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March 4, 2020

I learned a lesson early about the importance of the words I use in taking care of patients. I’m not sure where I learned it, but the value of the lesson became quite apparent in this one patient encounter.

Setting:  I was on-call for my small private pediatric group and was called to see an infant at Harrison Memorial Hospital in Bremerton, Washington. While at the ER before I arrived, this febrile infant had a febrile seizure but recovered quickly and fever controlled quickly. The exam was normal and young child was alert, happy and no longer ill appearing.

I introduced myself, but the young parents appeared quite alarmed by my diagnosis of “febrile seizure.” I explained the exam and how this is a fairly common occurrence but not dangerous.  However, the father remained quite agitated and insisted we take him over to Children’s Hospital in Seattle, an hour’s ferry ride away.

I then started using ‘different words’ for the same condition and all of sudden the father smiled and was visibly quite relieved!  He then blurted out, “You said febrile seizure and now you said febrile convulsion!”  I said yes, they are the same problem but I am using just a different word for the same problem.

He then remarkably replied: “Oh, I am not worried about febrile convulsions, because three of his siblings had that more than once and did just fine! “When you said ‘seizure’ I thought you meant ‘Heart Seizure or Heart Attack’ and my father had that and died!”

Ah, the words we use can make such a difference for our patients’ understanding.  So, my learned lesson had been confirmed by this one encounter. Keep the practice of changing the words that mean the same thing because our patients may understand the words in such different and unexpected ways.

About the Author

Mark Nupen, MD, is a retired pediatrician active with MNAAP’s Senior Pediatricians’ group.

The Senior Pediatricians’ group will meet on Thursday, March 19 from 12 to 1:30 p.m. at The Wedge Table in Minneapolis. Email Melissa DeBilzan at          debilzan@mnaap.org to RSVP.

MNAAP is collecting stories from retired pediatricians to share more broadly. If you have a story to share, email Bethany Venable at venable@mnaap.org

Dr. Lisa Cinar serves on the  Board of Directors, acting as MNAAP’s chapter climate advocate. She has been an AAP member since 2006 and joined MNAAP in 2016.

Dr. Cinar answered these questions from Minnesota Pediatrician as part of our quarterly member spotlight.

What does a typical work day look like for you?

As a general pediatrician, I see children for all types of medical and behavioral concerns. This includes preventive care such as well child checks and vaccinations, as well as sick care for asthma, influenza, broken bones and chronic diseases. I have a special interest in mental health, particularly because so many children and adolescents struggle with depression, anxiety, ADHD and trauma-related disorders. Lifelong developmental issues such as autism are typically diagnosed in childhood, allowing me the opportunity to help families through the often difficult process of diagnosing, treating and accommodating children with special health care needs.

You recently became the chapter’s climate advocate. What interested you about this role?

I believe that climate change is the most important public health issue of our time.  Rising temperatures and carbon dioxide in our atmosphere have already caused significant annual losses in crops and livestock, resulting in millions more people going hungry every year around the world. We are also seeing our food supply become less nutritious and more polluted by the toxins we release into the environment. I am honored and excited to be the Climate Advocate for the Minnesota AAP Chapter because we need to take immediate action to decrease our carbon emissions and reverse the trend of climate change. By collaborating with other physicians and climate enthusiasts in the AAP, I believe that we can make a significant impact on the future of our planet and the human race. Not only can we advocate for more climate-healthy lifestyles in our patients and families, but we can also advise state and federal agencies to implement policies that will decrease our carbon footprint and improve public health on a much greater scale.

Why did you choose pediatrics?

I chose pediatrics because it’s the field of medicine that allows me to take a very well-rounded approach to improving the health and lives of children. In addition to providing routine health care and treating illnesses, I also help children and families to address social issues such as food insecurity, disability accommodations, education, bullying, family dynamics, child abuse, transportation, health care access and much more. Remembering that “it takes a village to raise a child,” I enjoy working with my entire team of professionals to help families and children live their best possible lives.

Outside of work life, how do you enjoy spending your time?

I have a passion for gardening, not only as a hobby but also as a way to feed my family fresh, healthy, locally grown produce. The positive environmental and health impacts of home gardening are amazing, and it’s a relaxing way to enjoy our Minnesota summers outdoors. Our vegetable, fruit and flower gardens have been a huge attraction for bees, butterflies and other important pollinators that are crucial to our global food supply. I also have a lifelong love of music, and I enjoy playing the piano and the French horn.

MNAAP has more than 1,000 members with careers that span differing lengths, specialties and interests. The Member Spotlight offers a chance to meet a fellow MNAAP member and learn a little bit more about them.    

If you are interested in being the subject of a Member Spotlight or have a suggestion of someone Minnesota Pediatrician should interview, email Communications Manager Bethany Venable at venable@mnaap.org.

By Jodi Fenlon Rebuffoni

Medical devices available for children are approximately a decade behind those available in the adult market. This innovation gap results in families and health care providers frequently improvising or making due with inadequate products across the spectrum of healthcare from intensive care to home health. An example of this disparity is the external pump ventricular assist device available for children as opposed to the internal and mobile ventricular assist devices available to adults.

As a pediatric ICU physician, Gwen Fischer, MD, FAAP, witnessed this technology gap first-hand. Drawing from her clinical experience, as well as knowledge gained through her fellowship in the Earl. E. Bakken Medical Device Innovation Fellows Program at the University of Minnesota (UMN), she formed the Pediatric Device Innovation Consortium (PDIC). The PDIC is dedicated to understanding and overcoming the complex barriers to pediatric medical innovation.

The PDIC program at the UMN includes three primary components:

An advisory board comprising industry and academic medical device experts to provide guidance to innovators of pediatric health technology

Funding to support the creation of new pediatric health innovations being developed at the University of Minnesota, and in collaborations between the UMN and industry, community or other academic partners. The PDIC funding programs were developed through a strategic partnership with the Office of Discovery and Translation, part of the University of Minnesota’s Clinical and Translational Science Institute.

A unique program that solicits descriptions of unmet needs and challenges caring for children’s health needs directly from patients, parents and other care providers in the community. This program is intended to help the PDIC better understand important unmet needs in pediatric health. Unmet needs are evaluated for innovation opportunities, and in certain cases, funding is dedicated to advancing a new solution.

Goals of the PDIC Program

  • Identify unmet pediatric medical needs and opportunities for innovation; including unique challenges of care in low-resource settings
  • Support the development of pioneering medical solutions that improve care for the pediatric population
  • Form innovative partnerships that advance pediatric device development

The PDIC has awarded more than $500,000 in project funding to advance 20+ unique pediatric innovations and licensed two technologies to UMN start-up companies. Nearly one-third of PDIC-supported projects include collaborations between the UMN and industry or non-profit organizations.

Looking forward, the PDIC aims to raise awareness of the work being done at the UMN to close the innovation gap in child health. Through outreach, collaborations and strategic thinking the PDIC hopes to increase the reach and impact of its successful programs toward a better future for children. The PDIC is interested to hear from pediatricians about needs and challenges their patients have faced that could potentially be improved through innovation of new medical solutions, and medical device solutions pediatricians may be developing.

Learn more at www.thepdic.org.

Inquiries can be directed to contact@thepdic.org.

Long Acting Reversible Contraceptives (LARC) methods, which include intrauterine devices (IUDs) and the etonogestrel implant, are the first-line birth control methods recommended for adolescents. However, their use extends far beyond contraception alone.  This article will review medical indications of LARCs for non-contraceptive use.

Adolescents with dysmenorrhea, anemia and bleeding disorders

Many adolescents experience heavy, painful periods that interfere with their quality of life. Hormonal IUDs can be an excellent therapy, especially the 52mg levonorgestrel device, as 90 percent of users report reduced blood loss or amenorrhea. Those with anemia or bleeding disorders, such as Von Willebrand disease, may also benefit from this side effect. While most users will experience irregular spotting after initial placement, bleeding patterns tend to improve over time.  If placement is a barrier to treatment, placement under anesthesia or with sedation can be considered; however, most adolescents tolerate placement quite well.

Unfortunately, the etonogestrel implant’s bleeding pattern is less predictable. About 22 percent of users experience amenorrhea, 24 percent experience light/infrequent spotting, and about 25 percent experience increased and/or irregular bleeding. Thus, the etonogestrel implant may be less preferred for patients with heavy bleeding.

Adolescents with learning and/or physical disabilities

Many adolescents with disabilities have unique physical needs, and menstrual suppression may be desired by the patient and their caregivers. Hormonal IUDs may be considered to achieve this goal, as they may have a more favorable safety profile than other methods of contraception. For example, estrogen-containing methods may be contraindicated in adolescents with limited mobility or prolonged immobilization due to the increased risk of thrombosis. Oral contraceptive pills may also require attention to dosing as they can interact with other medications, such as antiepileptics. In some patients, anesthesia or sedation may be necessary for placement; therefore, the benefits and risks should be discussed with patients and families using shared decision-making.

Transgender, non-binary, and gender non-conforming adolescents

In some patients experiencing gender incongruence, menstruation may contribute to worsening gender dysphoria and can result in significant distress. While transmasculine patients on testosterone typically experience amenorrhea with appropriate dosing and duration of testosterone treatment, trans and non-binary patients may wish to induce amenorrhea without the use of testosterone. If this is the case, hormonal IUDs may be considered, particularly if the adolescent would also gain contraceptive benefit.

Adolescents with polycystic ovarian syndrome (PCOS)

Adolescents with PCOS are at increased risk of endometrial hyperplasia due to prolonged exposure of the endometrium to unopposed estrogen, which occurs in the setting of chronic anovulation. Similar to combined hormonal contraception, hormonal IUDs can be used to reduce this risk by thinning the endometrium. There is evidence suggesting that the etonogestrel implant is similarly protective, although high-quality studies are lacking.

In summary, LARCs have a wide range of uses beyond contraception and should be considered as viable treatment options by pediatric providers.

 

About the Authors

Katy Miller, MD, FAAP; Janna R. Gewirtz O’Brien, MD, FAAP; Mollika Sajady, DO, FAAP; Taylor Argo, MD; Nicole Chaisson, MD, MPH; Christy Boraas, MD, MPH contributed this article.

Works Cited

1. Braverman PK, Adelman WP, Alderman EM, et al. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299

2. Jeffery E, Kayani S, Garden A. Management of menstrual problems in adolescents with learning and physical disabilities. Obstet Gynaecol. 2013;15(2):106-112. doi:10.1111/tog.12008

3. Teal SB, Romer SE, Goldthwaite LM, Peters MG, Kaplan DW, Sheeder J. Insertion characteristics of intrauterine devices in adolescents and young women: Success, ancillary measures, and complications. Am J Obstet Gynecol. 2015;213(4):515.e1-515.e5. doi:10.1016/j.ajog.2015.06.049

4. Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon® on menstrual bleeding patterns. Eur J Contracept Reprod Heal Care. 2008;13(SUPPL. 1):13-28. doi:10.1080/13625180801959931

5. WPATH. Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming people – WPATH World Professional Association for Transgender Health.

6. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod. 2018;33(9):1602-1618. doi:10.1093/humrep/dey256

The Centers for Medicare and Medicaid Services (CMS) proposes to adopt the following policies for Office Visits effective January 1, 2021:

  • Separate payment for the five levels of Office Visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021, and resurveyed by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC). This includes deletion of CPT code 99201 (Level 1 New Patient Office Visit) and adoption of the revised CPT code descriptors for codes 99202-99215.
  • Elimination of the use of history and/or physical exam to determine code levels.
  • Choice of time or medical decision-making (MDM) to decide the code level of Office Visits

The American Academy of Pediatrics will be providing many coding resources to help members prepare for the Office Visit coding changes in 2021, including:

The AAP Pediatric Coding Newsletter, available at https://coding.solutions.aap.org/Coding-Newsletter.aspx.

Previous and upcoming newsletter topics include:

Overview of changes, overview of MDM, overview of time, MDM — problems, MDM — data, MDM — risk, MDM — calculation.

Additional education opportunities include:

The 2020 National Conference & Exhibition will have a session dedicated to the Office Visit codes.

AAP Pediatric Coding Webinars on the Office Visit codes

Coding resources for the Office Visit codes on our Coding @ the AAP web site available to members.

Members and staff may submit questions to the AAP Coding Hotline by emailing aapcodinghotline@aap.org.

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