The majority of Minnesota’s pediatricians are located in the metro area and there is unequal distribution in rural areas. In fact, only 10 percent of Minnesota’s pediatricians are located in rural areas though it’s home to 30 percent of the state’s population. Additionally, the ratio of children per every 1 pediatrician is much higher in rural areas. There are 5,173 children for every 1 pediatrician in Northwest Minnesota, for example, compared to 898 children per pediatrician in the Twin Cities.
One of the ways Minnesota clinics and hospitals have been trying to address provider shortages is to rearrange how health care is delivered. The medical home approach is growing, EMR systems are being implemented, telemedicine is being explored, and non-physician clinical providers are stepping up.
The pediatricians at ACMC clinic in Willmar have managed to replace retirees and career-changers over the past few years, but it’s been a challenge, according to Michael Hodapp, MD, a general pediatrician at the multi-specialty clinic. In November, the clinic added a fifth pediatrician to replace one who left to become a hospitalist in the cities. Now the clinic needs to hire at least two more before Hodapp and a colleague retire in the next couple of years.
&#8220;There’s a definite need for more pediatricians here,&#8221; Hodapp said. &#8220;We get a lot of referrals from Southwest Minnesota. There’s just one pediatrician in Marshall. Otherwise there’s no pediatricians west of the border and no pediatricians south of the border until you get to Mankato.&#8221;
Aside from working and living in a rural setting, the 24/7 call responsibility is one of the reasons recruitment is more difficult. There are just five pediatricians to cover deliveries, newborn nurseries, ER and urgent care. They rely on locum tenens to cover one out of five weekends as well as some holidays.
Hodapp estimates he sees about 5,000 patients per year.
&#8220;We keep in contact with residency program directors,&#8221; Hodapp said. &#8220;And we keep close tabs on the local med students who come through. But we don’t rely on PAs and APNs in pediatrics like the rest of the clinic is doing.&#8221;
In 2013, the number of pediatric and med-peds residents who graduated from Mayo and the U of M was 46. Most stayed in the state, but only one chose to practice in rural Minnesota despite a generous federal loan forgiveness program.
The graduating classes from each school were comprised of more women than men, a strong desire to pursue subspecialties, and increasing interest in hospital medicine.
Large hospitals aren’t immune from hiring difficulties either. Children’s Hospitals and Clinics attempted to fill 20 positions for pediatricians and pediatric specialists between January 1 and October 1 of 2014. It only filled 8.
&#8220;We have had high-quality applicants for most of our positions,&#8221; said Ryan Berreth, DASPR. &#8220;The quantity varies on position; we have some very hard to fill sub-specialties, where we have limited amount of applicants. We also have other positions that receive a fair amount of applicants.&#8221;
Trends in recruitment and retention, he said, include providing an adequate CME budget, pairing new hires with individual physician mentors, and encouraging involvement with administration. Work life balance is important, too.
&#8220;Physicians are wanting a stronger work life balance with a fair/flexible schedule, including call,&#8221; Berreth said.
A large-scale survey conducted by Merrit Hawkins between March and June 2014 revealed that 81 percent of physicians described themselves as &#8220;over-extended&#8221; or &#8220;at full-capacity.&#8221;
Still, 71 percent said they would choose to be a physician if they had to do it all over again.

Sustaining Minnesota’s Pediatric Workforce

By Michael Severson, MD, FAAP, pediatrician and EHDI Advisory Board Member; Faith Kidder, CPNP, Child and Teen Checkups at the Minnesota Department of Health, and Cara Weston, Newborn &amp; Child Follow Up Unit at the Minnesota Department of Health
Hearing screeners in Minnesota have a valuable new resource in the Guidelines for Hearing Screening after the Newborn Period to Kindergarten Age, recently approved by the Minnesota Newborn Hearing Screening Advisory Committee.
The new guidelines provide Minnesota-specific information and resources, including details on screening equipment, protocols, and pass/refer criteria, as well as Individuals with Disabilities Education Act (IDEA) Part C and Part B referral and evaluation. They also clarify documentation and reporting requirements.

The biggest impact of these guidelines on the primary care provider’s practice is the definitive direction given to screeners thereby streamlining their decision making and referral process, which in turn assists providers in the timely identification of children most at risk for permanent hearing loss. The guidelines provide different referral recommendations and timelines for at-risk children, which separates them from those who have transient or fluctuating hearing loss due to otitis media with effusion.
Consistent with American Academy of Pediatrics (AAP) and Joint Commission on Infant Hearing 2007 recommendations, children who pass their newborn hearing screening but have a risk factor for hearing loss should be referred to an audiologist by 24-30 months of age. The guidelines clarify that this should occur as soon as a concern is identified.
The guidelines give specific direction regarding the appropriate use of otoacoustic emissions (OAE) screening for children after the newborn stage through three years of age, or when developmentally necessary in older children, and the use of tympanometry in identifying the absence of middle ear effusion. The screening algorithm for OAE and tympanometry calls for a waiting period of 14-21 days if a child has a REFER on both OAE screening and tympanometry, but primary care providers can proceed directly to the step of middle ear evaluation—saving valuable time for the family and potentially reaching a diagnosis more quickly.
Pure tone audiometry is recommended for screening children age three and older, with tympanometry used as indicated by the guidelines as a second stage screen for children with a pure tone screening REFER. For children who REFER on pure tone audiometry screening at a primary care visit, the provider may proceed directly to the step of middle ear evaluation.
Hearing screening in early childhood plays a critical role in the EHDI process by identifying children with permanent and longstanding fluctuating childhood hearing loss that may affect health, communication, learning and development. With prompt referral and follow-up, Minnesota children have an opportunity to receive appropriate and timely care and services which lead to better health and educational outcomes. For more information, please contact the Minnesota EHDI program at ehdi@state.mn.us or call (651) 201 &#8211; 3650 or visit www.improveehdi.org/mn/index.cfm 
Find the guidelines online at: www.improveehdi.org/mn/library/files/afternewbornperiodguidelines.pdf
Screening algorithm for OAE and tympanometry: <a href="http://www.improveehdi.org/mn/library/files/oaetympflowchart.pdf">www.improveehdi.org/mn/library/files/oaetympflowchart.pdf</a>

Have You Heard? MN has Updated its EHDI Guidelines

Grand Itasca Clinic & Hospital is seeking a board certified/board eligible outpatient Pediatric Physician to join our busy and growing primary care clinic practice. Grand Itasca is a fully integrated multi-specialty clinic and hospital located in Grand Rapids, Minnesota.

Pediatric Physician

Partners in Pediatrics, Ltd. is seeking a full time BC/BE Pediatrician. The standard work week for a full-time pediatrician is 4 days a week plus a rotation of nights and weekends. Night and weekend shifts are shared equally among all providers. The salary package is competitive. You will have paid time off (PTO) and be given a CME allowance as well as CME days to further your medical education. We offer health, dental, disability and life insurance. You will also be eligible for a lucrative profit sharing 401(k). For inquiries, please contact our recruiting leads, Dr. Lisa Irvin at lirvin@pipstop.com and Dr. Megan Camerino at mcarmerino@pipstop.com

BC/BE Pediatrician

We’re excited to announce an opening for a Communications Manager at the Minnesota Chapter of the American Academy of Pediatrics (MNAAP). This part-time, remote role is a unique opportunity for a communications professional with at least five years of experience, who is passionate about advancing child health through advocacy, education, and special projects.

Michael Severson, MD, FAAP Category