California
Chapter 1
News Update November 1998
| How Can Busy Northern California Pediatricians Prevent Violence? | Hotline Report |
| President Column | Hotline Statistics |
| Vice President Column | Then and Now… |
| District Chair Report | Chapter 1 Website Information |
| Member at Large Report | Resource Guide |
| Conference Announcement | Letters to the Editor |
| Many California Communities are Ignoring the Swimming Pool Safety Act |
How Can Busy Northern California Pediatricians Prevent Violence?
By Aparna Kota
The unimaginable involvement of children in horrible violence can be overwhelming for us as pediatricians; however, several factors associated with increased violence have been delineated, and there are substantial efforts to stem the violence epidemic. Pediatricians, parents, school officials, law enforcement officials and community group leaders can work together to ensure that children at risk for violence receive the appropriate community and health services. Children at risk may present with: weapon carrying, depression, bullying, withdrawal, lack of connection with peer groups, witnessing violence, subtle or overt signs of abuse or neglect, suicidal thoughts, substance abuse, and excess exposure to violence.
The Centers for Disease Control has found that children under 15 are 12 times more likely to die from firearm injury than their counterparts in 25 other industrialized nations combined. A child dies of firearm Injury in the United States every hour. Firearm injuries and deaths in children is a public health epidemic. In 1995 in the United States, 5,170 children ages 0-19 were killed by handguns.
The AAP California District has developed a questionnaire to assess children’s risk of experiencing violence. The parents and/or teen answer a brief set of questions. The physician can address red flags that may put the child at risk or refer to appropriate services.
The AAP trained over 100 pediatricians in the US to speak to other groups about firearm injury prevention. The major themes are:
If you would like to have a 1 hour AAP supported conference on firearm violence prevention at your institution or in your community to discuss facts and local solutions, please contact: Jim Lemesurer, MD (707 579-0652); Margaret McNamara, MD (415 885-7705); or Aparna Kota, MD, MPH.
If you are interested in the District survey, please call Aparna Kota, MD, MPH at
(707) 579-4437 or e-mail: akota@compuserve.com
Change on the Horizon
By Tom Long
Each evening before retiring one of my “jobs” is to walk the dog. Now my lab does not talk much so I have had time to focus on something else — usually the moon and stars. The skies intrigue me. I cannot believe that it took me so many years to appreciate orbits and rotations and the summer versus winter celestial show. Now I find myself predicting where and when the moon will appear, conjunction features and the star relationships to our polar star. The constancy of the stars is a wonder of the universe.
Not so constant is the world of pediatrics. Change seems to be always on the horizon. Our particular specialty is only 50 years old. New biologic and physiologic information guided us in the past. Infectious diseases were scientifically studied and new antibiotics evolved. Technologic advances also have had unbelievable impact. What forces will influence our future role?
The question is an important one I think. Change for us is inevitable. The role of pediatricians evolved with the years. Population growth, manpower, resource considerations, data based decision making, recognition of cost benefit factors achieved with early intervention are but a few influential factors. I do not see the pediatrician as the hands on health care manager for a child with a common upper respiratory infection or the usual gastroenteritis type problem and maybe some not so benign ailments.
So what prompts these thoughts, which incidentally I do not consider pessimistic. The fall is a busy time in the Academy. Our Chapter sponsored the Getting to Know You Dinner, our education committee produced two Life After Residency programs, and the finishing touches have been applied to the Winter Meeting — School Health, Challenges and Solutions. I have been to the Annual Chapter Forum and of course the Annual AAP meeting occurred in October in San Francisco. At every turn I meet our young aspiring pediatricians whose future practice will likely be very different from the one for which they were trained. My practice too is far different than I ever imagined.
Our National American Academy of Pediatrics is rich with resources. You have no doubt seen some recent information about a Medical Home Training Program. We must become a better community resource. There are hosts of children with physical, medical and psychosocial needs for whom we can be advocates with expertise. The cost benefit gain of maximizing their potential is huge. We pediatricians are uniquely qualified to fill this need. A training program to ensure that children with special needs have a medical home is being pilot tested. It should be available in 1999. The Future of Pediatric Education continues to focus on the pediatrician of the tomorrow. In the midst of all this “futures stuff” are the real down to earth needs of today. The AAP has CATCH. This program enables pediatricians to obtain grants, institute programs, and improve the health care of children locally. These grants empower pediatricians to exercise their resource value. A CATCH program coincided with the national meeting, designed to assist pediatricians in identifying appropriate projects and grant writing.
In short, I see the pediatrician of the future still quite in keeping with today’s American Academy of Pediatrics Vision Statement. “... Pediatricians are the best qualified of all health professionals to provide child health care…(1 ) advocate for infants, children, adolescents, and young adults, (2) collaborate with others to assure child health care, and (3) ensure that decision-making affecting the health and well-being of children and their families is based upon the needs of those children and families.”
Our lives may not know the constancy of the stars but you know as surely as the sun will come up tomorrow that there will be children in need.
By Paul Jewett
Tom Long, Mark Simonian, and I were pleased to represent Chapter 1 at the September Annual Chapter Forum in Chicago. As always, that meeting provides an exciting opportunity to see the Academy of Pediatrics up close and in action. Several members of our Chapter and District submitted resolutions, and many of these were not only discussed by the Forum, but passed and will be considered for action by the National Academy’s Board and Committees. Resolutions approved included such topics as increasing Medicaid-SCHIP reimbursement, improving CPT coding and RBRVS payment scales to appropriately reflect pediatric care needs, and providing adequate payment and coverage for vaccines. Other resolutions that passed encouraged the Academy to evaluate chiropractic care for children and infant management programs, to advocate for studies and strategies to prevent the sexual exploitation of children and to better deal with issues of school violence, to improve information regarding child auto-seat restraint choices, to support legislation to mandate improved hygiene facilities for field food pickers, as well as resolutions concerned with other advocacy issues. This is by no means an exhaustive list of the resolutions that passed the Forum. If you desire more detailed information or the outcome of a specific resolution, please contact me at your convenience. I also have information about the disposition of the resolutions that were passed in 1997.
We also heard several stimulating presentations at the Forum, including talks on the impact of advertising and the media on children, as well as the dangers of unsupervised access and use of the Internet. Tom hopes to have some of this information available as handouts at our Chapter’s Winter Academic meeting on School Health issues in San Francisco.
Finally, we all attended other sessions that provided insight into what concerns other Academy Chapters around the country have, and what they are accomplishing. Needless to say, your efforts in Chapter 1 are well known and appreciated! Keep up the good work for children and begin thinking now what resolutions you would like to see considered next year. See you at the December Winter Meeting.
Missed Opportunities: Prevention of Firearm Injuries
Less than two weeks before Governor Wilson again vetoed firearms safety bills authored by state Senators Polanco (SB1500) and Hayden (SB1550), I shared the speakers podium with Mrs. Gayle Wilson at the First Annual California Medical Services for Children Conference. As did Mrs. Wilson, I chose to speak on the topic of prevention, knowing that she and the Governor enjoy being associated with prevention of childhood disabilities. My topic addressed missed opportunities in the prevention of firearms related injuries to children.
Although opportunities missed in pediatric practice are more commonly associated with preventive immunizations, I employed some convincing slides and data to show how we commonly miss opportunities in our offices and patient interactions in the emergency department to screen for the presence of firearms in the home, school, or play environments of children and youth. Opportunities to counsel and defuse thoughts of retaliation by friends and peers or relatives are also missed in the wake of children being killed or injured intentionally or as unintentional targets caught in the crossfire of rival gangs or drive-by shootings.
I described how the growing epidemic of violence, especially firearm-associated violence in our society should be approached from a public health perspective. The lethal nature of firearms as a vehicle of injury is self explanatory, whether considering homicide or suicide. Suicide attempts are much more likely to be fatal with gunshots than with drug overdosages in children and youth, as well as in adults. I explained how unsafe guns could be picked up by a toddler, who places the gun automatically, like everything else, in his mouth. If the toddler stumbles, the inexpensive Saturday night special weapon will discharge and literally blow off the back of the child s skull, since such weapons are commonly produced without a reliable integral safety lock, making them less expensive and more unsafe.
Mrs. Wilson appeared to be taking notes when I showed the slide noting that 40% of 3 and 4 year olds and more than 90% of 7 year olds have adequate trigger strength (about 10 lb. worth) to fire almost any handgun.
I also spoke on the costs of firearms related injuries - more than $20 billion annually - and the fact that for each individual killed by gunfire, there are 3 who survive, often with lifelong disabilities secondary to their gunshot wounds. There were 5300 children killed by firearms in the U.S. last year, about 450 per month. More than 1400 children in California died by violent means, mostly gunfire, last year. That’s more children killed than in any other state and the District of Columbia, simply because of California’s vast population and the ready access to unsafe firearms, more than 90% of which are manufactured within a 5 mile radius of Los Angeles.
The fact that firearms are excluded from the Consumer Safety and Protection Act makes the consideration of safety relevant to guns of all types. I seriously doubt that guns will disappear from our society. Nonetheless, the interventions which consumer protections have effected with motor vehicles and highway safety have resulted in continuing decline from fatalities secondary to motor vehicle injuries. At current rates and trends, fatalities in children due to firearms injuries will exceed those from motor vehicle injuries by the year 2001 or sooner. However, we know that certain interventions such as integral safety locks on weapons, trigger locks, lock boxes, separate storage of weapons and ammunition, and restriction of access to firearms are effective deterrents to injury and/or suicide.
Governor Wilson has now missed two opportunities to sign legislation passed by both houses of our State Legislature which would outlaw the manufacture of unsafe firearms, as well as legislation which would encourage weapons dealers to make available information about trigger locks, lock boxes, and safe storage considerations to purchasers of firearms in California. While Governor Wilson stated in the previous legislative session that he vetoed similar bills because his grandfather had been killed by an armed intruder and he thinks that people need guns to be able to defend themselves, only 1% of guns in this country are ever used in self defense.
Gov. Wilson has certainly accomplished a lot in terms of preventing accidental injury and death for California’s children by signing legislation requiring bicycle helmets and swimming pool safeguards, and preventive legislation authorizing Healthy Families and other programs. However, whatever reasons he will give for these most recent missed opportunities to really establish himself as committed to prevention of what will soon be the number one cause of death for children in California seem inadequate in the realization of more children to be pronounced dead or disabled due to gunfire. I cannot begin to tell you how disappointed I am with Governor Wilson’s veto of these bills. We must demand more from our next governor.
Meanwhile, we Californians must become better educated about the resources available to not only restrict access to firearms by children, but to address improving the safety of guns and the manner in which they are stored. It is not enough to decry “What’s wrong with kids today?” when confronted with headlines of children shooting children and adults. Adults are responsible for making guns available in our society.
As citizens, parents, and physicians concerned with the fate of our children, we must encourage non-violent means to problem solving and teach conflict resolution. We must also take seriously any child who threatens violence and see to it that appropriate counseling and/or mental health services are made available to them. We must screen more diligently and consistently for the availability of firearms to children and describe means for safer storage and restricted access. As voters and as a society, we need to educate our next governor and all elected officials that consumer protection for safer firearms is our demand and our right.
Member at Large Report, Stockton
Community Pediatricians Seek Efficient Use of Scarce Resources To Increase Child Immunization Rates
Concerned pediatricians affiliated with the Immunization Collaborative of San Joaquin County, known as “Community Pediatricians” convened an historic forum of state with local officials on August 13, 1998, in Stockton. This forum began an important dialogue about child health and a serious exploration of ways to eliminate bureaucratic barriers to increasing child immunization rates. It marked the first meeting between any County group of private practice pediatricians and representatives of all public agencies with child health requirements.
Community Pediatricians’ particular concern at the forum was standardizing the timing of office visits for child immunizations and physical examinations by public agencies. The ultimate goal of Community Pediatricians, however, is to raise child immunization rates and increase the quality of child physical examinations while reducing the wasteful use of scare resources in a county where the most generous ratio of physicians providing primary care to children 0-18 years of age is 1:612, where 40% of children are enrolled in Medi-Cal or the Child Health & Disability Prevention (CHDP) Program, and 85% of children have medical homes in private practices. Pediatricians face Medi-Cal patient loads ranging from 20% to 80%, and most have Medi-Cal loads of 45-55%. Thus, there is no margin for wasted resources.
Currently there is no “official” coordination or standardization for timing office visits. As a result, physicians face repeat office visits which are not always reimbursable, vaccine costs which are not always reimbursable, and excessive use of scarce human and material resources. Duplicate office visits lend themselves to “over” immunizing children who keep repeat appointments and “under” or “never” immunizing children whose working parents are unable to accompany children to repeat office visits. In addition, separate forms and paper work from the various public agencies requiring immunizations and exams add an enormous burden to already low-staffed practices.
Concrete outcomes of the forum consisted of the following:
(1) an agreement among Community Pediatricians and panelists to use CHDP forms;
(2) an agreement to have the Regional Manager present a formal request to the State Immunization Branch for the creation of (a) universal timing schedule and recordation forms for pediatric office visits for comprehensive child health needs as well as State and local agency requirements (CHDP, WIC, Head Start, child care centers and schools) and (b) an expanded and updated CHDP periodicity chart that would serve the common purposes of all public agencies with child immunization and physical exam requirements and provide the standardized form for recordation and inter-agency communication at local and state levels;
(3) a decision by Community Pediatricians to pursue needed changes with the American Academy of Pediatrics in the event insufficient action was forthcoming from the State;
(4) an offer by the San Joaquin Medical Society to facilitate lobbying on behalf of Community Pediatricians
(5) an agreement among all forum participants to continue meetings as a means of developing and maintaining communication, inter-agency coordination and joint problem solving to benefit children in San Joaquin County. (The complete text was edited and can be found at the newsletter section at www.aapca1.org)
By Susannah Donahue
Pediatric Environmental Health: Putting It Into Practice June 4-6, 1999 Westin St. Francis Hotel on Union Square San Francisco, CA
If you are a pediatrician or other health care provider who works with children, this multidisciplinary conference will help you to address pediatric environmental health concerns that you may confront in your practice.
Prominent experts in the field of pediatric environmental health will interweave up-to-date, clinically relevant information with skills you can use to diagnose and evaluate environmentally related child health outcomes. Plenary and workshop topics will focus on a wide range of environmental toxicants and childhood health effects, including asthma, childhood cancers, water contamination, and pesticides.
Special Bonus Session For Health Care Faculty: Teaching Pediatric Environmental Health June 6 - 7, 1999
The Pediatric Residency Review (Committee of the Accreditation Council for Graduate Medical Education) requires that all pediatric residency programs provide instruction in environmental health. Is your program prepared to meet this requirement?
If you are a faculty member in a pediatric residency program, we encourage you to take advantage of this opportunity to learn how you can integrate pediatric environmental health into your program’s curriculum. Teaching Pediatric Environmental Health will be a special working session for health care faculty, offered at no additional charge to faculty who attend Putting It Into Practice.
For more information about attending Pediatric Environmental Health: Putting It Into Practice, or Teaching Pediatric Environmental Health, please contact the Children’s Environmental Health Network at (510) 450-3818.
(The conference is being co-sponsored by Children’s Hospital Oakland, which is providing CME credits for attendees.)
Many California Communities are Ignoring the Swimming Pool Safety Act
In 1996 Governor Wilson signed the Swimming Pool Safety Act. This new legislation beginning January 1998 required all new pool and spa owners to provide a barrier between the swimming pool and the home (if current legislation did not meet or exceed these standards).
Unfortunately, led by many city Planning and Inspection officials, these regulations are being ignored. Although the state legislation (AB3305) requires additional fencing to separate the pool from the home, exit alarm devices, self closing, latching exit doors, or pool covers, chartered cities are not required to comply with this Assembly bill.
Some chartered cities like Fresno are attempting to counteract the Planning departments reluctance to abide by the assembly bill by creating a new local law that will mirror the wording in AB3305 so the same safeguards will be used. These local legislative efforts are meeting considerable resistance from city and county officials and future success to write new law is unclear.
Chapter members should investigate whether their community is honoring AB3305. (Contact Mark M Simonian (209) 221-7192 if you have any questions.)
“Pediatric Hotline. This is a pediatrician.”
Twenty Bay Area pediatricians manned the phone lines in the second AAP Chapter I Pediatric Phone Advice Hotline October 18. Although phone glitches hampered initial efforts, staffers fielded nearly 70 calls over four hours.
Topics ranged from breastfeeding to skull shape to toxin exposure. The majority of questions focused upon sleep, behavior, and feeding issues (not surprising given that 80 percent of the callers’ children were aged 5 years or younger).
A previous hotline in 1992 yielded about 500 calls over 7 hours and was widely publicized by its sponsor the San Francisco Chronicle. This year most callers responded to a mailed flyer and public Town Forum October 17, with a minority hearing through local media.
The statistical data reported does not describe the feeling of camaraderie and sense of accomplishment that pervaded the morning. Our wonderful dedicated volunteers included: Bill Byrne, Lucy Crain, Carol Gill, Colleen Hogan, Daryl Homer, Paul Jewett, Bob Kadas, Rik Kasuga, Harvey Kayman, Monty Kong, Roy Lin, Brian Linde, Toby Lustig, Cathy McDonald, Donna McMahon, John Nackley, Thu-Ha Pham, Maxine Sehring, and Tracy Trotter.
A valuable Bay Area resource guide is being compiled by the Hotline Subcommittee to assist Hotline staffers, which will be available to Chapter members (date not determined). It will contain local referral sources, including asthma associations, various help-lines, obesity programs, 12-step programs, and teen resources. We will notify members in a future issue of the newsletter or check the website for its availability.
One father, requesting developmental information about his premature child, expressed his gratitude for the “fine service”, as did many other parents who took advantage of the free advice.
Hill Physicians Medical Group and Johnson & Johnson Pediatric Institute sponsored the hotline, and each participant received a Child Health Month T-shirt and two of the AAP’s recently published books. Thanks to Tom Long for finding us a beautiful location and for his continued support through the event. Special thanks to Jennifer Souza of Hill Physicians for taking her Sunday to help us get the lights and phones to work properly. Thanks also to Johnson & Johnson for their financial support and for the delicious breakfast for our group.
Hotline coordinator Mika Hiramatsu commented that despite not having a media co-sponsor she considered the event successful in providing a helpful community service as well as positive exposure for pediatricians.
These statistics are summarized as part of the Telephone Hotline conducted during the AAP National meeting and staffed by Chapter 1 pediatricians.
There were 66 calls taken between 8 am and noon.
Age breakdown
0-1 years 17%
1-5 years 66%
5-10 years 15%
Male 55%
Medical problem 48%
Behavior or development 52%
By Beverly Busher, Chapter Executive Director
Then:
In 1971 while I was a graduate student in Health Science at SF State, I met the man who became my friend and mentor — Dr. Martin Gershman. Dr. Gershman was already “Mr. Pediatrics” to everyone who knew him, and was an active advocate for pediatrics on a chapter, district and national level. I took Dr. Gershman’s Human Sexuality class (along with about 150 others). It was a great class and I came to know Dr. Gershman and his lovely wife, Millie, when he held a dinner at his home for the class where we also took our written final exams. It was my first and only “dinner exam” in graduate school. After the semester, Dr. Gershman asked me if I might like to work part time to help the Academy chapter secretary, who was about to undergo back surgery. Having gotten to know Dr. Gershman and what a wonderful person he is, I thought the Academy would be a good group to work with, so I accepted Dr. G’s offer.
My first duty was to meet with the current secretary and assess how I might assist her during her recovery. So, Dr. G and I drove to Alameda on the first leg of a journey that still continues.
In 1971 the Chapter 1 membership roster consisted of a file box which contained approximately 1,400 3x5-index cards, each with the name, address, and occasionally phone number of the chapter members. After learning briefly about how the chapter was organized, Dr. G and I took the box of 3x5 cards, and walked outside to begin our return trip to San Francisco. Alameda can be a very windy area and this day was no exception. As we headed to Dr. G’s car, a gust of wind caught the file box top and blew it down the street, closely followed by all of the membership information cards. We all ran after the cards and managed to retrieve most of the 1,400 index cards. And so, my first real task for the Academy became membership - as in reorganizing the 1,400 cards into alphabetical order.
The chapter used this archaic system to keep track of membership until I purchased a computer and put the membership on a rudimentary database program. My computer had 64 k of storage, no hard drive, and ran as quickly as a silent typewriter. But the database allowed us to keep an accurate roster of our members through the years, the database was updated and transferred from computer to computer, until the National AAP got computers and developed a database program for membership.
Now:
Mark Simonian took the membership database, which we purchased from National, and modified it to allow me to make instantaneous changes and to keep track of our committees and the board. Now we also have a database of school districts throughout Northern California, job opportunity listings, and potential corporate sponsors for our medical education meetings. The chapter notebook computer has 4 gigabytes of storage, runs at 233 megahertz, has a CD-ROM drive, a floppy drive, Internet capability, and a postscript printer. Our chapter’s computer file includes membership information with office and many home addresses, e-mail addresses and fax numbers. It also lists the committees to which members belong. We have a digital camera to bring the faces of our membership to you through our brochures and the newsletter.
Times have changed dramatically in the 27 years I have been with the chapter. The one constant has been my deep respect and affection for the wonderful pediatricians and their families with whom I work. As we all endure the changing face of medicine in the era of managed care, it is nice to remember that progress is also a good thing, that change can be for the better, and that computers are our friends (even if they are very frustrating at times). Our members are the hearts and soul of our organization and you should all be very proud to be a part of this active community we call the American Academy of Pediatrics.
By Mark M. Simonian
I encourage Chapter members who have not visited the website lately to look again (www.aapca1.org). Each newsletter over the last 2 years is available. There are plans to make all past newsletters available online. So if you are interested in looking back at past issues please log on. Besides a review of the history of the Chapter, you can find any topic easily by using the new search feature available.
Besides topics of interest, you can find quite a bit of member information. There are links to the CMA member directory that includes quite a bit of member information like address, telephone, fax, and e-mail (if you are a CMA member). Check to see if they are sharing more than you wish. Also available online is your state license number. (Thank heaven our DEA number is still private. Tomorrow my college grades may be online, oh no.)
Whenever possible, I have tried to include pictures of Board officers, members-at-large, and committee chairs. Also included is a listing of our Chapter representatives to national committees and sections. If you see someone accidentally omitted, please let Beverly Busher at the Chapter office know. Our hope is that these representatives, many of whom are appointed, will share their experiences with the Chapter. We want everyone to know who they are and what they are accomplishing at these national meetings.
Eventually there are plans to allow only AAP members to access information regarding their membership. This information will only be available by using a unique log on and password.
There are efforts now to provide a medical resource guide for Chapter members. We want this list to be a guide for members and hope that it will be a large database that anyone can access through our Chapter web pages. We are still collecting information, so if you have collected your own list or know of one we might use, contact Beverly Busher at the Chapter 1 office.
Medi-Cal Reimbursement
Mr. Roberto Martinez of the rate setting office for Medi-Cal in California had indicated by letter some months ago that there would be a raise for Medi-Cal but did not say when it was to go into effect. The increase for care of children was supposed to be 20% and for adults l0%. The first checks written for the new rates has mistakenly applied the adult increase to children. EDS supervisors report by phone that they will be issuing correction checks that supposedly do not require doctors offices to submit underpayment claims but that it will take until March or April of 1999 to start receiving correction checks. The date of service that is supposed to warrant the increased rate is 8/1/98.
A few other states have lead the way in the past for paying a higher rate for care of children than for adults. California may have actually been paying more in the past for care of adults than children without our knowing. This was manifest mainly in higher payment for lab work done on adults than for the same type of lab work for children, according to Alan Burckin. The letter from Mr. Martinez did mention that they planned to bring the payment level for children up to that of adults which was kind of an initial clue that this had been going on in the first place.
It is no surprise that the instruction to increase the payment for children has been incorrectly applied and it is no surprise that EDS plans to take six or seven months to straighten this out. I suppose we have to be grateful that there has been any increase at all after thirteen years of drought. Pediatricians have to keep up the education of their legislators about the fact that California is still bottom fishing on Medicaid rates.
from Edward B. Feehan,
Merced Pediatrician
This page create11/23/98 Last Updated 01/08/04
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