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Articles

In a recent study, reductions in body mass index along with further beneficial effects were found when using oral butyrate supplementation for treating pediatric obesity.

Butyrate effective for treating pediatric obesity

At the 44th National Association of Pediatric Nurse Practitioners Conference, drug products abused by teenagers were discussed.

Which drug products are abused by adolescents?

At the 44th National Association of Pediatric Nurse Practitioners Conference, methods of treating atopic dermatitis were discussed.

Treating pediatric atopic dermatitis

At the 44th National Association of Pediatric Nurse Practitioners Conference, pediatric aggression was discussed, including which patients are at greater risk and which management strategies are most appropriate.

Managing aggression in pediatric patients

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Spotlight

2022 Best Tech

Contemporary Pediatrics® Resident Writer Program

Demystifying Infant Formula

Do we take RSV disease seriously enough?

Food Insecurity and the Dangers of Infant Formula Dilution

Getting into the Roots of Childhood Atopic Dermatitis

Opt-Out Chlamydia Screening in Adolescent Care

The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants

Update in Pediatric COVID-19 Vaccines

Clinical

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1rem

Clinical Focus

Earlier this year the Centers for Medicaid and Medicare implemented a new evaluation and management coding system for outpatient visits, which was meant to ease documentation burdens.



 sat down with Andrew J. Schuman, MD, FAAP, to discuss the levels of Medical Decision Making and offers examples of what types of visits would account for those levels.

Contemporary Pediatrics sat down with Andrew J. Schuman, MD, FAAP, to discuss the levels of Medical Decision Making and offers examples of what types of visits would account for those levels.

Exploring the 2021 evaluation and management coding update: Part 2

 sat down with Andrew J. Schuman, MD, FAAP, to discuss what went into this new system.

Contemporary Pediatrics sat down with Andrew J. Schuman, MD, FAAP, to discuss what went into the new system.

Exploring the 2021 evaluation and management coding update: Part 1 

Technology has rapidly changed over the past few decades and radically changed the day-to-day life of everyone. This technological boom has also been felt in medicine, making paper charts and waiting days of lab reuslts a thing of the past.



 sat down with Andrew Schuman, MD, FAAP, to discuss how to effectively use technology in the pediatric practice and what upcoming tech has him interested.

Contemporary Pediatrics sat down with Andrew Schuman, MD, FAAP, to discuss the effectively use of technology in pediatrics.

Utilizing technology in the pediatric practice

Although it may be hard for us to admit, physicians face the same types of mental health conditions as our patients.

How to recognize and help a physician colleague in emotional distress

MGMA survey quantifies rising costs, revenues, patient encounters, and more.

How bad is inflation? Physicians, financial managers report the latest

Don’t click on links or attachments unless you’re sure they are legitimate.

Feds warn of monkeypox-themed malicious email campaign targeting health care providers

Harnessing digital marketing tools can help your medical practice grow.

Marketing tips for your practice

What you need to know to avoid claim denials and to maximize practice revenue.

The 2022 coding guide

Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, attending in the division of infectious diseases and medical director of the International Patient and Destination Services Program at Ann & Robert H. Lurie Children’s Hospital of Chicago, Illinois; professor of pediatrics, Northwestern University Feinberg School of Medicine; spoke with 

® to highlight the procedures in place at the Ann & Robert H. Lurie Children’s Hospital of Chicago to keep pediatric patients feeling as relaxed and safe as possible.

Some of the examples Tan discussed included an onsite playroom, volunteers that play with the children, provided toys, and interaction with hospital staff in fun activities, like kids riding scooters down the hallways or children visiting each other in their rooms.

Videos

In a video for Contemporary Pediatrics®, Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, discusses how the Ann & Robert H. Lurie Children’s Hospital of Chicago, Illinois, caters to their pediatric patients in an effort to keep them de-stressed and comfortable. 

Keeping children calm and comfortable at pediatric-exclusive hospitals

Vi T. Nguyen, MD, board-certified pediatrician in San Diego, California, affiliated with Kaiser Permanente San Diego Medical Center, found herself, in her words, “crashing and burning” 3 years ago. She put this down to stresses from her management role, and 2 particularly sick patients, one of which that passed away. While she said it wasn’t apparent to her at the time, she was experiencing burnout and even considered changing her job. Now, she said she is on the other side of burnout and happy all because of picking up trash on the beach and her climate activism.

Vi T. Nguyen, MD, discusses how she got to the other side of physician burnout. Her secret? Collecting trash on the beach. 

Fighting health care provider burnout through climate activism

Burnout continues to affect the health care field in various ways, with the COVID-19 pandemic only heightening the issue. In a video, Andrew J. Schuman, MD, clinical assistant professor of pediatrics, Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire, and editorial advisory board member of 

®, highlighted the behind-the-scenes statistics of why burnout thrives in our medical specialties, and gave advice on how to combat the burnout beast when it comes knocking at the door.

In a video with Contemporary Pediatrics®, Andrew J. Schuman, MD, gets into the numbers when explaining the true extent of burnout in the health care community. 

Anxiety

Health care provider burnout: get the stats

For many physicians, burnout can be a real issue that may lead to leaving the field of medicine if it becomes too onerous. 

 sat down with Carl D. Sorgen, MD, FAAP, DABP, who was a partner and founding father of Children's Medical Group, in Poughkeepsie, New York, with offices in Rhinebeck, Hyde Park, Fishkill, Modena. Hopewell, Kingston, and Newburgh, to discuss his advice for combating the issue.

Burnout is an all too real phenomenon for many in health care. Here's a look at some ways to tackle and prevent it.

Tackling burnout by being a group

The new evaluation and management (E/M) coding system for outpatient visits deployed by the Centers for Medicare & Medicaid Services was created to ease the burden of documentation for providers.

sat down with Andrew J. Schuman, MD, FAAP, to discuss the nuances of the new system.

Contemporary Pediatrics sat down with Andrew J. Schuman, MD, FAAP, to discuss the nuances of the update.

  

Utilizing the 2021 evaluation and management coding update

With more and more clinicians becoming employees and not practice owners, the shift from paper records to electronic health records, and the increasing prominence of telemedicine because of the pandemic, the need for solid practice management is bigger than ever. Andrew J. Schuman, MD, FAAP shares his thoughts.

As technology and the role that clinicians have with running the practice have changed, so have the needs for practice management. Andrew J. Schuman, MD, FAAP, shares his guidance for practice management.

Tips for practice management

 sat down with Andrew J. Schuman, Editorial Advisory Board member, clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and practicing pediatrician, to discuss what he’s learned about utilizing telehealth during the COVID-19 pandemic and how it’s shaped his practice.

 Now that you've done both telephone and telehealth visits for 2 months from home, can you compare the 2 in regards to effectiveness?

 Pediatricians are used to interacting with patients via telephone for years, decades. It's our traditional way of providing care to patients. Interestingly enough, it's services that we have provided free of charge. If you need to communicate small bits of information, telephone communication is more than adequate.

Ideally to mimic a real in-person visit you'd like to do a telehealth visit. There are many advantages in virtual video visits that are not present in telephone encounters. It's very important for physicians to interact and see facial expressions, to see how their recommendations are received, to perceive attitudes among patients. The telehealth visit is in many ways superior but not necessary.

In my own practice, I've found that it depends on the need of the patient, their technology capability, the software that your practice is using. There are many factors that go into the decision which to use, but both have their advantages as well as disadvantages.

 Do you have any new recommendations for selecting a telehealth service?

 Yeah, I do. There are many platforms available. The one that my institution uses patients continue to have problems with because they have to download applications, put in passwords, and so forth. There's lots of glitches that make 50% to 60% of our telehealth visits ineffective. I've done a little research and I find that there are 2 apps that I like to recommend for first time telehealth users.

One is Doxy.me, which is inexpensive, and is a web based application. Pediatricians, primary care providers can just enroll for a reasonable fee. I think it's $35 a month per individual. You merely send a link to a patient, they click on it, and you're there in a reasonable good quality video visit.

What's perhaps even more easy to use is a new application from Doximity, which at the moment is a smartphone-based application. You launch the application and you do nothing more than put in a phone number and send a link to the patient, they click on the link, and you're there. It's very simple, straightforward and it just works. The majority of my calls these days are by way of the Doximity app. I think in terms of technology, simple is probably better at the moment.

Once we emerge from this crisis, this pandemic, then one can decide what platform you want to use. It will depend on reimbursements and a number of different factors, but we'll have to see what happens.

 During the pandemic, have you seen a change in your management of ADHD (attention-deficit/hyperactivity disorder) patients and those patients with anxiety and depression via telehealth?

 I have indeed, for a variety of reasons. Patients are home with their parents; parents are home with their children; and parents have the opportunity to observe firsthand the activity level and the focus of their children. Whereas before the pandemic, they were getting reports from the teacher who had to pay attention to 20-30 kids. Now parents know firsthand if the medication is effective at the dosages we prescribe. It's also a very stressful situation for parents and children. So I've had to initiate medication and recommend video counseling for a lot of patients. I've had to adjust a lot of medications to more suit the environment that we're seeing in the midst of the pandemic. It's very interesting.

 Do you have any new recommendations regarding deciding whether to prescribe antibiotics during a telehealth visit?

 Yeah, I do. I have made some general recommendations and made the observation that pediatricians who have been doing pediatrics for a number of years, have acquired a skill set that enables you to look at a patient and without touching the patient, determine many things whether the patient has respiratory distress, is the child really sick or not. These are the basics that we know.

Over the course of many weeks, I've been surprised how few antibiotics I've prescribed. High quality video visits are ideal. It's easy to diagnose certain things by video, including certain rashes, impetigo, diaper rash, conjunctivitis, and so forth. I've been very surprised how well one can visualize the throat of a patient by video to the point of looking for tonsillar hypertrophy, exudate, and so forth.

Although one can’t auscultate the lungs, you can look for signs of respiratory distress. Audible wheezing is very apparent. There are lots of things pediatricians can do to continue to prescribe antibiotics judiciously. You cannot do a strep test, you know remotely, but sometimes symptoms indicate whether the patient may be at risk for strep or not. If a patient has a cough, then it's unlikely that it's strep, but ultimately, it's your decision to err on the side of caution and prescribe an antibiotic.

I think the most challenging is the febrile patient with a cough, you need to of course eliminate COVID as a possible cause. In that instance, particularly for an asthmatic child, or one with some early signs of respiratory distress, I've been erring on the side of prescribing antibiotics.

The last thing is if someone complains of ear pain, then if a child is able to do a Valsalva maneuver or equivalent, if they can blow a whistle, if they can blow into a party horn, or actually do a Valsalva, if they're old enough. If there's fluid in the middle ear space, they're going to have pain with that maneuver that would lead me to believe they have a middle ear process going on. In that instance, I would tend to prescribe an antibiotic so it's a surrogate, not ideal.

Contemporary Pediatrics sat down with Andrew J. Schuman, Editorial Advisory Board member, clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and practicing pediatrician, to discuss what he’s learned about utilizing telehealth during the COVID-19 pandemic and how it’s shaped his practice.

News

Telehealth lessons learned during the COVID-19 pandemic

 spoke with Andrew J. Schuman, Editorial Advisory Board member, clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and practicing pediatrician, about incorporating virtual patient visits-telehealth-into one’s pediatric practice during these times of social distancing and self-quarantine.

Dr. Schuman also spoke about tackling the issues that arise when a pediatrician can't physically examine a patient and how to manage potential payment issues.

Dr. Schuman, for pediatricians who are utilizing telehealth for the first time because of the COVID-19 pandemic, how can they ensure a successful transition?

 First and foremost, I think pediatricians need not be fearful. Telehealth is very easy to implement. It is something that you get used to very quickly, and patients appreciate the fact that you're reaching out to them. You see them, they see you, and it cements the relationship that you've established over weeks and months with your patients.

Telehealth is an awesome service. The way to implement telehealth is to download and install and subscribe to any of a number of telehealth services. There are innumerable ones available. Zoom, for example, has a new service, and Zoom is awesome and affordable. So, I would recommend that pediatricians consider that one. There are also programs such as SnapMD, Anytime Pediatrics, Doxy.me-a whole bunch of applications available.

You connect to the patient by way of a virtual waiting room, and then you communicate with them as you would in a typical FaceTime or Google Duo type of interaction. I usually recommend using a smart device like a phone or a tablet so you can see the patient while you're on your computer and looking at the chart so you can review the information with them, confirm their pharmacy.

It's also important to realize that there are limitations to the telehealth visits in terms of what you can see and not see, but I am very impressed by the ability of pediatricians to deal with patients who are ill by way of telehealth. Pediatricians have used telehealth in the past for managing patients on ADHD meds or meds for anxiety or depression, but over the last few weeks, I've adapted my practice to see mostly patients who are ill. Also, the skills that pediatricians have acquired over years are very useful in communicating with patients and evaluating patients with ill visits. So, it's something that pediatricians should not be fearful of and can get used to very quickly. Patients appreciate the fact that they can communicate with their established pediatrician as opposed to someone unfamiliar, such as at an urgent care facility.

 What are the insurance payment issues that a pediatrician might face with telehealth services and what can they do to potentially prevent these issues from popping up?

 Telehealth has been around as an option for practices for many years, and through the request of primary care providers, states have dealt with requests from doctors to get phone co-payment at parity for telehealth visits. Each state is dealing with this in its own way. In my state of New Hampshire, after pediatricians and primary care providers pushed for legislative reform, we now can provide telehealth visits to patients with a physician at a medical facility or a physician in his/her home and the patient at their home. That did not used to be. In the past, telehealth was limited to patients in medical facilities.

There's been an evolution and revolution in telehealth services. This has been fast-tracked with the COVID-19 pandemic situation, so it should not be a concern in most states. However, most insurances are not paying for well visits per se. They do pay for sick visits as such. If you want to provide services that are similar to but not exactly the same as well visits, one could code a visit as a developmental check or weight check or well-being check, and those codes are being reimbursed by insurance companies. I would say check with your state medical society and pediatric society to see what the state of telehealth is in your own community. In many states with stay-at-home mandates, the governors have issued new regulations indicating that all insurances will pay for telehealth services at least until the COVID crisis is over.

 How can pediatricians tackle the challenges that telehealth can present for indications that require a physical examination, such as for a patient who's complaining that their ear hurts?

 Okay, as stated a moment ago, it is really impossible to do a full physical examination because you don't have the ability to examine a patient. That may change in the future because there are products available to patients that enable a physician to do remote physical examinations. There's a product called TytoCare, which is based out of Israel. For $300, patients can order the TytoCare system, which consists of a thermometer, a camera for viewing the throat, and an otoscope, and you could use this in conjunction with the patient at home and essentially do a full physical examination. At this point in time, however, few parents have that. So, at the moment, you could do a modified physical exam coded as a well-being check or developmental check or a weight check for parents and patients in need of that service.

When you're talking about ill visits, you have to use a lot of judgment. I've been doing sick visits during the COVID pandemic for a couple of weeks now, and I'm surprised how the skills I've acquired as a pediatrician are extremely helpful in evaluating those patients. One can visually look at a child by way of telehealth and see if that child is in respiratory distress, if his/her color is off, does this child appear ill, and then we can get down to the fine points of is there a rash, and if there is a rash, then I can take a look at the rash and make an assessment of what the rash is and how I treat it.

Obviously, I cannot look in the ears or look at the throat, although I've had some parents actually take a picture of a sore throat and forward that to me, and that's very helpful in allowing me to determine if I'm suspicious of strep or no strep. One has to use some clinical judgment, deciding whether one will empirically start any antibiotic or other medication when a child is complaining of something such as a sore throat or an earache. It’s not that difficult to decide if you're going to err on the side of prescribing an antibiotic or not. It's just a matter of getting comfortable with your existing skills and still not giving out too many antibiotics, but prescribing antibiotics appropriately given the situation.

 So it seems as if there's going to be a change to the well-child developmental visit because of virtual visits. What can pediatricians do to ensure that children still are getting what's needed from these important visits?

 As of 2 weeks ago, the American Academy of Pediatrics (AAP) recommended that pediatricians remain flexible during the pandemic, and they have to be cognizant of what's going on in their community, whether a lot of patients have been diagnosed with COVID-19 or not, and what's the risk for the provider and staff as well as the patient to come into an office when we're starting to see patients with COVID-19.

Officially, the AAP recommends that we continue to perform well exams on young children, providing them with full examinations and giving vaccines. It also advises using personal protective equipment (PPE) appropriately to protect patient and staff. Pediatricians can be creative, and many pediatricians have started drive-through services for performing well exams and sick visits and giving immunizations as well.

These are steps that everyone should consider, but I would err on the side of caution in keeping patients and staff safe, depending upon what's going on in the community. We'll see how things go over the next weeks. The AAP may or may not change its stance, but we all should check the Internet and check the AAP website and 

 Speaking of vaccinations, what should pediatricians tell parents about immunizations during telehealth visits, especially as children now are being self-isolated in the home?

 Vaccinations have always been a mainstay of pediatric practice. We always have recommended them and always will continue to recommend vaccinations. Where at all possible, we continue to emphasize that vaccines are important. However, in my view, we need to realize that during this period of social distancing and self-quarantine, kids are not around other kids, so I'm seeing fewer kids with strep infections, fewer kids with influenza. In my view, given certain circumstances, the well visits can be pushed off and we could make up for vaccines in the future, assuming this pandemic lasts only a few weeks or months. I think there are options around for vaccines. There's also this concept of herd immunity in that kids are protecting other kids by virtue of having been vaccinated in the past. So again, in my view, we need to be flexible whenever possible, and we should continue to give vaccines to young children.

Contemporary Pediatrics spoke with Andrew J. Schuman, Editorial Advisory Board member, clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and practicing pediatrician, about incorporating virtual patient visits-telehealth-into one’s pediatric practice during these times of social distancing and self-quarantine.