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Nurturing Young Lives: Pediatric Advocacy and Mental Health · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Today here in the podcast studio with me is Dr. Sandy Chung.
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She's the immediate past president of the American Academy of Pediatrics,
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founder and and Medical Director of the Virginia Mental Health Access Program.
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CEO, Trusted Doctors, Medical Director of Informatics at Children's National
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Hospital's Pediatric Health Network.
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Dr. Chung, thank you so much for being here in the podcast studio.
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Thank you so much for having me. It's a pleasure. I loved your Grand Rounds talk this morning.
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You're doing some incredible work. First of all, as president of the American
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Academy of Pediatrics, You were in a different hotel room, was it every week on the road?
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Basically, yeah. I think I've clocked around 500,000 frequent flyer miles in the air.
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But what's been wonderful is traveling not just the country,
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but also the world and meeting pediatricians everywhere.
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And wherever I travel, pediatricians are so similar. We all care about children.
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We are mission-driven. And we're all struggling with some of the same things,
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too, and dealing with things like youth mental health. payment issues, workforce issues.
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So really, the interesting and fun part about traveling last year and this year
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is seeing how much we are similar in that no one's alone.
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That's wonderful. And we have our listeners from all around the world.
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And I think that's such an important thing to know that you're not alone because
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it can be so tough, you know, especially through the pandemic.
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And our pediatric practitioner listeners have so much coming at them.
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And there's this perception that you're expected to constantly be available
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or on call and know everything.
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What do you say about that, the kind of the pressure? Sure. Yeah.
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What I reminds me, what reminds me of why we do what we do is when I'm in my
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clinics, I'm a general pediatrician in Northern Virginia. I run this very large group.
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We have over 220 clinicians in D.C., Virginia, and Maryland.
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But my primary practice is in Virginia.
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And so when I'm sitting at the nurse's station and listening to what's happening
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at the office, when we walk into an exam room,
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you know, the first thing we do when we walk into the exam room,
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regardless of how our day is going, is we put on a big smile.
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We go in. We're happy. You know, you get down on your knees or get lower and
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you talk to the children.
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You talk to the babies. You say hello to the caregivers.
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And you're there for them. And you're there to help them. You're there to provide support.
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And in that moment, no matter what's happening in your day, you remember,
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oh, this is fun, you know, this is a joy, and this is why I do what I do.
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And that is also uniformly true across pediatrics, where, you know,
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if we walked into our room and we were super grumpy, right, we wouldn't be a
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very popular pediatrician at the end of the day.
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So remembering why we do what we do is so critical. But I think that's how,
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at least for me, how I get through the day is remembering why I'm in this field and how much fun it is.
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That's wonderful. I know one doctor I was talking to, he, in between each going
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into each exam room, he takes a deep breath in, exhales and thinks like showtime.
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And he walks in and this is a new patient. This is fresh.
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You know, this patient deserves all of my attention.
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Yes. And also for our own well-being, actually. So even if you're,
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you know, acting, if you will, when you first walk in, at some point you actually feel it.
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You know, we know from cognitive behavioral therapy that your feelings and your
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behaviors and your thoughts are intertwined.
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And so if you walk in there with a big smile and you're really interested and
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you're there to help and you're concerned and focused on that family,
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that you will feel that as well.
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And so we know that that is going to be beneficial to you as an individual.
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Dr. Chung, may I call you Sandy? Of course. Of course. So Sandy,
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you liken being a pediatrician, caring for patients to gardening. I love that.
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Yes. So I love to garden. I don't know if anyone else who's listening likes to garden.
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So when you're gardening, you plant a seed or maybe you have a seedling and
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you nurture it and you water it and you give it sunlight and you talk to it.
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You know, all the things we do to make sure that that plant grows up to be a healthy plant.
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And if you only focused on the fully grown plants, you would never have an ongoing garden, right?
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You need to focus on those baby plants and the little teenager plants and get
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them to the point where they grow up to be healthy adult plants.
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And in pediatrics, it's very similar. That's what we do for society.
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You know, the work that we do is that we're taking care of the youngest of our community.
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And when we do our jobs well, and we help those children and babies and adolescents
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thrive, then we have a healthy, functioning future society.
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And children represent roughly 20 to 25 percent of the population,
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but they are 100% of the future.
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And so again, pediatrics, the work we do is so critical.
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And a lot of pediatricians, we know a healthy diet is so important,
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but there's a lot of patients where there's a financial burden there.
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So when you say more fruits and vegetables, and those are expensive,
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can you tell us, Sandy, about your personal experience early on in life and
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now some new developments that you've helped.
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Make happen for WIC? Oh, sure. Of course. So my parents were immigrants to this
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country. They came from China.
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And despite having advanced degrees, they had master's degrees,
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they weren't able to get jobs in their profession because their English wasn't strong enough.
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And so my father ended up being a waiter in a restaurant, and my mom sewed clothes in a factory.
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And then I was born. I was born in the United States, but we were quite poor.
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I lived in a trailer park.
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I was on Medicaid, we were on WIC, we had food stamps, all of that, the whole nine yards.
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So personally, I know how important those programs are for really sustaining a family.
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I think without that, my family, my parents would have struggled mightily to
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make sure that we got the food and the nutrition that we needed.
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But because WIC was there, we were able to at least not worry about parts of it.
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And so WIC, to me personally, is really foundational for a lot of families in
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in order to provide them the supplements that they need to keep their children healthy.
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So WIC is for pregnant women and also for children under age six, so five and under.
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And it provides supplemental nutrition and then also education, health education.
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More people who are on WIC end up continuing breastfeeding.
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And so we know that those who are supported, their long-term health outcomes
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are better. And so recently, in the past few years, there was an increase in
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the allowance of WIC to add more fruits and vegetables.
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As a pediatrician, we know how important that is to make sure that the food
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that's being sustained or provided is healthier.
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And so fruits and vegetables are wonderful, but they are more expensive.
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And so because of that, though, WIC then would, as a federal funded program,
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would have not had enough money to provide the fruits and vegetables that were
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needed for so many families, millions of families across this country.
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So through AAP, with academy efforts, through with multiple stakeholders,
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working with several federal agencies and advocacy groups, we've been advocating
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for increased funding for WIC so that the families who rely on this service
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are getting the healthiest foods for their kids.
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For example, in my practice, we had a family with a three-year-old and a six-year-old and an infant.
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And the families knew about WIC. The family knew about WIC, but they were only
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using it for the infant to get supplements.
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What they didn't realize is their three-year-old and five-year-old could also
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get more nutrition. And the three-year-old especially was quite obese and needed healthier foods.
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And the family was saying, we can't afford that. We just can't.
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And when we taught them about WIC and the availability of fruits and vegetables
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through the WIC program, they went back and they were able to feed their child
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healthier foods and the child did much better going forward.
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So that's the power of WIC.
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And so what's been exciting, though, through the advocacy work is that Congress
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recently approved through the Agricultural Appropriations Bill that now there
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will be a billion dollars additional added to the WIC program so that now families
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across the country can get additional fruits and vegetables for their children. learn.
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That's incredible. I mean, that just, that must be the best feeling to go from
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having that personal experience and now to know this, what a huge difference
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that's making. Yeah, indeed.
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You know, I think advocacy is very much a part of what pediatricians do.
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We do that every day in our clinics. When we talk to a family and we're describing,
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you know, how they can help their child sleep better, grow better,
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develop differently, you know, develop optimally, all the things that we do
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to help families, that's advocacy, one-on-one advocacy.
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And so we're very naturally good at that because that's what we do all day.
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Of course, there's advocacy on a different level, right? If you want to continue
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to do political advocacy or policy advocacy.
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My guess is that you probably already do that a little bit already.
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So when in your practice or in your system, if you see something where,
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oh, gosh, I really want to implement the screening, for example,
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or we really it's best practice to do X, Y, Z, and you go to your group and
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you say or within your practice and you say, hey, let's do this, let's implement that.
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And you do that form of advocacy right there.
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And so that's doing it on a broader level. And then being able to do that in a community level.
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And then ultimately, if you want to also do it in a legislative sense,
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that's absolutely open, you know.
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And it can be as easy as an email or a phone call to your local legislator,
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writing an op-ed, you know. In the American Academy of Pediatrics,
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we have lots of resources for pediatricians.
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So if you want to do it, but you're not sure how, please contact us.
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You know, if you go on our website, there's a whole advocacy section,
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and there are places where you can contact people.
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And that's a great way to get engaged, you know. One thing I like to tell people
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is that those who are making rules and legislation and regulations around what
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we do, most of them aren't pediatricians.
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And we are the expert in child health. And without us being at the table and
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helping to educate, it can be challenging.
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And sometimes we end up with things that aren't the best for kids.
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And so having us at the table is really critical. And I just urge everyone to
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get involved as much as you're able to.
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I agree. The 10 years that I worked as a broadcast journalist,
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we loved to hear from doctors.
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And a lot of times it was difficult on a deadline to get a doctor to speak out
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about something. Even we would say, can you step out of the exam room? We'll be all set up.
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And the ones who would, it would make such a difference. That message would
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get directly to people. Yes, absolutely.
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And I remember being a young pediatrician, and my mentor, she was probably 15
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years ahead of me, she was being interviewed for a magazine.
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And she said to me, she's like, Sandy, would you like to be interviewed?
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And I said, absolutely not.
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You know, I'm not an expert, you know, no, no, no. And then what I learned over
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my career is that we truly are the experts.
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I mean, we went to 23rd grade to learn how to be pediatricians.
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We have spent a lot of time being trained and learning about what affects children's
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health and development.
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And so you do know a lot. You know, we know a lot.
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And so I think it's so important for us to share that, not just with your patients,
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but with anyone who's asking, quite frankly. And you say it's and it's not a
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political statement, but tell us about this current Congress. Oh, sure.
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So, you know, it's not about politics, but it is proof.
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I mean, a fact, I guess. When you look at the number of bills that have been
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passed in this current legislative Congress, it is the slowest number in a very,
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very long time, in over 50 years, in fact.
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So I think that it's important that when we're trying to advocate for things,
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so youth mental health is a great example of this.
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There are bipartisan issues that affect all children. And youth mental health
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is something that every pediatrician is facing more of in our clinics where
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families are experiencing it.
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There's probably not a day that goes by where you aren't seeing a child with
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a mental health issue or a behavioral health issue.
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And so we need to be able to address those issues.
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But it comes with additional time. It comes without additional funding.
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And so to be viable as a pediatrician, there needs to be recognition of the
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fact that the funding streams need to be different.
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The way that we do this work needs to be different.
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If we want to integrate therapy in our offices, I have four therapists for my
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very large group, but it's not enough.
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But we lose money on every therapist we hire because the funding stream is not
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appropriate. or yet the insurance payments are not high enough.
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So at AAP, we're doing a lot of advocacy work to try to improve that and change
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that, get recognition of, yes, we want to help.
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In fact, we have to. The families are right in front of us.
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But when we do this work, it takes more time. And when that time isn't paid
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for correctly, then it actually becomes not sustainable.
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So again, we're doing it. It's the right thing to do.
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It's where those of us who want to do it are definitely doing it.
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Those of us who don't want to do it sometimes have to.
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And so in order to remain viable, though, we need to change and transform how
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the payment system's set up.
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There is a code I'd love to talk about that's new. It's G2211.
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The G2211 code is newer. It's basically there to recognize that as pediatricians,
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we have a longitudinal relationship with our patients.
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It's actually for all primary care and specialties as well.
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If you are taking care of a family over time, you're allowed to add this code
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to every visit except for well visits or visits it's where you're doing a procedure.
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So this is getting into the weeds a little bit, but if you add a 25 modifier
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to a visit, you can't bill this code.
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But that means every other visit you can, all your sick visits you can,
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and you don't need extra documentation.
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And what happens is that there's additional payment, CMS values is around $16, $17.
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And so that's additional payment for the work that you're doing.
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So if you're not billing for this code, I'd highly recommend men starting to.
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And it's not every payer's paying it, but we all need to be billing it in order
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to advocate so that it gets paid.
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And it's showing the value of that longitudinal care.
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That's right. That's right. You know, when we are seeing a child who we've been
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seeing for years and years, and we're recommending something,
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there's an additional thought process, a cognitive load that's happening because
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we know the family, we know the environment, we know what's worked for that
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child in the past, what hasn't worked for that child in the past.
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So having all that information and having to process that additional work is
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now being recognized in this code.
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And it's true for like a specialist as well. So if a cardiologist is following
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a child long-term for a cardiac condition,
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and they know that family, and they know that child's history,
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and then again, know what works, what doesn't work for that family,
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there's recognition that that takes additional effort.
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And I know you're instrumental in a lot of the progress that's being made in
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mental health and availability of providers here in Texas.
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As you know, we have CPAN, where a provider can get.
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Pediatric psychiatrist on the phone within 10 minutes. I think the slogan is
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no call is too small, which I love.
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And, but a lot, we know a lot more needs to be done on all of our listeners.
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There's so many areas where it's, including here in Texas, it's a,
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it's a mental health desert.
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You've had a personal experience with a horrible mental health issue where,
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can you tell us a a little bit about that? Sure, sure.
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So again, I work in Virginia.
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And in Virginia, we are the ranked 48th lowest in the country for access to
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mental health services.
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And so before the pandemic, again, in practice,
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when I was trained as a resident, I was taught to identify that a child might
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have a mental health condition, but then to refer that patient,
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refer them to psychiatry, psychology, therapy, whatever the need was.
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And over the years, as more and more children have needed mental health help,
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we have had the waiting list basically getting longer and longer and longer.
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So before the pandemic, I had this patient.
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He was a 14-year-old with bipolar disorder, and his child psychiatrist had retired.
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And the family called our practice. We were their primary care provider and
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was asking for help because when they got an appointment with a new child psychiatrist.
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It was four to six months later.
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And so they wanted to know if we could refill his medications.
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Well, when we looked at the list of medications, it was on five different medications.
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They were very complex. They were not ones we typically prescribe.
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And then the other facet was that in Virginia, Medicaid actually wouldn't even
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pay for the medicine unless a child psychiatrist or a psychiatrist prescribed them.
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So we couldn't even refill them if we wanted to.
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So instead, we said, oh, we can't refill them. But what we'll do is get you
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an appointment quicker. Let's help you.
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And so I had a nurse in my practice call and call and call and call.
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And we were able to get an appointment for this child about four weeks later.
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So we figured that was great, you know, that he had to help sooner.
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However, during that month, unfortunately, he ran out of his medications.
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And when he ran out of his medications, his disease got out of control.
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And he had an exacerbation of his disease. He got into a fight in the parking lot near my office.
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And in that fight, he had a gun. And he shot and he killed somebody.
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So that young man ended up in juvenile justice. The other man lost his life.
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And to me, as a pediatrician, I felt like that could have been done differently.
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You know, there are many things that needed to change in order for that to be different.
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So one was learning how, right, learning how do you manage these types of medicines.
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The second was having access to a specialist to get help.
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So similar to CPAN, we did not have a program like that in Virginia.
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And so I learned about these programs and said, gosh, we need one here in Virginia.
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And then the family needed help finding care sooner.
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And so having care navigation resources was really important,
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too, to make sure that families get appointments in their communities quicker.
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So all of that led me to go around and talk to people all around the state.
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So patient advocates, mental health advocates,
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behavioral, I mean, physical health folks, pediatricians, primary care providers,
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insurance companies, health systems, and legislators and those who could help
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fund such a program and asked, you know, this is a need. Do you all agree?
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And everyone said yes, thankfully. And then eventually we got additional funding.
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We got put into the state budget, and our state actually funds this program now.
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And now we're also expanding to moms so that if moms are identified as having
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postpartum depression or peripartum anxiety, that those taking care of the moms
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can also call the line and ask for assistance online.
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And that's been wonderful. So it's the Virginia Mental Health Access Program.
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And because I was about to be American Academy of Pediatrics president,
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I just wanted to make sure that no matter where a child was in the country,
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that we could continue to have this.
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And lots of people worked on this. It certainly wasn't just me.
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In Virginia or nationally, lots of stakeholders advocating for this.
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So now we have funding for programs like CPAN in every state,
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tribe, and territory available.
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And so we're really excited that, you know, across the country,
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pediatricians who are doing this work can now call and get help from a specialist
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to be able to provide this type of care.
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In fact, I was interviewing a pediatric psychiatrist here in the studio and he was on call for CPAN.
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So we paused and I stepped out and he took the call and helped the pediatrician to help the child.
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And it was great to see, you know, him in action. Yes.
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And it's still such a challenge. What advice do you have for our pediatric practitioner listeners?
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I know when I'm talking to pediatricians, some are hesitant to use that line.
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I don't want to bother them. Is this really something they could help with?
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So, you know, I think for us, it's important to recognize as pediatricians that
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we do this already for all of our other things.
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You know, if we have a question about a child's thyroid labs.
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We will call and speak to our local pediatric endocrinologist and do a curbside and get advice.
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And this is exactly that same model. And so just with mental health providers, right?
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So for us, it really shouldn't be much different than what we're already doing.
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And the nice thing is that there's no judging, you know? So if you're calling
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because you have no idea what to do, great, you know, there's someone there to help you.
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Or if you have done lots of things and tried to help this child and whatever
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treatment you're trying isn't working, then again, asking for help.
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And it can be very complex.
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I was just talking to a pediatrician the other week. She had a child who had
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been in psychiatric inpatient residential facilities for two months and was
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just being discharged and now showed up in her office. And she's like, what do I do?
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You know, this child is very complicated, doesn't have their follow-up appointment
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for another two to three weeks.
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And so she was able to call our child psychiatry consult line,
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and they taught her, you know, what she should be checking for,
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what side effects she should be looking for, and really just provided that wraparound
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service for us, you know, to make sure that we're comfortable with that work.
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And again, realizing it's a team sport, you're not doing this alone,
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and it's very complicated.
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So, and whether or not you identify yourself as a mental health provider or
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not, we are seeing kids all day long with these issues.
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And having a specialist behind you and supporting you is just incredible.
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And here in Texas, we have a program called T-Chat through the school system
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where a lot of our listeners already know,
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you probably already know about this, but where you can get the parent or caregiver
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can work with the school system and get free telehealth visits with a pediatric
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psychiatrist. That's wonderful.
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There's probably in other states, things like that that are happening.
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I don't know. Yeah, I think every state, region, and county,
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you know, is being very creative and trying to figure out how do we help children wherever they are.
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And schools, obviously, they're at school most of the day, every day, and during the week.
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And so I think, again, it's going to take all of us to solve for this.
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What advice would you have, though, or do you have any other advice with mental health?
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Do you see that as the biggest challenge right now in pediatrics?
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I think there are a few things that we're facing.
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You can, clinically, certainly mental health is an area where there's a youth mental health crisis.
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You know, AAP and the Children's Hospital Association and the American Academy
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of Child and Adolescent Psychiatry declared a national youth health emergency
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in mental health a few years ago, and we continue to renew that.
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The access to care issue because of the workforce issue is a challenge in mental
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health, but it also in pediatrics generally.
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Workforce is a problem right now, not just with ourselves having enough pediatricians,
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pediatric specialists, pediatric nurses, you know, having enough staff at our offices.
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Is at AAP, we do a survey of pediatricians every year, sort of a longitudinal survey.
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And what we've we asked them, you know, what are some burning platform issues?
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And unlike years prior, workforce has bubbled up to the top.
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And, you know, having enough people in your office to see the patients,
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help you see the patients is a challenge.
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And that's across healthcare globally, Globally, not just locally.
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I traveled to Argentina last year, and the topic that they wanted to talk about was workforce.
25:11
The second topic they wanted to talk about was youth mental health.
25:14
And so, again, across the world, you know, we all just went through a global pandemic.
25:19
So we've all had this collective experience and have also seen the same sort
25:25
of downstream impact that's happening.
25:27
And so learning to figure out how do we be creative and how do we enhance workforce?
25:33
AI might be a solution for some of that. So there's that.
25:37
More to learn there. Yes. Let's talk about AI.
25:40
Should we be, you know, is there, and when it comes to medicine,
25:44
this is going to help us. We're already using it in some ways.
25:48
There's, it sounds scary, but really there's so much good that can come from
25:52
it. Yes. I think there are.
25:55
You know, several ways and paths that you could think about AI.
25:59
But let's sort of focus on children and AI and then AI and pediatrics.
26:03
So children and AI, I think, is something where pediatricians really,
26:07
really need to be at the table.
26:08
We really need to step up because we've seen with social media what has happened,
26:13
you know, when the algorithms are not designed for kids.
26:15
And so instead, kids are being exposed to things that are not healthy.
26:20
I was talking to a 24-year-old woman recently, and she said she was a survivor of an eating disorder.
26:27
And she said, when I was 13, I got my first cell phone, and it taught me how
26:32
to have an eating disorder.
26:33
You know, it taught me that my body was not the right size.
26:38
It taught me, you know, what I needed to do to fix that, quote unquote.
26:42
And then also, you know, taught me how to hide it from my parents,
26:45
how to hide it from my teachers.
26:47
And it wasn't until she ended up in the PICU that she realized it wasn't healthy.
26:52
And so having algorithms that bring up content that isn't safe for the developing
26:58
brain and the young people that are using all these apps is critical.
27:03
And so there's an advocacy piece there. And so at AAP, we've been doing a lot
27:07
of advocacy work to make sure that with social media that children are safe.
27:11
There are positive things about social media. With social media,
27:15
that's how people communicate with each other.
27:17
That is how children can find people who are like them. You know,
27:21
how you can find like-minded communities.
27:23
There's a lot of benefit to social media. So we don't want to just ban it.
27:26
That's not really what the goal is. But in order to change the design of the
27:31
algorithm so that it's safe for kids is important.
27:34
So when we talk about AI in children, the same thing needs to happen.
27:38
What the design of AI needs to be such that when children are interacting with
27:43
it, that it's safe. life and the vendors and people who are programming and figuring this out.
27:49
It's a incredibly fast, rapid rate of development, but I can guarantee you that
27:55
they don't all have pediatricians sitting in there at their tables trying to
27:59
help to ensure that things are safe for kids.
28:01
So if you're a pediatrician interested in technology in any way,
28:05
you know, look around, see if there's a way for you to get engaged at AAP.
28:09
We have a Council on Clinical Information information technology that's focused
28:12
on this. So there are ways to get engaged if you're interested.
28:15
You're looking for people to be, doctors to be a part of that council?
28:19
Always, yeah. And AAP has many section councils and committees with lots of
28:23
different areas of focus, you know, on education, nutrition, etc.
28:27
So there's something for everyone. So certainly, if you're interested,
28:30
please look and see how you can become a member of these things so that you
28:34
can be a part of the conversation.
28:36
AI in medicine is a different area where I think, you know, we're going to see
28:41
some really wonderful things.
28:42
But again, it needs to be with pediatricians at the table to ensure that when an AI,
28:48
for example, for clinical decision support is developed, that pediatrics and
28:53
all the nuances around taking care of kids is included in the development of that product.
28:58
We already have AI. It's not new. So if your EMR already reminds you what immunization
29:04
a child needs today, that is a form of AI.
29:07
So that's not new. What might be new, though, is how much it may be helping
29:12
you now or going forward.
29:14
When in my practice, we're actually using AI scribes. Several of our physicians
29:20
are using AI scribes, and they love it.
29:22
They absolutely love it. And it's a little bit like having a medical student
29:26
in your practice who you send into the room first, and then they come out with
29:30
a finished note, and then you
29:31
go through and you edit it and change it or do what you need to do to it.
29:34
It's very much like that, but it's a time saver.
29:37
So typically you go in with the AI scribe, either on your phone or on a computer,
29:43
and it's recording the visit and transcribing.
29:46
But it's not just transcribing, because it knows what is, or at least the ones
29:50
we use, knows what's just chit-chat, you know, when you're talking about the
29:54
weather or how was your vacation. It knows not to include any of that.
29:58
But it does know when you're talking about the fever and the cough and the runny
30:01
nose and the vomiting and diarrhea that that's relevant.
30:04
And we'll add that to the HPI. And then if you talk about allergies,
30:08
it'll add that to the allergy section.
30:10
It will basically write what's called a soap note, and it can put things in different places.
30:15
If it's integrated in your EMR, sometimes it can do even them more,
30:18
like open up the prescription page when you're talking about an antibiotic or
30:21
a medication that you want to refill.
30:23
So again, the pediatricians in my office have used it, love it.
30:28
It really helps with the sort of the, oh, by the way, conversations that happen at the end of a visit.
30:32
And it saves them time. One clinician was saying it saves her 10 hours a week.
30:37
Wow. So it's been amazing. Yeah. That's huge.
30:40
It is. And in the editing of this podcast, AI helps us.
30:44
And it feels like I have an assistant who doesn't need a lunch break,
30:49
never complains, or goes on vacation.
30:51
But it's really helpful. I've been amazed.
30:54
Anything else you want to say about AI? No, other than, you know,
30:59
I think thinking about AI as a tool, you know, and not to be afraid of it.
31:03
I think with AI, it can be, it will be very helpful.
31:07
We do need to make sure it's being steered in the right direction and the databases
31:11
that it's being trained on are equitable and have have information that makes
31:16
sense and that is appropriate.
31:18
So that's where we can be if we're involved in sitting at the table.
31:21
It can make a big difference.
31:22
But yeah, I think not being afraid of it is important. And just play with it.
31:27
There are lots of ways you can interact with various AI things online now and
31:31
for free. And just play with it and see what it can help you with.
31:35
Dr. Chung, do you have any advice when it comes to cell phones and children
31:40
for the pediatric practitioner?
31:42
What do we say to families? And then also, what would you say to parents directly?
31:48
Yes. So, you know, when we talk about, it used to be at AAP,
31:52
we had a recommendation for screen time in a certain number of hours.
31:56
That doesn't work as well anymore because they're using screens at school.
32:00
They're using screens for homework.
32:02
You know, so screens are pretty ubiquitous at this point.
32:05
What we want to do, though, is think about it in a different way.
32:08
So AAP has a center on social media and youth mental health.
32:13
And that development, that center is really a great resource for family.
32:19
You can go online and see. You could type in questions even.
32:23
So as a parent or as a clinician or as a child, you could type in questions
32:27
and ask, you know, what's appropriate for my child, blah, blah,
32:31
blah, you know, or what should I do here? and an expert will write you back
32:35
and answer your question.
32:37
And we have mental health providers, we have pediatric providers,
32:40
we have technology folks that are helping to work on the answers.
32:45
I think the thing to understand with cell phones and interaction with social
32:50
media and so forth is that banning the technology is not necessarily a solution
32:57
for all children because of the need and how much it's become a part of their
33:02
lives and educational process.
33:04
However, what you want to see is whether or not it's replacing and pushing out
33:09
other things that are healthy for children.
33:11
So if your child is spending so much time on their phones that they're not going
33:16
outside and playing or they're not reading or they're not doing activities with
33:21
their friends, then that's too much.
33:24
At that point, we need to pull back a little and say, let's put that down and
33:29
let's go do something else.
33:30
And it's balancing that and seeing how your child is when they're using it.
33:36
I have four kids, and so they're all teenage or young adults now.
33:40
And so my youngest loves video games. He is on video games all the time. My son does, too.
33:47
Yes, and it's a part of the world, right, that they're in.
33:51
Now, I used to play video games as a child, but I think what's different is
33:56
that the designers of some of these games now are design worlds that are so
34:01
immersive that you don't want to leave the game, right?
34:04
So there's psychological tools that are being used to keep you attached.
34:07
So different from Pac-Man? Yes, a little bit.
34:11
Where it ends. You went somewhere to play the video game and it was this big
34:16
machine and you put money in.
34:17
Yes, that's right. And you can only play for a certain period of time and the game was over.
34:21
So now instead, video games are designed such that you need to be with your
34:26
own device, your own headset, your own microphone, your own laptop.
34:29
So if you're with your friend and you're like, hey, let's go play whatever, you then separate.
34:35
You go back to your own homes, to your own rooms, to your own devices,
34:39
and it's very isolating. Even
34:40
though online, you're getting ready to play with that exact same friend.
34:44
And so what happens is because of the way this is designed, now our children
34:49
are seeing the world differently.
34:52
And so we as parents need to be able to say, okay, well, you can play up to
34:57
this point, right? Because I know you're playing with free people you know.
35:00
And I know you're engaging in social activities.
35:03
But then in a little bit, we're going to go for a walk, you know,
35:07
or we're going to go outside and do something. thing so that you're balancing
35:11
the other things that are really important for health with the social interaction
35:15
that's happening online.
35:17
Straight bans on ages, there's been some talk about that. That is not necessarily
35:22
something we support at AAP.
35:24
And the reason for that is when you look at a 13-year-old, for example,
35:29
some 13-year-olds are ready to be able to turn off the device or shut down the
35:34
app, you know, and can do stuff.
35:37
And some 13-year-olds are not, you know. And so a straight age cutoff doesn't
35:42
actually quite solve for that.
35:44
And then sometimes when you put in rules around ages, it actually makes it more
35:48
attractive as opposed to what you're trying to actually accomplish.
35:52
You know, if one can imagine looking at drinking ages as an example of that,
35:56
you know, trying to do it if you're not 21 or 18, depending on your state,
36:01
you know. So So it becomes more attractive to try to do the thing when you're
36:05
an adolescent developing.
36:07
So we don't want that, you know. That's a great point. Yeah.
36:10
So I think straight age lines may
36:13
not be the right answer, although it's attractive to think about. Yeah.
36:17
I know the game that's wildly popular, Fortnite, I mean, it's so violent,
36:24
basically going around trying to shoot someone else.
36:27
And but that seems to be more accepted now.
36:31
I when I saw my son playing that, I'm like, this is Fortnite.
36:35
I was just, you know, like, we need to limit this for sure.
36:38
But he's like, everyone's playing Fortnite all the time. Yeah, yeah.
36:42
And I think, you know, there's lots of debate about whether or not the violence
36:47
within video games is encouraging violence elsewhere.
36:50
I think at certain ages, that's true. You know, when you're looking at the younger
36:55
children who don't yet understand real, not real, where they're still having imaginary thinking,
37:01
you know, meaning like five, six, seven-year-olds, at that age group,
37:05
it's probably not appropriate for them to be playing things like that.
37:08
Now your teenagers, they are a little bit more aware of real, not real.
37:13
I remember watching a little documentary on video games, and the thought was
37:19
when video games from when we were kids started, that it would just ruin society.
37:26
That all things would go badly. So I think there might be a little bit of that, too.
37:30
But it is important, though, as pediatricians understanding child health,
37:34
that as they're developing video games, that we are at the table and saying, wow, that's not okay.
37:40
Common Sense Media is a platform that rates things and helps parents understand
37:46
how much violence might be in a product or foul language and all of those things.
37:52
So that's a great resource as well. Wow. I agree.
37:54
Now when I say I have three children, I'll say, okay, let's look at common sense
37:59
media. They're like, no, mom, don't. Don't look there.
38:02
They don't want to know the answer.
38:07
So I know you're giving a talk in a little while for a women in medicine luncheon.
38:13
And as we know, burnout is high in this profession, but it's higher in women.
38:21
Do you want to say anything there to our female practitioner listeners?
38:26
Sure. Certainly, as a mom of four, I fully understand a lot of the things that we go through.
38:32
Now, to be fair, my husband actually does a lot of the work to help out my children.
38:38
And I couldn't do all the other things I do if it weren't for him.
38:41
So I'm very grateful for him.
38:43
And I think understanding that there's a partnership in many families,
38:47
not every family, though. But for women in particular, we are trained culturally
38:53
to feel a certain way, be a certain way.
38:57
And so when they do surveys and look at women in medicine or just women generally,
39:02
women tend to feel more guilt about whatever they're doing if it's not focused
39:06
on the family or being at home or all of those things.
39:09
And so that additional guilt burden is a challenge for us.
39:14
And I think understanding and recognizing that for the first of all, that that's true.
39:20
And guilt tends to stem from anxiety and not feeling like you can't do all the
39:26
things perfectly, you know. And so does that go along with shame?
39:30
I've heard that. Yes. They're all very much linked. And when you look at external
39:35
feelings or behaviors, you know, like anger, sadness.
39:39
It tends to be the outward behavior for an underlying feeling,
39:44
which is often anxiety, shame, guilt, those things.
39:48
And so, for example, there's stuff where I remember going home,
39:53
especially during the pandemic, when it was just super stressful.
39:56
You know, every day something new was happening, and you had to figure out what
39:59
you were going to do in your practice to deal with whatever the new recommendation was.
40:04
So it was very anxiety-provoking. And I also had to spend a lot of time at work.
40:08
And so I would get home, and...
40:11
My husband, for example, would have made dinner, which was lovely, but the place was a mess.
40:16
You know, the kitchen was a mess, and that would just drive me crazy walking into the door.
40:20
That was just something I needed to look clean in order to feel good about my environment.
40:25
And I would just get mad because I'm like, I've been doing this all day long,
40:28
and I come home, and you guys could have at least put the dishes in the dishwasher.
40:33
And they would look at me like, what is wrong with you?
40:38
And it was very much a manifestation of a feeling I was having because of all
40:42
the other things going on in my life and understanding and recognizing that
40:47
and changing my thought process.
40:48
Because what I learned is that,
40:51
okay, my husband also had been working all day. He was working at home.
40:54
So for me, it was different, you know, but he had been working all day.
40:58
He had just gotten to make dinner for my kids.
41:01
My kids had just gotten home from school, but I didn't know any of that.
41:04
You know, I kind of walked in and saw the mess and had the thing.
41:07
And so I think understanding the thinking behind it, not the they are not doing
41:14
their part or they are waiting for me and why do I have to do it.
41:18
So if I change the thought to say, oh, this is really hard for all of us,
41:21
you know, we've got a lot going on.
41:23
So why don't we all chip in and fix this?
41:26
You know, just changes how you feel, changes your behavior.
41:29
And that ability to change our thought, our underlying thought is really important.
41:34
And also focusing only on what you can control.
41:37
Control that in medicine we hear a
41:40
lot of news about all sorts of things happening and that
41:43
can be very overwhelming i know at times i have
41:46
to turn off the news so i don't hear what's happening just for
41:49
mental health reasons i need to take a break and so because knowing i don't
41:53
have control over all of those things and focusing on what i do know i have
41:58
control over is really important and when you do that that changes somewhat
42:03
you know what you're how you face the day just focusing on what you know you can control.
42:09
That's great advice, Sandy. And it sounds like you're also talking about stepping
42:13
into curiosity instead of judging the situation.
42:16
Yes, that's right. That's right. And really, for cognitive behavioral therapy,
42:21
we may refer patients for that.
42:23
But if you've never experienced or you don't know what cognitive behavioral
42:26
therapy is, it is actually that.
42:28
What you're thinking changes how you behave, which changes how you feel,
42:32
which changes how you think. And in this, it's a triangle.
42:35
And so if you intervene and change that underlying thought, and again,
42:39
in the way we started this podcast, we were talking about, you know,
42:43
walking into the exam room, seeing a patient.
42:46
And when you go in with that big smile and you are focused on them,
42:50
you just change what you were thinking about.
42:52
You know, right outside the exam room, maybe you were thinking,
42:55
I've got eight notes to write. I haven't had lunch yet.
42:57
You know, there's this thing happening at home. You are thinking something totally different.
43:01
But when you walked into that exam room, you're thinking and you're smiling
43:04
and you're doing this and you feel different. We actually feel different.
43:08
And the reality is we can do that all day.
43:11
We don't have to go back out of the exam room and change what we're thinking about.
43:15
And so when you see 18 to 20 patients a day and you saw 17 patients that were super happy to see you,
43:22
but there was that one patient that was late and was super complicated or mad
43:26
at you because of something you did, you know, instead Instead of thinking about
43:29
that one patient all day,
43:31
instead think about the 17 who are so grateful to you and so grateful for all
43:35
the work that you did for them.
43:37
And if you focus on them, then the way you feel will be very different.
43:42
Sandy, I think that's so true and such wonderful advice. And we made it through
43:46
the pandemic to see, and especially pediatric clinics, the adaption.
43:50
So many patients had COVID-like symptoms and to adapt with the changing recommendations and everything.
43:57
Do you think we can get through anything now? Well, I would say pediatricians,
44:01
we are one of the most resilient specialties ever.
44:04
I mean, everyone is, but pediatricians, we are really good at this.
44:07
And so, again, I think part of that is the people we're taking care of,
44:12
you know, knowing that children count on us, that gives us purpose and mission and joy,
44:19
and that helps us to make decisions and do what we need to do to get through
44:24
the day. So I'm optimistic.
44:27
Do you want to tell us before we wrap up what you do to unplug or unwind? I'd love to.
44:32
When I'm not advocating or working and doing all the other things, I love to be outside.
44:39
I love to get away at a lake. And so I love water and I love,
44:44
you know, being around nature.
44:47
And that to me is my happy place.
44:50
And I think that's important for everyone is to identify where your happy place is.
44:53
It doesn't have to be a different physical location. even in
44:57
my own in my house I have a sunroom with
45:00
lots of plants and that's my space and so what if I need to unplug and unwind
45:04
my whole family knows if I'm in there you know that I'm trying to be happy and
45:09
so and I and I also love to read and paint and you know find find hobbies to
45:14
to really focus on myself and and that's important.
45:18
Do you have a particular book you want to recommend? Yeah, I love to read.
45:22
There's one that I read recently, Atomic Habits by James Clear, I believe.
45:27
And so that one, what I love about this book, so it's about how to change whatever
45:32
is going on in your life to make it a habit. bit.
45:36
And what's interesting is that if you change, what one thing he recommends is
45:41
that if you change something just 1% a day, then very quickly you've completely
45:47
changed, you know, just 1% a day.
45:50
And I feel like 1% a day is achievable.
45:52
And so for me, you know, if there's something I want to change,
45:56
just finding that small thing I can do and manage, even if it's not a day,
46:01
1% a month, 1% a year, whatever you need to do over time, that's pretty dramatic.
46:06
So taking on tasks and not trying to bite off all the things and making sure
46:11
you're successful is really important.
46:14
I'm looking forward to reading that. Instead of the mindset,
46:17
instead of I'm going to start lifting weights four times a week for an hour,
46:22
I'm going to put on exercise clothes.
46:24
Exactly. That's right. That's exactly right. And then you're more likely to
46:27
actually do it. To do that, yes.
46:29
As pediatricians, we need to advocate for ourselves and for children.
46:33
And it will be important in the world of payment, in the world of legislation,
46:38
in the world of regulation, that we continue to advocate for pediatrics in children.
46:43
Children because in the house of medicine, we are the only real family medicine
46:49
a little bit, but pediatricians are really the voice of children.
46:52
And if you go back to thinking about a garden and making sure that the baby
46:57
seedlings grow up to be healthy plants, you know, as pediatricians,
47:01
that is our role and our space.
47:04
And for the future of society, it's going to be important that pediatrics is
47:09
sustainable and that pediatrics is supported.
47:12
And with advocacy, that can absolutely happen.
47:19
Music.
47:28
We hope you've enjoyed this episode of Pediatrics Now. Click on the link for
47:32
free credit if you're a practitioner.
47:34
You can also email us with questions or episode ideas.
47:37
That address is pediatricsnow at U-T-H-S-C-S-A dot E-D-U.
47:44
We release a new episode every Friday.
47:47
I'm Holly Wayment. I hope you can join us for our next episode. Thanks for listening.
47:52
Also in this Pediatrics News Feed, we have an episode called The New Asthma
47:58
Guidelines, What Were They Thinking?
47:59
I interview a doctor who was on that expert panel.
48:04
Our sister podcast is Pediatrics Now for Parents.
48:08
That website is pediatricsnowforparents.com. That podcast can also be found
48:14
wherever you get your podcasts.
48:16
We cover a lot of the same topics that we cover here in Pediatrics Now for the
48:21
Practitioner, but it's in small bites for the a busy parent.
48:25
We hope it's one less thing you have to say in the exam room.
48:29
That's our sister podcast, Pediatrics Now for Parents.