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June 13, 2019

Firearm-related fatalities are the third leading cause of death among children in the U.S., taking about 1,300 young lives annually. Several thousand children are injured by firearms yearly, and as many as 4 percent of children have witnessed a shooting in the past year causing immeasurable psychological trauma.

But what can we, as pediatricians, do to protect children from gun violence?

We can give very specific guidance to parents on how to safely store guns (if owned) and how to talk to their children about firearms. We can advocate for policies that have a track record for decreasing gun violence. This is an issue “in our wheelhouse” that we are equipped, and obligated, to address.

As pediatricians, we are in a unique position to rise above the partisan debate and advocate for children in the office, in our communities, and in our capitol.

Guidelines for Safe Firearm Storage

A 2018 study from the Journal of Urban Health found that 4.6 million U.S. youth live in homes with at least one loaded, unlocked firearm. Safe gun storage prevents accidental injuries and suicides. States with laws that require handguns to be locked have 68 percent fewer firearm suicides per capita than states without such laws, even after controlling for confounding variables. Share with parents and caregivers:

  • Hiding a gun in a drawer or closet is not safe storage
  • Firearms should be stored in a locked cabinet, gun vault or safe and/or secured with a gun-locking device (e.g.cable lock).
  • Ammunition should be stored and locked separate from firearm

Messaging for Children

  • Ask children to problem-solve at well check appointments: What would you do if you were playing at a friend’s house and found a gun? What if it looked like a toy?
  • The message you can share with children is: Stop. Do NOT touch the gun. Don’t let anyone else touch it. Even if the gun looks like a toy, don’t touch it because some real guns may look like toys. Go tell an adult.

Legislative Advocacy

Reducing firearm violence is one of MNAAP’s legislative priorities. The chapter advocates for policies that can protect children, including:

  • Background checks universally applied to all gun sales
  • Laws requiring waiting periods that create an important window for gun purchasers to reconsider their intentions and prevent impulsive acts of violence, particularly suicide
  • Minimum age for purchasing a firearm should be 21 years old
  • Safe storage laws can mandate safety requirements such as a locked container or gun lock

Additionally, since the federal assault weapons ban expired in 2004, banning assault weapons and large capacity ammunition magazines is an important area of policy to prevent mass shootings.

 

About the Author

Nadia Maccabee-Ryaboy, MD, FAAP, is a pediatric hospitalist at Children’s Minnesota. She serves on MNAAP’s child safety workgroup.

 

A teenage patient who has been coming to you her entire life is brought in by her parent, who is concerned with
the teen’s complaints of stomachache, fatigue, and loss
of appetite. The teen denies having intentions of losing weight, and her BMI is still above 50 percent. However, her weight has dropped significantly enough that she has steeply fallen off her growth curve, and she hasn’t had a period for five months. When a patient like this presents to your clinic, an eating disorder needs to be on your mind. In primary care, we are well-positioned to identify eating disorders early and intervene. We just need to ask.

Eating disorders in children and adults frequently go undetected for lengthy periods of time. This is a concern because early intervention is robustly linked to positive prognosis in these deadly illnesses. Pediatricians have the perfect vantage point to initiate intervention with children and adolescents with eating disorders. This is because patients often present first in primary care, usually with nonspecific concerns such as stomachaches, fatigue, depression, amenorrhea, or unexplained weight loss. When pediatricians screen for eating disorders, we are often able to identify them earlier and support families in seeking appropriate care.

Eating disorders are typically considered mental health issues which manifest physical changes. In children and teens, however, it may be more appropriate to think of eating disorders as physical conditions with mental health side effects.

Intervention in a primary care setting can also reduce the risk of patients failing to follow up with specialty care, which is another barrier to intervention for eating disorders. When a primary care provider diagnoses an eating disorder it can reduce some of the stigma of having an illness, because it recasts it as a medical issue, rather than a mental health issue. Additionally, pediatricians often have long-standing relationships with families as trusted medical experts.
This relationship can help parents feel supported as they struggle to take action to address their child’s disorder.

Good evidence-based outpatient care for eating disorders exists, but it is frequently very hard for patients to access. Family-Based Treatment (FBT) is considered the first line evidence-based outpatient treatment for treating adolescent eating disorders, however, fewer than 100 practitioners worldwide are certified in this method. Most of those who are certified are located near a major metro area, which limits rural patients’ ability to access treatment. Mayo Clinic has developed and piloted a modified version of FBT for delivery in primary care, by a primary care provider. This intervention is called Family-Based Treatment for Primary Care (FBT-PC). This interdisciplinary program allows for the comprehensive management of both psychological and medical factors at a single location and has the potential to improve access to eating disorder care for anyone with a primary care provider.

In early 2017, two pediatricians and one family medicine nurse practitioner at the Mayo Clinic received training in FBT-PC. All providers in the pilot program were volunteers and saw FBT-PC patients as part of their standard clinical practice. Providers received four hours of initial training led by two clinical psychologists who specialize in the treatment of adolescent eating disorders, one of whom is FBT-certified. The content of the training consisted of FBT interventions that focus on weight restoration and normalization of eating by empowering parents to take charge of refeeding their child through monitored meals. Throughout the pilot, providers participated in monthly hour-long FBT-PC case consultation meetings with the psychologists and had the ability to consult with them in between sessions as well.

Results from a pilot study of FBT-PC suggest the intervention is suitable for implementation in primary care settings and was associated with significant improvement in patient BMI percentile after three months. The rate of weight gain was comparable to that recommended in standard FBT. Providers had success engaging caregivers or parents, and retaining families in treatment. These findings suggest that additional study of the FBT-PC intervention is warranted, and confirms the idea that primary care is a feasible and potentially effective setting to implement eating disorder care for young patients.

Pediatricians are dedicated to the sustained health and wellbeing of their patients. The standard practice of reserving eating disorder interventions for specialists, and failing to involve primary care in the treatment ignores the powerful role pediatric providers can play in helping young patients get care. By shifting the paradigm and arming pediatric providers with the evidence-based tools they need to help families of children and adolescents with eating disorders, there is the potential to increase early intervention and improve patient outcomes.

 

Jocelyn Lebow, PhD, LP, is a clinical psychologist at Mayo Clinic and is certified in Family-Based Treatment.

Cassandra Narr, APRN, CNP, MSN, Angela Mattke, MD, FAAP, Janna Gewirtz-O’Brien, MD, FAAP, Marcie Billings, MD, FAAP, Robert Jacobson, MD, FAAP, and Leslie Sim, PhD, of Mayo Clinic collaborated on this article.

 

The much-anticipated warm weather and activities are upon us. I live in Duluth, so when we start to see ships passing under the Aerial Lift Bridge it’s official: Spring is here! I am pleased to report that advocacy has been the driver of a great deal of energy in the Minnesota Chapter of the AAP these past few months. We had a robust attendance of more than 140 at our Pediatricians’ Day at the Capitol this year. Having the opportunity to learn more about our legislative priorities and meeting with Minnesota lawmakers enriches our advocacy experience, and the engagement was palpable this year. The Minnesota State Capitol has been literally buzzing with activity. It was a vigorous legislative session in 2019 with over 5,000 bills introduced. Thousands of those failed to meet deadlines, but many have made it through the relevant policy committees in the House and Senate. I want to acknowledge and thank all the pediatricians who have given testimony in the hearings for several relevant bills. We have a “deep bench” of participants and have been able to call on them with short notice.

In addition, many pediatricians have been speaking up at their local city councils on behalf of Tobacco 21 ordinances in the metro area and in greater Minnesota. Tobacco 21 ordinances would raise the purchase age for tobacco products to 21 and can help prevent or delay nicotine addiction. The pediatricians who are sparking conversation and encouraging change are the “boots on the ground” folks. You have been very influential in getting these ordinances passed. There are many pediatricians across the state that apply advocacy in their practice, schools, and communities. I thank you for your dedication and tireless efforts. I am currently reading a book about Eunice Kennedy Shriver, who lived a life emblematic of advocacy.
Even though she lived in the shadow of her politically accomplished brothers, she had a fervor for advocacy that resulted in the formation of the Special Olympics. She was described as impatient, insistent and formidable, qualities that led to a lasting legacy of social justice. It is with that same persistence and passion that we will continue to speak up and speak out on behalf of all children and families of Minnesota.

 

MNAAP members are committed to protecting and advancing the health of every child and adolescent in Minnesota through advocacy, education and special projects.

The 2019 legislative session has been an active one, with opportunities for MNAAP to be represented in different formats. Many thanks to members who have stepped up to testify in legislative committee hearings, written letters to editors on priority issues, and dedicated their efforts to the health and wellbeing of Minnesota’s children.

Testifiers

Dr. Sheldon Berkowitz in support of immunization education bill (HF 1182)

Dr. Mike Severson in support of Paid Family Medical Leave

Dr. Marilyn Peitso in support of banning conversion therapy (HF 12)

Dr. Nate Chomilo to reduce disparities in prenatal care (HF 909)

Dr. Andrew Kiragu in support of requiring criminal background checks for private firearm sales and transfers (HF 8) in addition to the “red flag” bill (HF 9)

Dr. Gigi Chawla to increase funding for Reach out and Read (HF 2111)

Dr. Sheldon Berkowitz on the effects of screen time in children (informational Senate hearing)

Dr. Lindsey Yock about the link between child hunger and health (informational House hearing)

 

Letters to the Editor

Dr. Sue Berry in support of the provider tax in the Star Tribune

Dr. Ann Sneiders on the importance of immunizations in Owatonna People’s Press

Dr. Nate Chomilo on the need for paid family medical leave in the Star Tribune and the Sun Post in support of the provider tax

Dr. Mike Severson on preserving the provider tax in MinnPost

 

Chapter letters of support or written testimony

Immunization education bill (HF 1182) to House HHS Finance Committee

Provider tax to House HHS Finance Committee Funding for mental health services to homeless youth (HF 1542) to Rep Ruth Richardson

Funding to expand Reach Out and Read (HF 2111) to House Early Childhood Finance and Policy Committee

Funding for a work group to examine links between health disparities and educational achievement (HF 2171) to House HHS Policy Committee

Funding for mental health training for pediatric residency (SF 1702)

Opposition to legalization of recreational marijuana to Senate Judiciary Committee

 

Chapter letters of support – Federal

Public health research on firearm morbidity and mortality prevention to Congress

President’s Emergency Plan for AIDS relief to U.S. Rep. Betty McCollum

(Updated 6/12/19)

May 29, 2019

Marshall Land, Jr., MD, FAAP, presented at the May 3 Hot Topics in Pediatrics Conference about innovations and improvements in maintenance of certification. He asked conference attendees to use notecards to leave him follow-up questions about MOC4. Below are the questions that were posed, and the answers from Dr. Land. (A video of Dr. Land’s presentation is available below the Q and A section.)

Q: MOC is stated as voluntary, yet it is now required for us to continue caring for patients – it’s tied to hospital credentialing and to insurance reimbursement.  If we don’t pay it, we can’t practice.  Isn’t that extortion?

A: Certification and ongoing certification (MOC) are voluntary.  Like all other medical specialties and virtually all other professions, a certification process is in place based on standards of excellence for that profession.  Almost all professions have a continuing certification process (such as MOC).  As an example, American Airlines pilots are required to maintain their “certification” by traveling to Dallas and participating in 3-day learning and testing activities every 6 months.  My cousin, a very experienced American Airlines pilot, needed a medical leave of absence for 12 months for cancer treatment, and now must go back for one month of “re-training” before he’s allowed to fly again.  The ABP does not ask hospitals or insurers to require certification (or ongoing certification); that is up to them.

Q: Why must MDs continue to pay to practice medicine?  Non-physician providers have no regulatory MOC and are able to practice independently with less than 3 percent of our training.  In no other field does this happen.

A: Again, virtually every profession requires maintaining certification within that field.  Physicians Assistants, for example, have requirements to maintain their certification every 2 years.  Nurse practitioners must renew their certification every 5 years.

Q: Are you grandfathered in and not participating in MOC?

A: Yes, I do qualify for being grandfathered in, but I actively participate in MOC, because I think it is the right thing to do.  This winter, I completed my second Part 4 practice improvement project within my current cycle.  My cycle does not end until December of this year, but because I have completed my requirements for this cycle, I have already signed up for my next cycle which will end in 2024.

Q: Why are physicians prior to 1988-1993 grandfathered in?

A: The issue of “grandfathering” is a tough one.  We do have an awkward situation in this regard, but we are honoring a promise made to those physicians when they were initially certified.  We are proud that a large percentage of those pediatricians have voluntarily chosen to maintain their certification; although the number of grandfathered pediatricians is decreasing, the number signing on to participate in MOC is increasing, partly due to the improvements and innovations in the process.  All of the over 250 pediatricians who do the work of the ABP, full time or volunteer (around 240 of the total are volunteers), and regardless of whether they are eligible for “grandfathering”, must be maintaining their certification by the same process as all other diplomates; there are no exceptions.

Q: What makes the ABP think that pediatricians will stop “lifelong learning” and why must we continue to pay to be able to practice medicine?

A: The ABP does not think that pediatricians would ever stop lifelong learning; they are the most dedicated group of individuals anywhere.  As a certifying organization, the ABP is trying to show the public that pediatricians are keeping up with lifelong learning and practice improvement.

As I answered in a previous question, virtually every profession, medical and non-medical (physicians, physician assistants, nurses, pilots, lawyers, electricians, etc.) requires maintaining certification within that field.  The ABP enrollment fee includes participation in MOCA-Peds, as well as access to all ABP activities needed to complete Parts 2 and 4 of MOC at no additional cost.

A word about the cost.  The ABP is nonprofit and works very hard to steward the resources we have.  MOC is not a “money maker” for the ABP; it actually loses money.  The ABP produces over 50 separate examinations as well as many Part 2 and Part 4 activities that can be used to complete MOC for both generalists and sub-specialists. Unfortunately, most of the sub-specialty examinations cannot cover their expenses given the small numbers involved (just 20 or so rheumatology fellows exit training each year for example, but the costs remain the same).  Although most people tend to equate the cost of certification and maintenance of certification with the perceived costs of exam development and administration, the fees for certification and maintenance of certification must support all of the Board’s operations of which development of multiple examinations is only one part. These include, but are not limited to development of initial and recertifying examinations in general pediatrics and for each of the 16 sub-specialties; the staff who review eligibility requirements, work with residency and fellowship program directors on details related to resident and fellow tracking, and develop and administer in-training examinations; development of instruments to assess the general competencies of trainees in both general pediatrics and its sub-specialties; examination psychometric analysis; participation in national efforts related to competence, quality improvement, and standard setting; participation in all functions of the Residency Review Committee in Pediatrics of the Accreditation Council for Graduate Medical Education; and membership in the American Board of Medical Specialties (ABMS) just to name a few of the less visible activities.

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