WHAT CAUGHT OUR EYE

You’re Asking ME??!?

"Isn't there something natural or a diet we can use instead of these poisons?" This is a question all of us hear on a regular basis. And while we may believe we are recommending treatments utilizing the best evidence, that may not be the perception of some families....

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Does Depression Cause Arthritis In Teenagers?

Mental illness is certainly an important aspect of many of our patients’ struggles, and I hope I’ve made the case earlier that it’s something pediatric rheumatologists should be paying attention to… There is a lot of good literature to show that patients with chronic...

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What Caught My Eye

It is not unusual for pediatric rheumatologists to be asked to see a child with persistent fever, without arthritis, who may or may not have had rash. Usually by the time the rheumatologist is called, the child has often been treated with antibiotics, and bacterial cultures have been done and were negative, and serologic or PCR studies for tick related illnesses and other infectious etiologies are in process or negative. Viral studies are done, and how specific/ disease related is the finding of a positive recovery of a respiratory pathogen from a nasal swab?

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Some breast milk a day keeps the IVIG away?

Perhaps you missed the New York Times article published in October 2015,  “Overselling Breast Feeding” or the firestorm that erupted afterwards. I didn’t. I was up nursing my newborn on our first week home and reading resultant Facebook posts, emails, and even an...

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Are we doing enough sharing with our caring?

By Jay Mehta, MD

As the parent of a 4-year-old, and the resident of a major metropolitan area, the word “share” (and its various constructions) is a daily part of my lexicon. I’m constantly reminding my daughter the importance of “sharing” (which she thinks is giving her friends the toy that she doesn’t want to play with). The other day I took an Uber, and on my last vacation, I stayed in a house I found on AirBnB, both of which are parts of the “sharing economy.” And yesterday, I “shared” with my Twitter followers an interesting article on medical education.

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Of Mice and Men…and Maybe Muscle

By Kenneth Schikler, MD

As I am sure occasionally happens to us periodically, a young toddler was referred to me by gastroenterology after being evaluated for hepatopathy regarding elevated “liver enzymes.” This young boy ended up having muscle disease, and genetic testing confirmed Duchenne Dystrophinopathy. While he has been sent on to our MDA clinic for his future care, I was interested in looking into what was new in Muscular Dystrophy.

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What Caught Our Eye

by Brian M. Feldman, MD, MSc, FRCPC

We often hear of the glass ceiling that prevents the rise of women in academic medicine. In 2016, there is still much gender inequality in the world, as the UN clearly pointed out late last year. I’m old enough to remember the iconic “bra-burning” episodes in the 1960s; while much has been achieved, it’s remarkable how far we still have to go.

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What is our role in tackling mental health disparities in kids with rheumatologic diseases?

By Tamar Rubinstein, MD, MS

A month ago, the CDC came out with a report about a recent increase in suicides in the United States. The most disturbing trend was an increase of 200% among girls age 10-14 from 1999 to 2014. This statistic was quickly picked up by news outlets across the country. I heard it on NPR on my morning drive to work. But what about our kids? Are we sufficiently treating our patients in pediatric rheumatology for depression and anxiety? Are we sufficiently identifying them in the first place?

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Fish Oil: RA Prevention…or Just a Load of Carp?

By Jay Mehta, MD

“What about dietary changes?” I’m sure I’m not alone in getting this question more and more frequently with each passing year. It’s interesting that as our drugs get more effective at treating patients, families seem to be more interested in trying to treat with non-pharmacologic means.

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Are we doing enough sharing with our caring?

July 15, 2016 

By Jay Mehta, MD

As the parent of a 4-year-old, and the resident of a major metropolitan area, the word “share” (and its various constructions) is a daily part of my lexicon. I’m constantly reminding my daughter the importance of “sharing” (which she thinks is giving her friends the toy that she doesn’t want to play with). The other day I took an Uber, and on my last vacation, I stayed in a house I found on AirBnB, both of which are parts of the “sharing economy.” And yesterday, I “shared” with my Twitter followers an interesting article on medical education.

As physicians, we are, no doubt, familiar with the concept of “shared decision making (SDM),” in which both the clinician and patient (and/or parents) express their opinions and values and a decision about how to proceed is made together. (For her part, the previously mentioned 4-year-old tried to engage in shared decision making with my wife and me when we told her she was going to have a little brother: “I don’t want a little brother. Can I have a sister instead?”).  Our adult colleagues have embraced SDM in recent RA Treat to Target recommendations (Overarching Principle A: “The treatment of RA must be based on a shared decision between patient and rheumatologist.”).  In other chronic diseases, SDM has been shown to improve adherence and, in pediatrics, SDM has been associated with decreased decisional conflict and improved knowledge.

So it’s no surprise that 75% of pediatric rheumatologists and gastroenterologists  (no difference in responses between the two specialties) say that SDM is their typical approach initiating anti-TNFα agents, as reported in a recent paper in the Journal of Pediatrics by colleagues at Cincinnati Children’s Hospital (including CARRA’s own Dan Lovell).  In this study, use of SDM was assessed by presenting 4 examples of approaches to treatment decision making and asking which the respondent would use. They then asked what factors facilitated SDM and found that parent trust and parent emotional readiness were very helpful. When using SDM with adolescents, patient trust, emotional readiness, and the patient being ready for the discussion were thought to facilitate the discussion.

They also investigated what kept pediatric rheumatologists and gastroenterologists from using SDM. They found that insurance limitations and adolescent difficulty with accepting the diagnosis were the main hindrances. We’ve all had the adolescent who refuses to believe he or she is sick. That patient’s preferences include “Let me go home.”

But what really caught my eye is that the same group of authors found that what we say we should be doing is not actually what happens in the real world. They observed real clinic visits with pediatric rheumatologists and gastroenterologists where prescribing biologics was discussed. In almost all of these discussions, the patient was not included in the discussion. In most discussions, the provider provided detailed information about his or her preferred treatment option, and there was not much elicitation of parental preferences, treatment goals, or parental knowledge. Even though it was rarely requested, an explicit treatment recommendation was given in almost all visits. Most surprising, in 1/3 of visits, a treatment decision was never made explicit but the provider took steps to implement the preferred treatment.

So where’s the disconnect? Why are we not as good as we think we are, like the 80% of people who think they are above-average drivers? Personally, I didn’t realize there’s a systematic approach to SDM, that it’s not just “Here are the ways we can treat your child’s arthritis. What do you want to do?” Rather, it’s important to start by reminding parents they have options and that their preferences are important, and only then present the options, all the while exploring the patient’s and parent’s preferences. Finally, if a decision is made (which doesn’t need to happen right then and there) we need to remind patients that we will re-review the decision in the future.

Voltaire said “The art of medicine consists of amusing the patient while nature cures the disease.” As the annoyed looks my teenage patients often give me when I try to make jokes indicate, sometimes patients just don’t want to be amused. I should probably first ask them what they prefer.

Share your thoughts about What Caught Our Eye in the comments section!

3 Comments

  1. Brian Feldman

    I use them in the room with the patient and family. I ask them what interests them most, and then work our way through them in order.

    Reply

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More from What Caught Our Eye

Does Depression Cause Arthritis In Teenagers?

Mental illness is certainly an important aspect of many of our patients’ struggles, and I hope I’ve made the case earlier that it’s something pediatric rheumatologists should be paying attention to… There is a lot of good literature to show that patients with chronic...

read more

What Caught My Eye

It is not unusual for pediatric rheumatologists to be asked to see a child with persistent fever, without arthritis, who may or may not have had rash. Usually by the time the rheumatologist is called, the child has often been treated with antibiotics, and bacterial cultures have been done and were negative, and serologic or PCR studies for tick related illnesses and other infectious etiologies are in process or negative. Viral studies are done, and how specific/ disease related is the finding of a positive recovery of a respiratory pathogen from a nasal swab?

read more

Some breast milk a day keeps the IVIG away?

Perhaps you missed the New York Times article published in October 2015,  “Overselling Breast Feeding” or the firestorm that erupted afterwards. I didn’t. I was up nursing my newborn on our first week home and reading resultant Facebook posts, emails, and even an...

read more