Diane J. Madlon-Kay

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment.

Objective.To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. Design.Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. Subjects.Children ages 4 to 15 years seen consecutively for nonemergent care. Measures.Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. Results.Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. Conclusions.Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

Childhood Vaccine Beliefs Reported by Somali and Non-Somali Parents

Background: In 2011, an outbreak of measles in Minnesota was traced back to an unvaccinated Somali child. The purpose of this project was to (1) ascertain whether Somali parents are more likely than non-Somalis to refuse childhood vaccinations, particularly the measles-mumps-rubella (MMR) vaccine and (2) determine what factors influence the decision not to vaccinate. Methods: We explored parental perceptions and utilization of vaccines through a survey distributed to a convenience sample of Somali and non-Somali parents of children ≤5 years old in a family medicine clinic in Minneapolis, MN. Results: A total of 99 surveys were completed, 28% (n = 27) by Somali parents. Somali parents were more likely than non-Somali parents to have refused the MMR vaccine for their child (odds ratio, 4.6; 95% confidence interval, 1.2–18.0). Most of them refused vaccines because they had heard of adverse effects associated with the vaccine or personally knew someone who suffered an adverse effect. Somali parents were significantly more likely to believe that autism is caused by vaccines (35% vs. 8% of non-Somali parents). Somalis were also more likely to be uncomfortable with administering multiple vaccines at one visit (odds ratio, 4.0; 95% confidence interval, 1.4–11.9) and more likely to believe that children receive too many vaccines. Conclusions: Statistically significant differences in perceptions and use of vaccines were reported by Somali and non-Somali participants. Somali parents are more likely to believe that the MMR vaccine causes autism and more likely to refuse the MMR vaccine than non-Somali parents. These beliefs have contributed to an immunization gap between Somali and non-Somali children.

Health promotion counseling in residency training

This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient “Health Habits Questionnaire” and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion.

Clinician Adherence to Guideline for Phototherapy Use in Newborns

Objectives: The objectives of this study were (1) to determine clinician adherence to the 2004 American Academy of Pediatrics guideline for phototherapy use in newborns; (2) to compare adherence to the guideline in 2 different hospitals; and (3) to determine whether adherence to the guideline improved after the phototherapy nomogram was available in newborn charts. Methods: This study was a retrospective review of medical records of 1160 newborns receiving care at the normal newborn nurseries at 2 Twin City, MN, hospitals. Four hundred thirty-six infants received phototherapy. Results: When phototherapy was administered, it was indicated in 37% of cases and not indicated in 8%. In 56% of cases it was considered subthreshold. When phototherapy was not administered, it was appropriate in 99% of cases but was inappropriate or missed in 1% of cases. There was a significant difference in clinician adherence to the phototherapy guidelines between the hospitals. The addition of the phototherapy nomogram to the newborn charts did not change adherence to the guideline. Conclusions: Clinicians infrequently missed providing phototherapy when it was indicated. Most infants received phototherapy when their bilirubin level was in the “optional” range. The interhospital variability of guideline adherence confirms results found in other studies. Because the addition of the phototherapy nomogram alone did not improve adherence to the guideline, alternative interventions targeted at nurseries should be considered.

Effect of Revised Nursery Orders on Newborn Preventive Services

Objective: Aspects of neonatal care that are the subject of evolving guidelines include hepatitis B virus (HBV) immunization; discharge follow-up recommendations; and prevention of perinatal group B streptococcal (GBS) disease. In 2007, a university hospitals standardized newborn nursery orders were changed to reflect current recommendations in these areas. The objective of the study was to determine the effect of new nursery orders on the quality of care provided to these newborns. Methods: The study was a retrospective review of medical records, birth certificates, and a computer database of 857 infants. The nursery orders changed in the following ways: (1) physicians had to “opt out” of HBV immunization; (2) discharge follow-up recommendations were based on American Academy of Pediatrics (AAP) recommendations; and (3) AAP recommendations for GBS were followed except blood cultures were not required for certain infants. Results: The percentage of infants receiving HBV immunizations increased from 74% in 2007 to 83% in 2008 (P = .0018). The percentage of infants whose mothers received antibiotics for GBS less than 4 hours before delivery and who received a complete blood count increased from 36% to 83% (P < .0001). The percentage of newborns who had discharge follow-up plans consistent with AAP recommendations did not change significantly. Conclusion: A simple change in nursery orders was associated with significant improvement in newborn care.

Rubella immunity in chemically dependent adolescent females

Congenital rubella syndrome continues to be a problem in this country because of the continued existence of a substantial susceptibility to rubella in young women of childbearing age. The objectives of this study were to determine the percentage of chemically dependent adolescent women in a residential treatment center at risk for rubella infection and to correlate their immune status with history of immunization. Although only one individual was reported as not having been vaccinated for rubella, 12.4% of the 129 subjects were found to be nonimmune by titer. No statistical relationship was found between self- or parent-reported immunization status and actual titer finding. Of the 16 women found to be not immune, only 56% were successfully vaccinated. Patient history appears to be of little value in establishing immunization status in this population. We recommend vaccination of young women in residential treatment centers who do not have documented histories of vaccination.

Current Scope of Practice for Newborn Care in Non-Intensive Hospital Settings

The scope of practice for newborn care in nonintensive hospital settings is ever changing, with obstetric care advances, shorter length of stay (LOS), and increased family-centered care.[1][1] In response to the US Surgeon General’s call to support breastfeeding and Baby Friendly USA, more infants

Effect of an educational intervention and parental vaccine refusal forms on childhood vaccination rates in a clinic with a large Somali population

Objective The purpose of this study is to improve vaccination rates at a clinic with a large Somali population, and many vaccine hesitant parents. The study evaluated the effectiveness of some new materials for vaccine hesitant parents. Methods Educational sessions were given to providers and staff to give “talking points” and to introduce a vaccine refusal form. Chart reviews were done for notes from 50 random well child visits per month of children less than six years old for 7 months before and after the intervention. Results Before the intervention, 44% of Somali children who needed shots did not get them at their well child visit. Afterwards, 34% of the Somali children did not get their needed shots. Of non-Somali children, 16.8% did not get needed shots before the intervention, and 12.7% did not get needed shots after the intervention (P=0.07). The MMR was the most frequent vaccine omitted. After the intervention, 29 parents signed the vaccine refusal form. Conclusion The “talking points” and vaccine refusal form were associated with improvements in immunization rates in this challenging patient population that were not statistically significant. Refusal form use was not well documented, so its true value requires further study.

A Clinical Atlas of 101 Common Skin Diseases with Histopathologic Correlation

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Women's Mental Health in Primary Care

increased. For the most part, the book is organized by body systems, with additional sections on accidents and emergencies and on adolescent medicine. Some sections with new authors have been completely revised, and others with the same authors have had major revisions. The chapter on the newborn has increased from 85 to 139 pages, and the section on human immunodeficiency virus infection has increased from 5 to 25 pages. Material is as up-to-date as one can expect from a textbook that addresses such current topics as the ipecac vs activated charcoal for acute poisoning, the essentials of the new Centers for Disease Control guidelines for the treatment of otitis media in an era of increased antibiotic resistance, storage of umbilical cord blood as a source of stem cells, newer antibiotics, and treatment of Helicobacter pylori in children. Each section has selected references, which, too, have been updated. While the title says current therapy, discussions are narrative and instructive and are not limited strictly to treatment but include information on pathophysiology, disease processes, differential diagnosis, and some aspects of diagnostic evaluation. Styles vary somewhat with different authors, but readability and clinical relevance are generally good throughout. Contributors are allowed to share their personal views, such as with the discussion of infant colic. There is no formulary; and specific medications are listed in individual sections usually by their generic names. There is liberal use of charts and tables, particularly to list differential diagnoses, drug treatments, and other therapeutic modalities. This book is not a substitute for a standard textbook of pediatrics, but it is a definitive work that addresses therapy for the entire range of pediatric problems. Although it is much too big to fit in a pocket or purse, it should be available as a reference wherever sick children are treated. For the busy practitioner who already owns the previous edition, there is sufficient revision in this edition to justify an updating. Leland J. Davis, University of California, San Francisco Santa Rosa, Calif