Joan E. Hodgman, MD, FAAP
Transcription
Joan E. Hodgman, MD, FAAP
SENIOR BULLETIN AAP Section for Senior Members Editor: Associate Editor: Advocacy for Children Editors: Travel & Leisure Editor: Financial Planning Editor: Health Maintenance Editor: Computers Editor: General Senior Issues Editors: Outdoors Editor: Joan Hodgman, MD, FAAP Arthur Maron, MD, MPA, FAAP Lucy Crain, MD, MPH, FAAP Burris Duncan, MD, FAAP Donald Schiff, MD, FAAP Herbert Winograd, MD, FAAP James Reynolds, MD FAAP Avrum Katcher, MD, FAAP Jerold Aronson, MD, FAAP Avrum Katcher, MD, FAAP Eugene Wynsen, MD, FAAP John Bolton, MD, FAAP Vo l u m e 1 7 N o . 2 – S p r i n g 2 0 0 8 Opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Message from the Chairperson Avrum L. Katcher, MD, FAAP Chairperson, Section for Senior Members Delighted to converse with you again. If you are reading this message, we are conversing. A conversation occurs in two directions, in contrast to a speech. I do not give speeches, but I am delighted to hold a conversation. That means, that the more you respond to these messages, the happier I am. And the more likely you are to make a different point, the better it is, because I am more likely to learn something from you. That makes a conversation, and since it will often appear in the next issue of the Bulletin, the better off we all shall be. What’s Inside? Message from the Chairperson . . . . . . . . . . . 1-2 Executive Committee/Subcommittee Chairs . . . 2 2008 National Conference & Exhibition . . . . . . 3 Section for Seniors Members Program Crucial Considerations for Grandparenting . . . . 3 Joan E. Hodgman, MD, FAAP . . . . . . . . . . . . 4-5 Lost e-mailer letter member sought!. . . . . . . . . 5 2008 Senior Bulletin Schedule . . . . . . . . . . . . . 6 Pediatric History Center . . . . . . . . . . . . . . . . 7-9 Promoting the Values of Pediatrics . . . . . . . . . . 9 The Oral Heal Risk Assessment Training for Pediatricians and Other Child Health Providers Training Kit . . . . . . . . . . . . . . . . . . . 10 PROGRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . 10 A Happy Spring Time to you all. And I hope that if you are in a Daylight Savings area you have completed your adjustment without difficulty. What do you think of Daylight Saving time? Should it be continued? Some scientists are saying that it does not add to conservation of energy or decreasing the number of greenhouse gases. What are your thoughts? What evidence do you have to support them? SCHIP: Good policy for children became ensnared in a larger debate on how to reform health care . . . . . . . . . . . . . . . . . . . . . . . . 11-12 Medical Home Program Expands to all Domestic Shriners Hospitals for Children . . . . . . . . . . . . 12 Over-the-counter cough and cold medicines for infants and children - Speaking Points . . . . . . 13 COOL AID . . . . . . . . . . . . . . . . . . . . . . . . 14-15 Have you looked at the AAP Home page on the web site recently? There is a spread to entice you to consider the National Sleep Awareness Campaign, a feature of the AAP and the National Sleep Foundation (NSF), for the millions of Americans who are not getting the sleep they need. Now don’t laugh. I went through this also, working for seven years as a solo Changing Times for Neonatologist in the Regionalization System . . . . . . . . . . . . . . . 16-17 The Contortionist . . . . . . . . . . . . . . . . . . . 17-21 Bond Basics. . . . . . . . . . . . . . . . . . . . . . . . 21-22 LINCOLN AND DOUGLAS . . . . . . . . . . . . 22-23 Update your Personal Profile . . . . . . . . . . . . . 24 Continued on Page 2 Copyright© 2008 American Academy of Pediatrics Section for Senior Members Executive Committee Avrum L. Katcher, MD, FAAP Chair Flemington, NJ David Annunziato, MD, FAAP Immediate Past Chair East Meadow, NY Michael O’Halloran, MD, FAAP Eau Claire, WI George Cohen, MD, FAAP Rockville, MD Lucy Crain, MD, MPH, FAAP San Francisco, CA John Bolton, MD, FAAP Mill Valley, CA Arthur Maron, MD, MPA, FAAP Boca Raton, FL Subcommittee Chairs Program Lucy Crain, MD, FAAP Financial Planning James Reynolds, MD, FAAP Membership George Cohen, MD, FAAP History Center/Archives David Annunziato, MD, FAAP Newsletter Editor Joan Hodgman, MD, FAAP 626/445-0178 [email protected] Associate Editor Arthur Maron, MD, FAAP 561/394-6114 [email protected] Staff Jackie Burke, Sections Manager 800/433-9016, ext. 4759 [email protected] Tracey Coletta, Sections Coordinator 800/433-9016, ext. 4926 [email protected] Mark A. Krajecki, Pre-Press Production Specialist 847/434-7866 [email protected] 2 Message from the Chairperson Continued from Page 1 practitioner, on call every night and every weekend, before my first partner, Glenn Lambert came to work with me. By retirement, we had 8 members in our group practice, and more on the way. But I still do not sleep as well as I should. The NSF has absolutely fascinating material on factors that promote healthy sleep and those that interfere with it. What you can do to enhance your sleep and other members of your home family are included. Well worth looking into if you feel there may be a sleep problem. Failure to sleep well may be associated with quite a number of behavioral and somatic difficulties, and often is readily improved. Go from the AAP home page, click on Sections, click on Section home pages then Senior Members to our refurbished web site, crafted by member Jerold Aronson and staff member Amy Beschta-Newborn. Here you will find a number of important sources of information. First, the Section for Senior Members education program for the NCE in Boston to be held on Monday, October 13, 2008 CRUCIAL CONSIDERATIONS FOR GRANDPARENTING Tax Exempt Investment Options to Assure College Educations for Your Grandchildren: Lorna Meyer, Senior Vice President, President of Private Banking & Investment Group, Merrill Lynch Foster Parenting & Grandparenting 101: Another Way to Stay Young? Dr. Errol and Mrs. Judy Alden, Executive Director, American Academy of Pediatrics Impact of Adult Diet, Health, and Lifestyle on Future Generations: Lisa Hark, Ph.D., R.D., Director, Nutrition Education Program, University of Pennsylvania School of Medicine. In addition to a series of important articles and references noted on that page in the center column, you’ll find on the right-hand Site Menu the Living Well Section including information on health, legal, financial, Medicare and many other topics of importance to all of us as we age. A similar compendium of useful facts is found under the block on Health and Fitness, together with many other thought-provoking ideas. Finally, we want you to be aware that your Executive Committee has been working hard on goals and objectives, structuring the areas of most importance to our members upon which we should be concentrating our efforts. We will be meeting in May to consider where we are. But, meanwhile, your input and thoughts are crucial to this process. Send along your ideas, to any member of our Executive Committee, myself, or our Section manager, Jackie Burke. Also don’t forget to consider that growing older, in the same fashion as growing up from childhood, is a developmental process involving progressive change leading to (we hope) enhanced ability to navigate the inevitable changes of aging, cruise the variations in personal and professional lives which ensue, and finally prepare, if we are given time, for the closing of life. With best wishes Avrum L. Katcher, MD, FAAP Chairperson, Section for Senior Members American Academy of Pediatrics Senior Bulletin - AAP Section for Senior Members - Spring 2008 Save the Date for the 08 AAP National Conference & Exhibition (NCE) in Boston, Oct 11-14 at the Hynes Convention Center with free pre-conference CME and social events happening Friday, Oct 10. There are many new and exciting changes for 08: session times were shortened to help you focus, and to give you MORE traveling and networking time between sessions; Plenary times have moved from early to mid morning; our exhibit floor will be packed again with state-of-the-art technology, products, and resources; and the annual pre-conference symposia series, Peds21, will focus on oral health. The AAP is honored to also announce the recent confirmation of Saturday’s Keynote speaker, Timothy P. Shriver, PhD, Chairman of the Special Olympics. Learn MORE at www.AAPexperieNCE.org and click on attendee. Get a first glance at 08 NCE sessions; click on attendee > education and view sessions sorted by topic or format (dates, times, and faculty will be assigned shortly). If you missed the 07 NCE, there is an 07NCERecap page under attendee, which has faculty podcasts on asthma control, treatment of epilepsy, effects of health information technology on therapeutic relationship, cerebral function monitoring, and HIV exposure. Also on this page are links to the daily conference newspaper, the photo album, Fund Run race results, and a link to purchase the 07 NCE sessions on tape in a variety of formats (MP3, CD-ROM, or CD player for PC). Each year, universities, medical colleges, and hospitals around the country choose to sponsor an “Alumni Event” any evening during the conference. These special receptions give you MORE opportunities to reconnect with old friends and mentors. Interested in booking an alumni event? Contact Jake Stein at [email protected] to reserve space today! Section for Seniors Members Program Crucial Considerations for Grandparenting Sponsored by the Section for Senior Members Monday, October 13, 2008 1:30 PM – 5:30 PM This special session will focus on tax-exempt investment options to ensure college educations for your grandchildren; foster parenting and grandparenting 101: another way to stay young; and the impact of an adult’s diet, health, and lifestyle on future generations. Faculty: Errol Alden, MD, FAAP; Judy Alden; Lisa Hark, PhD, RD; Lorna Meyer Senior Bulletin - AAP Section for Senior Members - Spring 2008 3 Joan E. Hodgman, MD, FAAP AAP Section for Senior Members • Executive Committee Member I am a true westerner. I was born in Portland, Oregon on Labor Day in 1923. My mother, perinatal before her time, had gone from Medford where my parents were living, to friends in Portland to get a real obstetrician to deliver her. I even had a pediatrician. We moved to Reno, Nevada and to Oakland, California following my father’s construction business. When I was four, we moved to Southern California and I have been here ever since. I went to South Pasadena High School, where I met my husband, Amos Schwartz. He sat behind me in Miss Foote’s Public Speaking Class and took me to the Junior Prom. He had just been elected as our senior class president so he was a “catch”. He waited for me while I messed around and we married after we had been out of high school ten years. I was an art major in high school; but in my senior year I switched to pre med. I have given my determination to go into medicine a great deal of thought and I still don’t know where it came from. I am the only physician in my family going back several generations. When I was a girl, women were supposed to be nurses not doctors. I knew if I wanted to be accepted to medical school I would need good grades so I studied for them and managed an A average in college at Stanford. I was still not admitted to Stanford medical school. Stanford at the time had no quota for women, but never took more than two in a class. I’ve never been unhappy with Stanford because they did me a big favor. I went up the peninsula and applied to UCSF which at the time was a much better medical school. I was admitted promptly and enjoyed my schooling there. Since being admitted to medical school, I have never been personally very aware of prejudice against women. I stayed at UCSF Hospital for a year of post graduate training before coming home to Los Angeles. World War II was over by then and the veterans were coming home, I was fortunate to get a resident position in Pediatrics at Los Angeles County University of Southern California Medical Center. When I was in medical school, newborns were not given medical care. They were given nursing care and if they survived they were discharged to a doctor. The only normal newborn I saw during all of medical school was the infant I delivered when I was anOB. Infants weighing less than one kilo were expected to die. When I was a resident, Lou Diamond of Harvard developed the exchange transfusion for rh disease, which accounted 4 for one third of the deaths in newborns at the time, and published the procedure in one of the journals in 1978. Dr. Robert Clelland, who was the Head Physician for Pediatrics and I as Chief Resident read the article and tried it out. Fortunately, the newborn infant did very well. That was my initiation into newborn care. When I finished my residency, I opened my own office, which was entirely possible at the time. Amos and I had been married while I was a resident and he was in USC Medical School. He was actually my student on Pediatrics which was considered an acid test. House calls were common at the time, and usually came in the evening. What did the new Pediatrician have to offer but availability, so when the phone rang, I went. My husband was doing his surgical residency and needed to be at the hospital for early surgery. I was spending my evenings making house calls and I knew what my husband sounded like on the telephone but I was having trouble recognizing him. After two years I decided that I didn’t need to work less hard but I needed more control of my time. The job as Head Physician in Pediatrics was open and I applied for it and was chosen over seven other applicants. I was the only full time member of the Pediatric faculty at LACUSC Medical Center. The remainder were practicing Pediatricians who donated time for rounds with the residents. They were excellent physicians and devoted to teaching, but there was no academic aspect to the program. Two years after I had started it was decided to add another Head Physician. The service was to be divided into the wards and the clinics and nursery. I had first choice and was going to choose the wards as the most important part of the service, but shortly before I had to decide I realized I would miss the babies in the nursery. So I chose the clinics and nursery. Among the first things I did was get rid of the clinics and then I could concentrate on the nursery. The gods were riding on my shoulders and I have never looked back. Our hospital was delivering between 15,000 and 18,000 babies per year at the time. We did not yet have an NICU but we did have a premature ward. We were the only hospital in town that admitted outside babies to its nurseries. The Health Department had evaluated all hospitals with delivery services and had established whether they could keep small babies or send them to us. We had microchemistries, Gordon Armstrong incubators and x-ray machines that could give a clear picture of the lungs even if the baby was breathing 80-100 times a minute. We did not have Continued on Page 5 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Joan E. Hodgman, MD, FAAP Continued from Page 4 ventilators as yet. In the 60’s we tried to establish an NICU. We would clean out a nursery for the purpose and come back the next morning to find it full of babies. Not surprising when you consider that 18,000 births equates to 50 deliveries per day. In 1968 we moved to another hospital on the same grounds and finally had room to start our NICU. It was the first one in Los Angeles. We had Fellows in training although there was as yet no national Fellowship program. Paul Werhle joined our faculty as Chairman of Pediatrics in the late 1960’s and brought an academic background. I sat at his feet and learned a bunch about presenting abstracts, clinical research and running a division. Neonatal care blossomed into a Division of Pediatrics with ever smaller infants being cared for. Feizal Waffarn, one of our junior faculty at the time and I started our Bioethics committee in the1970’s during the Baby Doe controversy. Our administration could not tell us not to hold meetings but they did ask us to keep the committee under wraps. I believe their reluctance stemmed from their worry about headlines in the LA Times about minority babies being done in at the County Hospital. Interestingly, in 2005 when JACOH evaluated our hospital, they were very interested in patient advocacy. Our administration was able to claim that we had had a bioethics committee since 1975. My husband and I had two daughters. I just made it under being an elderly primipara of 30 at the time. The second was born a year and a half later. I have four grandchildren, three boys aged 24, 20 and 20, cousins not twins, and finally an eleven year old granddaughter. My husband developed a lymphosarcoma and died at the age of 47 in 1970. They say only the good die young and he was very good. I have now been a widow almost twice as long as we were married. Technology in newborn care advanced rapidly. We added ventilator care, efficient incubators, blood gas determinations and routine monitoring of the infants. We also became proficient at clinical research. I now have a 36 page CV with 130 peer reviewed articles and almost twice as many abstracts presented at research meetings. Also, there are a number of other articles and book chapters including one book entitled SIDS with coauthor Toke Hoppenbrouwers. I have had the opportunity to travel to other units world wide and in at least two, Cali, Columbia and Poland I have been a factor in the improvement of their newborn care. I went through the levels of academic status, starting with instructor as a resident and ending with Professor of Pediatrics in 1969.When I retired recently I became Emerita Professor. I have had a number of awards of which I am proud but will only list two here. I was selected in1976 as the Los Angeles TimesWoman of the Year in Science. Then, my most prestigious award was the Apgar Award given by the Perinatal Section in 1999 at the NCE in Washington, DC. I stepped down from Chairman of the Division of Neonatology a number of years ago, but continued to take my scheduled rotation on rounds and teaching. A few years ago I gave up rounds in the NICU because it was too demanding. I miss not being responsible for the NICU as that is where I worked with the residents and fellows and got to know them. Recently I have spent most of my time with medical students, teaching and sponsoring them in clinical research projects. At the present time, I am involved in writing four papers for eventual publication in peer reviewed journals and I had two abstracts in the lastWestern Society for Pediatric Research. Not too bad for an old lady. I have been active in the AAP as President of Chapter 2 and Alternate Chair of District IX. I have belonged to national committees, especially Committees on Women’s affairs when that was necessary some years ago. Now, I am Editor of the Senior Bulletin of the Section for Senior Members. I have been president of all the local organizations to which I belong including the Los Angeles Pediatric Society, Salerni Collegium, a support group for the medical students at USC and the Southwestern Pediatric Society. I am a founding member of the California Association of Neonatologists and a member of the board. On January 1, 2008, I retired from LACUSC and received a nice parting gift. It was a very attractive chair with the medical school logo on the back, my name, “In Recognition for Dedicated Service”, and the years 1948-2008. Wow! Lost e-mailer letter member sought! I received a letter from one of our members with his parenting program outlined in answer to the article about parenting by Susan DiPietro in the Winter Bulletin. I wish to answer it but I can not find it in my email and nobody in the office has a copy. I would very much like the member to send it to me again. My email is [email protected]. Joan Hodgman, editor Senior Bulletin - AAP Section for Senior Members - Spring 2008 5 2008 Senior Bulletin Schedule Articles for consideration should be sent to the Editor at [email protected] with copies to the Associate Editor [email protected] and the Academy headquarters [email protected] Summer Bulletin June 2 articles due to Joan Hodgman MD, FAAP July 1 mailboxes Fall Bulletin July 15 articles due to Joan Hodgman MD, FAAP (this deadline is early because the editor spends August at her mountain cabin away from computers and email and must have the Bulletin prepared before she leaves) September 22 mailboxes Winter Bulletin December 1 articles due to Joan Hodgman MD, FAAP January 1 mailboxes Spring Bulletin 2009 March 17 articles due to Joan Hodgman MD, FAAP April 18 mailboxes AAP resolutions and the Annual Leadership Forum by Michael O’Halloran, MD, FAAP The more I learn about the Academy the more I’m impressed not only by what it accomplishes but also by the enormous amount of work that goes into getting it done. This spring I attended the four day Annual Leadership Forum (ALF) as Vice Chair of the AAP Section for Senior Members because our chair, Av Katcher was unable to attend. It was a fascinating and enlightening experience. The ALF is the climax of the whole AAP resolution process of getting our ideas to the leadership. seminars, interactive group discussions, leadership education and presentations from the AAP President, AAP Executive Director, and AAP President-Elect Candidates. Even with this full schedule, ample time is also made available for networking. This year there were 73 resolutions. Most were thoughtful and well reasoned. Here are some examples: The AAP should look into whether telephone care is cost effective; The AAP should support mandated Phy-Ed in grade schools; The Legislative Committee should generate a legislators’ report card on their record on children’s health issues. The Leadership Forum was conceived as a means for the AAP to understand the priorities of, and to draw on the expertise of, its grass roots. Originally, two voting members of each chapter met yearly for discussions. A few years ago this was changed to include the chairs of the Sections, Councils and Committees. The main task of the meeting is reviewing, debating, and voting on the resolutions submitted by Chapters, Committees, Sections, Councils and general membership of the AAP. Resolutions passed by the Forum attendees are advisory to the AAP Board of Directors. In addition to the resolution process, time is devoted at the ALF to offering a variety of learning opportunities. These include chapter business management So, here, in abbreviated form, is how a Fellow of the AAP might get an idea to the Board of Directors or onto the agenda of an appropriate Committee, Council, or Section. First one would write up the idea using the format and guidance found in the “Guidelines for Submitting Resolutions” page in the Membership Center of the AAP website. When the resolution is ready the author might submit an unsponsored resolution but it’s better to seek the sponsorship of a Chapter, or of an AAP Section, Committee or Council. Once that is done, the resolution goes to the Chapter Forum Management 6 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Continued on Page 7 2008 Computer Safety Update Continued from Page 6 Committee (CFMC) to make sure it meets formatting requirements. If the CFMC has any questions regarding a particular resolution, they must call the author for clarification or changes. By the time the resolutions reach this stage, they have also been looked at by any relevant department of the AAP staff for background information which might include, among other things, comments on fiscal impact. This information is then included with the resolution. The Chapter Forum Management Committee (CFMC) will then assign all resolutions to a Reference Committee based on whether it involves such things as education, advocacy, pediatric practice, etc. These reference committees preside at ALF sessions where the resolutions get a hearing prior to the voting. Then, on the last day of the ALF the resolutions are debated and voted upon at the general voting sessions. Authors of the resolutions who are not part of the invited leadership may attend the ALF to take part in the debate of their own resolution. Assuming the resolution passes, it then is reviewed by the Advisory Committee to the Board on Community, Chapter and State Affairs which refers them to the appropriate committee, council, section, or department, for a response. Their response is added to the resolution and a “disposition document” (which includes the status of all resolutions) is posted on the Member Center of the AAP Website. All responses are tracked by the District Vice Chairpersons and he/she reports on them in the fall at the district breakfasts at the National Conference and Exhibition (NCE). So that’s it. The process may seem cumbersome and messy at times but all of the steps seem necessary so that the actual debating and voting can be efficiently done; and, at the same time, be as scrupulously fair as possible. Co-Editor’s Note: If you have an issue which merits consideration, go for it! Historical Archives Advisory Committee by Howard Allen Pearson, MD, FAAP During the next year or so, the Historical Archives Advisory Committee of the AAP will present brief historical reviews of several important pediatric organizations in the United States. “Knowing where we have come from may give us insights into where we are going.” The History of The American Medical Association Section on Diseases of Children (Pediatrics) The AMA Section on Diseases of Children was organized at the thirty-first annual meeting of the AMA held in Richmond, Virginia in 1880. It was the first national American pediatric organization. In a historical review by Dr. Frederic W. Schlutz, chairman of the Section on its 50th anniversary in 1930, Dr Abraham Jacobi was described as giving an eloquent address before the House of Delegates of the AMA outlining the need for an independent Section and his rationale for considering pediatrics as a discipline separate from obstetrics and internal medicine. Dr. Samuel Busey of Washington, D.C. then offered a resolution to create a Section on Diseases of Children as the sixth section of the AMA, and the recommendation was adopted by the AMA House of Delegates. Dr. Schlutz quoted an early Section chairman: “Dr. Busey was the accoucheur on this happy occasion and Dr. Jacobi stood Godfather.” When asked later in his life about the history of the founding of the Section, Dr. Jacobi said: “There is no history, we just did it. It was a clear case of spontaneous generation. The Section was in the air and we were present when it condensed – that is all.” The first regular meeting of the Section was held in Richmond, VA in 1881 and 40 members and guests were present. The only requirement for Section membership was membership in the AMA. Dr. Jacobi was elected as the first chairman and delivered an address entitled, “The Progress and Knowledge of Acute Contagious Diseases and Infections.” Dr. Thomas Morgan Rotch of Boston was the first secretary. Continued on Page 8 Senior Bulletin - AAP Section for Senior Members - Spring 2008 7 Pediatric History Center Continued from Page 7 From its beginning, the Section meetings coincided in time and place with the annual meetings of the AMA. Dr. Schlutz meeting described the struggles of the Section during its early years due to the: “lack of cohesion and cooperation of a diffuse and unstable membership. It was not unusual for the chairman or secretary, or both, not to show up for the meeting. The program would often not be followed because the essayist likely as not would not show up.” There were no minutes of the Section published in the 1886 and 1887 Journal of the American Medical Association (JAMA). In 1889, a resolution was presented to the House of Delegates to dissolve the Section, but this did not carry. Despite these early problems, the Section grew in numbers so that attendance at the beginning of the 20th century averaged fifty to seventy-five. Section meetings, which were held concurrently with annual national meetings of the AMA consisted of three, half-day scientific sessions in which clinical papers were presented, followed by discussions. The titles of the presentations in the first years of the Section reflected the major pediatric concerns of the day: dentition and its effect on other diseases, croup, alimentary diseases including typhoid, and somewhat later diphtheria and diphtheria anti-toxin. The preoccupation of early pediatricians with nutrition, and infant feeding is reflected in the large number of presentations concerning these subjects during the Section’s first fifty years. The Section programs list participation of many of the great names in American pediatrics of the time, including Drs. A. Jacobi, L. Emmett Holt, K. Blackfan,Thomas Morgan Rotch, T.Cooley, J. Howland, I. Abt, J. Rurah, J. Brennenann, and many others. Many of the members of the Section were also members of the American Pediatric Society, as well as other international and regional pediatric organizations. Business meetings were usually brief, but resolutions were occasionally made which were then referred to the AMA House of Delegates for consideration and possible action. Because of the by- laws of the AMA, Sections could not function independently. The Section’s major function was to hold an annual scientific meeting, so there was little action to influence medical or social issues. However social and educational issues were frequently discussed, often in the annual addresses of the chairmen. Pediatric education was a repeated topic of discussion and debate. In 1909 the Section considered a resolution concerning pediatric education in medical schools. This topic had been addressed by Dr John Lovett Morse in his chairman’s address before the Section in 1905. Morse declared that only full time pediatric specialists were sufficiently knowledgeable to teach pediatrics. “Pediatrics can never be taught unless it is a separate department. If it is made a part of the departments of obstetrics or of gynecology, as in some schools, it is certain to be neglected and to be improperly taught. It is too important a subject to form a part of the department of internal medicine.” In 1910 the Section recommended to the trustees of the AMA the establishment of a new pediatric journal. The first edition of the American Journal of Diseases of Children was published in 1911 with Dr. Frank S. Churchill as its editor. In 1930, the Section passed a resolution to change its name to “Section on Pediatrics” The change was accepted by the AMA House of Delegates and was implemented in 1932. The Section had a continuing interest in legislation that affected the welfare of children. At its meeting in St. Louis in the spring of 1922, the Section debated The Sheppard-Towner Act (“Act for the Promotion of the Welfare of Maternity and Infancy”). This was ultimately approved by the U.S. Congress ( probably as a defensive response to the passage of the 19th Amendment of the Constitution which established women’s suffrage! ). This was one of the first health initiatives by the federal government to benefit women and children. By today’s standards, it was a small, rather modest proposal to provide grants-in-aid to states to develop health services for mothers and children. After extensive discussion the Section endorsed the Act by unanimous resolution. On the same day, the AMA House of Delegates, meeting across town, passed a resolution condemning the Sheppard-Towner Act as an: “imported scheme drawn chiefly from the radical, socialistic, bolshevistic philosophy of Germany and Russia.” Continued on Page 9 8 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Pediatric History Center Continued from Page 8 The next morning the St. Louis newspapers featured front page stories that reported the Section’s resolution supporting the Act. What then ensued was colorfully described by Dr. M. Carleton Pease: “The fat was in the fire. A Committee of Wrath was sent by the House of Delegates to reprimand the Pediatric Section but they were met with unrepentance and jeers.” The House of Delegates then promptly enacted rulings that no section of the AMA could independently adopt a resolution or in any other way indicate approval or disapproval of matters having to do with AMA policies: further, all sections of the AMA must confine their activities strictly to social functions and the presentation of a scientific program. For the next seven years, pediatricians chafed under this rebuke and put-down as indicated by Dr. Pease: “The status of being an unwanted child in the family of medicine was not a happy one for the average clinical pediatrician…Legislation on matters of public health often began with the mother and child, but pediatricians were not only not consulted, but worse were often ignored…The only ‘out’ seemed to be to form a new, unified national pediatric society.” This was set in motion at a dinner held in conjunction with the 1930 meeting of the Section in Portland, Oregon. The founding of the American Academy of Pediatrics (AAP) followed shortly. In 1975, a decision was made to discontinue scientific programs at Section meetings because the responsibility for continuing medical education (CME) was increasingly being assumed by individual specialty societies. A new role for the Council of the Section on Pediatrics evolved that markedly increased interactions between the AAP and the AMA. The Section Council was expanded to about 14 members who were also Delegates or Alternate Delegates of the AMA House of Delegates. Most members of the Council are appointed by the AAP. The Council now solicits and reviews resolutions from AAP Committees, Sections and Chapters. Resolutions that are approved by the Section Council are forwarded to the AAP Executive Board and if they also approve may be submitted for consideration by the AMA House of Delegates at its meeting in December. Over the years many of the policies deemed to be important by the AAP have been supported by the AMA through their acceptance by the AMA House of Delegates. Other current activities of the Council of the AMA Section on Pediatrics include nomination of recipients for the AAP/AMA jointly sponsored annual Abraham Jacobi Memorial Award, and sending nominations to the AMA Committee on Education for membership on the Pediatric Residency Review Committee. References: Schlutz FW. The first half century of the Section on Pediatrics. JAMA 1933; 101: 417. Pease MC. A History of the American Academy of Pediatrics. Published by the American Academy of Pediatrics, 1952 The Historical Archives Advisory Committee oversees the activities of the AAP Pediatric History Center (PHC), whose mission is to preserve and exemplify the value and core values of the professional of pediatrics. For additional information about the PHC and its programs, please contact John Zwicky, PhD, Archivist, at [email protected]. Promoting the Values of Pediatrics The AAP Department of Communications, with help from the AAP Private Payer Advocacy Advisory Committee, has created a new public awareness campaign, “Promoting the Value of Pediatrics,” designed to increase appreciation of one of the greatest values in health care today: pediatric care. Resources are provided for AAP members to help them implement the campaign at the local level. For materials and more information, go to the Promoting Pediatrics Web Site within the AAP Member Center. Senior Bulletin - AAP Section for Senior Members - Spring 2008 9 Now Available! The Oral Health Risk Assessment Training for Pediatricians and Other Child Health Providers Training Kit FREE to AAP Members The Oral Health Initiative of the American Academy of Pediatrics is pleased to announce the availability of the 2006 edition of the Oral Health Risk Assessment Training for Pediatricians and Other Child Health Providers training kit. Because pediatricians and other child health professionals are far more likely to encounter new mothers and infants than are dentists, the training was developed to support them in making timely and effective decisions regarding early childhood dental issues. The kit provides materials that give an overview of the elements of oral health risk assessment and triage for infants and young children. Included in the kit is a 59 slide PowerPoint Presentation with extensive speaker’s notes (on CD-ROM), and various AAP oral health materials. The 1-hour presentation, expands on the AAP oral health policy statement and teaches participants about the pathogenesis of caries, the pediatrician’s role in assessing a child’s oral health, the correct way to conduct an oral health screening examination, the development of a management plan, providing anticipatory guidance and education to families, and the referral to a dental home for children from birth to 3 years of age. If you are interested in having a copy of the training sent to you, or would like more information about the Oral Health Initiative, please contactWendy Nelson by phone at 800/433-9016 ext 7789 or by e-mail at [email protected]. PROGRESS by David Annunziato, MD, FAAP As we all know, one of the major goals of the Senior Section has been and continues to be to have a senior committee or group in every chapter. While we have not been fully successful in achieving this goal, we have made notable gains. A recent review, comparing the progress from 2006, indicates that there was a significant increase in senior activity in a number of chapters. In 2006, we note a marked increase in the number of chapters with senior committees. When we began our efforts with this goal, there were only two or three chapters with senior committees. In 2005 there were nine and in 2006 we note 14 chapters with functioning senior committees, a 65% increase in one year. Meanwhile three chapters are attempting to develop such a group and many more chapters have seniors active in their activities especially in the area of advocacy. Six chapters have published or are in the process of publishing a chapter history. It appears that most Chapter Presidents have attempted to develop senior committees in response to our frequent reminders, and almost every chapter notes discussion of this effort. Over the years, we have noted that changes in AAP activities at all levels takes time. Recently we have updated our senior section guide to developing chapter senior committees. We hope, using this and other reminders will be incentives for chapters to succeed in this endeavor. We will continue with our efforts to stimulate chapters to achieve this goal. To obtain a copy of this free guide visit www.aap.org/sections/senior members/chapters/chapters.htm. Click on Manual (2007) on “How to start a Chapter Committee for Senior Members”. 10 Senior Bulletin - AAP Section for Senior Members - Spring 2008 This article from the Office of Speaker Nancy Pelosi on SCHIP: AN UPDATE by Nancy Hardt, MD. Dr. Hardt is an obstetrician-gynecologist from Florida, who is immediate past RWJ Fellow in Health Policy and served in that capacity as advisor to the Speaker of the House of Representatives. I’ve long been impressed with Speaker Pelosi’s commitment to the health of children and families. When I first met her several years ago, she stated: “I always consider a piece of legislation with the health and well being of children in mind.” I think her record attests to that and consider her an admirable advocate for children’s health. Lucy Crain SCHIP: Good policy for children became ensnared in a larger debate on how to reform health care by Nancy Hardt, MD Former Robert Wood Johnson Health Policy Fellow for Speaker Pelosi State Children’s Health Insurance Program (SCHIP) is known to most pediatricians as the block grant (not an entitlement, as is Medicaid) that states can use to provide free or subsidized health insurance to children whose parental income disqualifies them for Medicaid. Pediatricians and hospitals love SCHIP because it helps them avoid gut wrenching conversations with families whose children need hospitalization but do not have employer based insurance or Medicaid to pay for it. Each one of us knows families whose financial wellbeing suffered a permanent reversal when a child became ill. on the open market. Both chambers rejected this proposal and made no effort to enact it. In frustration, the administration used one of its available tools: during August recess, the administration instructed states to cease extending SCHIP to children with family incomes above 250% of poverty unless virtually all children at or below 200% of poverty were already covered. Furthermore, to discourage parents from selecting SCHIP over employer based insurance, states were required to make uninsured children wait for one year before becoming eligible. States love SCHIP because it allows for a federal government match in spending up to the limits of the block grant. Waivers granted by the administration allow states to creatively meet the needs of their unique population. States, for the most part, purchase private insurance plans to administer required services. Before the recess, house Democrats worked out an ambitious package to include not only expansion of SCHIP, but a change in the SGR formula with a semipermanent fix to the Medicare cuts planned for physicians. To pay for these, a combination of tobacco tax and “right sizing” of payments to managed Medicare (Medicare Advantage) were proposed. Language neutralizing the administration’s instructions to states was included. The House reasoned that their more comprehensive package would not be vetoed by the White House. A popular program with both Democrats and Republicans, SCHIP was 10 years old last year and, by statute, needs to be reauthorized every five. The stars appeared well aligned, with new Democratic majorities in the House and Senate and a President who campaigned for re-election saying that the program reauthorization would meet the needs of more children. No one thought that SCHIP would become a political football, but it did. Both bills passed their respective chambers, but at the Senate Republicans insistence, the reconciled bill trimmed out the House’s Medicare related changes before it was sent to the President. During the negotiations, the White House signaled yet again that a veto would come, citing many issues which, overall, would “take the country in the wrong direction” towards government interference in the health care market. What happened? Issues included the sheer size of the expenditure, the magnitude of the new tobacco tax, the current definition of income which excludes child support and housing subsidies, the proof of citizenship requirement, the current coverage of some adults, etc. But the chambers persevered, hoping that the overwhelming support by governors, child advocates, and pub- First, the Senate worked out a bipartisan deal to expand SCHIP to more children and pay for the expansion with tobacco tax. During the negotiations, the President’s 2008 budget proposal included a reduction in SCHIP spending, to be replaced by tax deductions for families purchasing health insurance Senior Bulletin - AAP Section for Senior Members - Spring 2008 Continued on Page 12 11 SCHIP: Good policy for children became ensnared . . . Continued from Page 11 lic opinion polls would encourage Republicans to change the President’s mind. It didn’t work. The veto came and was sustained in the House, where only 45 Republicans broke ranks with their President. Although the senate had enough votes to override, it was moot. Within weeks, a renegotiated version of the bill was passed by the House and Senate, addressing the issues included in the President’s veto message. A second veto arrived, and again, only 44 House Republicans voted to override. Congress came to realize that the details of the legislation were not the issue. The issue was public insurance versus market driven insurance, a core issue in health care reform. But Congress did not have time to indulge in debate over health reform. An urgent need to provide ongoing funds for state programs remained. In order to be sure that children were not disenrolled, a continuation of SCHIP through March 2009 was included in a defense spending bill that the President would not veto. This funding temporarily allays state insecurity, but does not allow for program expansions, and also, it does not undo the regulatory changes to SCHIP advanced by the Administration. States such as California planning to move towards universal coverage with SCHIP as an underpinning were disappointed. What lies ahead? Congressional efforts to undo the regulatory changes by the administration (which undercut the safety net at multiple levels) consume considerable time and effort. The desired expansion of SCHIP will have to wait until another administration, unless the President has a change of heart on the run-up to the 2008 elections. Those that believe that government should support universal coverage of children will eventually have their way. House Democrats, led by Speaker Pelosi have long memories for this sort of policy disagreement, and fortunately will remain in Congress after the new administration is installed. The unwavering support of advocates for children, including pediatricians, will insure that this vital issue remains “top of mind” as substantive discussions of healthcare reform take place. Medical Home Program Expands to all Domestic Shriners Hospitals for Children Shriners Hospitals for Children, in collaboration with the American Academy of Pediatrics, has undertaken a nationwide plan to enhance their current communication practices to improve collaboration between primary and specialty care. The aim of this project is to improve the process of communication so that patients receive efficient, coordinated healthcare within the context of a medical home. Over the past year, the project was piloted in 7 Shriners Hospitals for Children to improve the adaptability of the intervention in various care settings that address orthopedic problems, burns, and spinal cord injuries. Elements of the project include identification of and communication with referring physicians from the time a child’s first appointment is made, system changes to make communication automatic when children are treated, improvement of telephone systems to facilitate communication from PCPs, and educational outreach programs. The remaining domestic Shriners Hospitals for Children were invited to join the roll out of the program starting in 2008. Eight hospitals started in January, with the remaining 5 starting in July. Currently, every Shriners hospital is at a different level of communication with referring primary care providers: some already have systems in place, while others will be just starting the project. The goals of the program are to implement consistent communication systems that work for staff, patients, and primary care providers, while also making these processes smoother and more efficient. The leadership team that is overseeing the implementation will be teaching hospital staff to use advanced quality improvement techniques, such as Six Sigma and Lean methodologies. This will ensure that all processes are streamlined and beneficial to patient care. This is one of the first initiatives to focus on co-management between primary and tertiary care providers at the level of an entire hospital system, as well as one of the first to implement advanced quality improvement techniques focused on the Medical Home concept. For more information in regards to this project, please contact, Jennifer Marks, MPH, Manager, Medical Home Quality Improvement Programs, [email protected] or 800/ 433-9016 ext. 4924 in the Division of Children with Special Needs. 12 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Over-the-counter cough and cold medicines for infants and children - Speaking Points Latest action: The Food and Drug Administration [FDA] on Thursday, Jan. 17, 2008, issued a public health advisory saying that over-the-counter cough and cold medications should not be given to children under age 2 because of the possibility of serious and life-threatening side effects. The FDA is studying what should be done in regards to these medications and 2- to 11-year-olds. AAP position: • Over-the-counter cough and cold medicines do not work for children under age 6 and, in some cases, may pose a health risk. • The efficacy and risk of such medications needs to be studied in children. As the AAP has testified: “If a medicine will be used in children, it should be studied in children. Cough and cold medications should not be exceptions to this rule.” • The labeling needs to reflect what we know: the medications are not effective for children under age 6 and their use, and misuse, could cause serious, adverse side effects. Speaking points: • The FDA’s action is a start. • More needs to be done; the medications’ efficacy and risks need to be studied in older children. • Dosage information for these cough and cold medicines is based on adult experience. But children are NOT little adults and studies show their bodies handle the medications differently. • That simple fact raises the risk of mis-dosing and overdosing. • Cold symptoms, while annoying and at times uncomfortable, are not dangerous and will go away in time. Questions reporters might ask: • Why are these medications dangerous? • What should parents do with the medications they already have at home? • What can parents do to treat their children’s cold symptoms? • When should they take their children to see a doctor? • Since the makers of over-the-counter cough and cold medications already announced in October that they would withdraw cough and cold medicines aimed at infants and toddlers under age 2 from store shelves, what difference does the FDA’s announcement make? [It underscores the fact that, under no circumstances, should these medications be given to very young children.] Senior Bulletin - AAP Section for Senior Members - Spring 2008 13 COOL AID by Eugene Wynsen, MD, FAAP Every day we read about global warming. It is a daunting subject and is replete with a lot of articles pro and con. The UN commission IPCC has pronounced it as an imminent threat of disaster to the planet, and is the result of anthropogenic causes, mostly by the use of fossil fuels resulting in elevated CO2 levels. For the lay person not skilled in climate matters it can be a very confusing issue to sort out. And, in fact, it is not entirely agreed upon by a group of skeptics who dispute that it is man-made, and that it is really just a continuation of the cyclic nature of climate change. There is general agreement upon the fact that there has been gradual warming since about 1860, after the little ice age was coming to an end. The global warmists point out that there has been a marked increase in temperature of the earth in recent years, and one study showed a graph indicating a “hockey stick” formation with the recent increase in the warming trend and they relate this to the elevated greenhouse gas, CO2, with the resulting “forcing” of the earth to warm. There is general agreement that the CO2 level has increased. They point out that the Arctic polar cap is melting, and glaciers are generally shrinking. A favorite is to show the glacier of Kilimanjaro, which is shrinking. But the temperature has not decreased on Kilimanjaro and is stable at about 7 degrees below freezing. It is dryer there now, not warmer, therefore there is less snow and ice. The global warmists insist that this trend will lead to disastrous results with warming (and cooling) which will lead to famine, flood, increased hurricanes, crop failure, droughts, rapidly rising sea levels with inundation of many islands and seashores, increased diseases like malaria, more deaths due to the warning, and melting glaciers with the resultant water loss in many areas. In order to combat this, they have proposed measures to reduce CO2 levels. This is no little task and is variously estimated to have costs in the range of several trillion dollars. It would basically amount to drastic reduction in the use of fossil fuels and finding and funding alternate energy sources. These would include wind, tides, solar energy sources, bio-fuels, and nuclear power. It would include using the resources that are there to best advantage, and be “Green” oriented. But it is widely thought that nuclear sources of energy are dangerous, and not popular. The warmists say that there it is unanimously agreed that the warming is threatening and is due to anthropogenic causes, and that anyone disagreeing with this is like ones who believe the earth is flat. They say that there is scientific consensus that this is true. They insist that more people will die as a 14 result of effects of warming. There are a lot of skeptics to the global warming. In spite of the pronouncements of the global warmists that anyone who disagrees is like the flat-earth people, there were at least 400 scientists who testified at the Government committee last spring, and gave their point of view as to why they did not agree. They are recognized experts in climate and other science areas, and have their objections based on their own evaluation of the issue. It was pointed out that to have a different point of view was a bit hazardous, as they had difficulty getting grants, and even in keeping their positions in science or institutions. But they pointed out that contrary to what the warmists were saying, it was not a settled question and that there should be open debate and inquiry. They indicated that there were a lot more scientists who did not agree, but had difficulty being heard, or were scoffed at and ignored. They also point out that consensus does not make a scientific truth. One does not vote on a scientific issue to determine if it is true. The skeptics point out that there have been cycles of warming and cold periods for thousands of years. There is a clear cycle of about 1,500 years of warming and cooling. We are in a warming period now, having come out of the “little ice age” after about 1860. There were also major cold times with massive glaciers, followed by warming. It is interesting to try to visualize the Chicago area with 9000 feet of ice about 15,000 years ago. There were no SUV’s and no power plants then. Where did the ice go? What caused it to melt? What caused it to be there to begin with? Also, there have been warm periods in the past, warmer than at present. They point out the medieval warming and the “little ice age” that followed. These are not apparent in the “hockey stick graph”, and therefore skeptics find the “hockey stick” graph unacceptable. There is a great deal of evidence for these periods, both in physical findings of ice cores, sea cores, etc, and in writings. Greenland was first settled by the Vikings about 965 AD and this was during the warm period. They were “iced” out about 500 years later by the little ice age. Glaciers destroyed whole villages in Europe, and there was famine due to crop failure. The ice age has been documented in Patagonia glaciers also, so it was not just local. During the halocene period it was warmer than today. The skeptics point out that the warming began before the industrial age of fossil fuels, and the more recent years do not show the expected warming that should be there if it was due to CO2. It has been shown that Continued on Page 15 Senior Bulletin - AAP Section for Senior Members - Spring 2008 COOL AID Continued from Page 14 warming leads to elevated CO2, and this occurs many years later. It is true also, that the inland area of Greenland is getting cooler, and the Antarctic is also getting cooler, with the exception of a small western area. The ice pack has increased, not decreased. There is some decrease on the periphery of Greenland. A big issue is the use of climate modeling. Some think that modeling is a “child’s game”, and has not been able to accurately predict climate. It takes 48 hours on a very big computer to process about 25 years of climate data, and would take over 200 years to model the last 100,000 years. It is usual to have the model data “tweaked” or “corrected” to make it come out right, as has been done recently. The instruments that measure the temps are not that accurate, and need to be adjusted in various ways. Most of us cannot evaluate these changes, as we do not have the expertise to do so. In determining the effects and costs of reducing the CO2 levels, it is estimated that one would have to essentially eliminate fossil fuels, and this would be a colossal feat. Some economic experts have calculated that for the immense cost and effort there would be a miniscule effect. It would likely make the third world poorer, as they could not develop without the energy resources. They would have to go back to burning wood. And the fertilizers that are made from fossil fuels would not be available, and thereby reducing the already low production of food. Fertilizers increase the yield up to four times. One should note that CO2 is a fertilizer for plants. There would need to be much more land farmed, with less production. Wind power would take up huge areas of land. Wind and solar are quite variable, and would need backup plants in any case. Malaria would not increase, as it is controlled by controlling the mosquito, and not the temperature. There was malaria in Russia, England, and in cities like Philadelphia in the past, and had little to with the temperature. The poor children in malaria prone areas are the main victims as they are weakened by poor nutrition and do not have access to good medical care. Millions of people get malaria every year, and a high percentage of them are children. And it is the children who are more likely to die from the disease. More people die as a result of cold weather than die from warm weather effects. The sea levels have not risen any more than the trend for the past 150 years. During the glacier ages, the sea level dropped as much as several hundred feet. It was a meter or two lower during the Roman times than it is today. The Romans are thought to have prospered Senior Bulletin - AAP Section for Senior Members - Spring 2008 because there was warmth enough to grow grains well. There were probably lakes in the Sahara desert then, as well. Grapes and grains grew well even in northern parts of Germany and England until the little ice age. There is considerable evidence that solar variations are likely to account for the cyclic nature of the earth. Sun spot activity increases the heat by various mechanisms. In addition, small deviations in the orbit of the earth, the tilt, and the changes in the shape of the orbit have been postulated as mechanisms for these solar cycles. It is not certain how these interact since the cycle’s interactions are very complex. Recent evidence shows that Mars and Jupiter are about 0.5 degrees warmer now, about the same as the earth. There are no SUV’s or power plants there either. Unfortunately, the issue has become a political one, not a scientific one. There has been much exaggeration, and some outright misleading statements. The warmists accuse the fossil fuel companies with putting out propaganda in their favor. But there is a lot of money to be made by some who push the warming point of view. One is hard pressed to say which is worse. Some skeptics say that it would be better to spend some money to relieve famine, water problems, and diseases like malaria and TB, than spend huge sums on ideas and methods that probably will not produce significant effects or at best minor ones. Benjamin Franklin wrote his own epitaph, which is very much like him, and summarizes the man. “The Body of B. Franklin, Printer, Like the Cover of an old Book, Its Contents torn out, Lies here, Food for Worms, But the Work shall not be wholly lost, For it will, as he believ’d, appear once more, In a new and more perfect Edition, Corrected and amended, By the author.” Av Katcher 15 Editor’s Note: Dr. Sami Elhassani was one of our very early Fellows at LAC USC Medical Center in the 1960’s, almost 50 years ago. Following his Fellowship he began practice in Spartanburg, South Carolina where he still practices although recently in a level II center rather than the level III where he spent most of his career. He has been there during the growth of Neonatology. Changing Times for Neonatologist in the Regionalization System by Sami B. Elhassani, MD, FAAP Mary Black Memorial Hospital - Spartanburg, SC For health care professionals, medicine and medical care is an art and a science and to most physicians, nurses and allied health personnel – a joy. Nowhere does this apply more aptly than in perinatal-neonatal medicine. After all, this specialty deals with the wellbeing of both mother and newborn infant and with all the complexities and challenges that stride towards good to excellent outcome. The most striking aspect of caring for sick neonates before the emergence of neonatology as a subspecialty of pediatrics is how much primary care pediatricians with special interest in the welfare of newborn infants were able to accomplish with simple technology. Dating back to late 19th century, Pierre-Constat Budin (1846-1907), the French gynecologist is credited as one of the fathers of neonatology and the author of the first book “The Nursing” devoted to diseases of the newborn. The introduction of Budin’s book dealing in neonatal medicine opened the door to important contributions to the field by many medical pioneers in the first half of the 20th century including J.W. Ballantyne, Arvo Yippo, Julius Hess, Sir Joseph Barcroft, and Mary Crosse, and the list of physicians is too long to be included in this article. Care of sick neonates remained as a matter of interest to few pediatricians until 1959 discovery by Drs Mary Ellen Avery and Jere Mead of surfactant deficiency in the lung of infants dying of respiratory distress syndrome (RDS), the most common cause of deaths in preterm infants, as one of the great success stories in neonatal care and possible the turning point in the intense interest by many physicians in improving early diagnosis and management of the many prenatal and neonatal diseases. Twenty one years later, Fujiwara suggested the use of surfactant as treatment of neonatal respiratory distress and ten years later after many controlled studies, FDA approved the drug as a standard treatment of RDS. The age of “neonatology” as a subspecialty of pediatrics dawned upon us in the early 1960s stemming from the real concern by many health care as well as non health care professionals of the high rate of infant 16 mortality (25/1000 live-births in the first year of life). Recognizing that the majority of those infant deaths occur in the immediate neonatal period, prompted the establishment of a discipline called “neonatology”, and in 1975, the first examination offered by the American Board of Pediatrics coined NeonatalPerinatal sub-board. In the early 1970s, the increase in the number of intensive care nurseries and thereby the number of neonatologists prompted the introduction of a new concept designating hospitals with facilities that have obstetrical units each according to the level of complexities in neonatal diseases. Moreover, the notion of regionalized Perinatal care was spearheaded by the 1976 March of Dimes report “Toward Improving the Outcome of Pregnancy” (TIOP) as a means expanding the services offered to high-risk patients in addition to the existing university affiliated hospitals and academic centers. Thus, different hospitals that care for newborn infants were included in the “regionalized neonatal care” and labeled Level I (basic), Level II (specialty), and Level III (subspecialty), and Level IV (regional) graded from providing care to healthy infants to the comprehensive care of the extremely high-risk newborn infants and those with complex and critical illnesses. This classification was modified in 2004 by the Committee on Fetus and Newborn of the American Academy of Pediatrics to Level I, Level IIA, Level IIB, Level IIIA, Level IIIB, and Level IIIC depending on the availability of experienced personnel and updated technology for intensive respiratory care, readiness of surgical services, quality of ancillary services, and accessibility of different pediatrics subspecialties. Many controlled studies concluded better chances of survival of very low birth weight infants delivered in a subspecialty facility rather than a basic or specialty center. Regionalized neonatal care is good for infants and mothers as long as the concept is not interpreted as Continued on Page 17 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Changing Times for Neonatologist . . . Continued from Page 16 centralized care with inadequate and inaccessible transport and back-transfer system. In addition, in many areas of the country, having an infant far away from where the parents live have created a needless trouble, especially when necessary care can be offered in nearby center. For Perinatal regionalization to be effective, a disciplinary collaboration is required among obstetricians, perinatologists, and neonatologists working in the three levels of care. Of great help to achieve this goal is an up to date Outreach Education Program in all perinatal regions with emphasis on close collaboration among all physicians involved. Depending on population concentration, geographic distances, the size of the state, and the number of retrieval center for sick neonates, different states have different laws to implement the criteria for regionalization. Thus, some states have legislative binding laws with monetary citations for any deviations by any hospital within the regional area from the regionalization laws. Other states however, require proof for services available and on long-term outcome of in-hospital admissions by thorough and systematic collections of data. These steps are essential to evaluate changes in perinatal care delivery systems as well as new technologies and therapies. Most neonatologists work at subspecialty (level III) or Regional (level IV ) centers. Although the data are unavailable, there is an emerging trend of second and third generation neonatologists changing jobs form taking care of high risk and very low birth weight infants to low risk and medium sized neonates (1500g and 32 week gestation)-thus cutting down but not out. Although one loss out on the extended management of high risk infants, the basic knowledge of neonatal care stays the same. In addition, working at level II nursery with fewer low risk infants renders more opportunities to interact with families of sick infants. Furthermore, those neonatologists will have extra time to be active in the local as well as national neonatal care politics. Medical care rests on a system of basic scientific knowledge, recognition of diseases, the ability to combine technology and clinical acumen, the strife for continuous improvement in health care delivery, and the firm belief in medicine as one of the most humane professions. From antiquity to the present time, medicine knowledge, technology, and the patient care has been achieved with physicians, including the fairly new subspecialty of neonatology, being in the forefront of the process. In conclusion, there is a rewarding life both professional as well as personal, working at specialty neonatal center. Reference: Stark AR. Level of neonatal care. American Academy of Pediatrics Committee on Fetus and Newborn. Pediatrics 2004;114:1341-7 Editor’s Note: Joan Hodgman Toke Hoppenbrouwers is a respected retired member of the Neonatal Division of LACUSC Medical Center. She and I have done a good deal of research on SIDS together since she joined our faculty from graduate school at UCLA. Our latest project is writing the papers from her trip to Indonesia looking for SIDS in that tropical country. The Contortionist by Toke Hoppenbrouwers, PhD During a night of insomnia early this week, I was reminded of a legendary weekend in the late Sixties when a group of about nine of us, friends during our UCLA graduate student days, took off for Ensenada in Mexico. This was the time of marches in San Francisco against the Vietnam War, where at night after the demonstrations we took in, en passant, the gay men’s clubs in San Francisco. My straight women friends were blown away by how handsome these men were. With this Mexico trip we were in the company of both men and women, gay and straight. Some of us were working together at the Neuropsychiatric Institute at UCLA in a program called the Drug Abuse Training Center— a rather dubious title. The US Army had contracted that program, and by inference us, to help eliminate drug abuse in their GI’s stationed in Germany. The irony. Continued on Page 18 Senior Bulletin - AAP Section for Senior Members - Spring 2008 17 The Contortionist Continued from Page 17 As far as I recall, we arrived late afternoon at a fairly seedy motel by the name of El Presidente that at the time was upscale for that town. We partied until 2:00 AM mostly with marijuana, our drug of choice. Then we caught a few hours of sleep. At 5:00 AM that same day, we set out on a deep-sea fishing trip on an undersized, hired motor craft. A grainy, overexposed film clip from that weekend shows me of all things, in a bright red DRESS, nodding off in cadence with the boat motor’s crashing onto the waves. The sun is bright. My co-travelers are busy throwing out their fishing lines; they have enjoyed a sizable amount of Tequila and their success in catching fish is only marginal. Nonetheless, the film shows the elderly captain cleaning the fish on the way back as is customary, and throwing the entrails and carcasses into the water. A huge flock of diving and screaming seagulls follows us. Upon returning to the harbor around 1:00 PM, my lover Ingrid cried out, “I see elephants!” Aware of her prior alcohol intake, none of us paid much attention. The next stop was the famous blowhole that, compared to earlier visits, had been made tourist-friendly, but that had lost none of its force and spraying power. We were all in our early and mid-twenties, loose couples or singles—and only one of these alliances has lasted. Ingrid and I separated in the late seventies. After the blowhole, we still found time to visit a beach where some of us were tempted to mount a couple of bony, skinny horses. Indefatigable, we segued into a stop at the famous Hussong’s Cantina, where an overflow crowd hardly permitted any movement, but just enough to sample Margaritas, the drink that originated in that place. In the same street we found a restaurant for a sit down dinner with tamales, pollo picado, empanadas and sopapilia. This scrumptious meal rejuvenated us and, fools that we were, not ready to go to bed, we sauntered down the street in the opposite direction, where we came upon an old fashioned circus tent with the performance about to start. Just the kind of entertainment that we, giddy with laughter and excitement needed. The mystery of the elephants was now solved. For decades Ingrid has chided us for our disbelief. I don’t remember much of the performance except the rickety wooden benches, our choice of seating, of course, high up in the tent, and the entry of the contortionist. He managed to take his arms out of their sockets and outstretched, reached around his ankles to join his hands in the front. I was reminded of my celluloid childhood doll whose arms and legs dangled because the elasticity had gone out of the strings that connected the limbs with her torso. The contortionist’s freaky looseness captured the tenor of that weekend. We weren’t really out of control. His super-worldly stretches seemed a metaphor for the range of activities pressed into that day, our drifting from one event to another and the unbounded laughter that still echoes in my body. How did I come to think of him during that sleepless night, now at least forty years later? The mysteries of language and memory . . . I have never been a frequent user of the English dictionary, even in my early days in the United States after my immigration from the Netherlands. I simply never had one. I learned to speak, by trying. Now, however, I have two pocket books, one in each direction from Dutch into English and from English into Dutch. It’s not rare that I recall a word only in Dutch and have to look up the English translation. Apparently, with increasing age, I can expect to revert to Dutch on a more regular basis. Being stoned, in those days, forced me back into Dutch to great hilarity of everybody around who suddenly ceased to understand my utterances. I recall once having to take a red eye to Boston for a conference after getting loaded with my friends. Ariella had to help check me in, because I had lost all of my English. “She is on the way to a brain research conference,” Ariella explained apologetically to the airline personnel behind the counter. They must have assumed I was a patient about to demonstrate some strange neurological defect, witness my muteness and our giggling. Continued on Page 19 18 Senior Bulletin - AAP Section for Senior Members - Spring 2008 The Contortionist Continued from Page 18 The 1960’s and early Seventies were followed by decades of seriousness, responsible behavior, purchases of houses, for some of us, having children; the building of careers and the like. That time was also marked by a turn toward serious writing as a calling. These days, I rarely touch any mind-altering drugs and my alcohol intake is restricted to an occasional glass of wine with dinner. Yet, at 69, I suddenly feel the contortionist in me again. Living alone, I have traveled solo to a host of foreign places, including some remote islands of Indonesia. There I feel unusually safe, despite US State Department warnings about terrorist threats, earthquakes and volcanic eruptions. Without hesitation I climb on the back of a motorcycle. I’m still involved in research and have branched out to investigate the presence of Sudden Infant Death Syndrome (SIDS) in Toraja, a rural area of the island Sulawesi, in that developing Asian Country. A fifteen-seater plane typically flies to Toraja a few times per week from Makassar, the capital of Sulawesi. I have preferred this mode of transportation to the ten-hour road trip. About a decade ago, however, I remember that just as I was reassuring myself that the pilots knew this trajectory as well as the inside of their pockets, the plane I was in, landed on one wheel and began to gyrate wildly on the runway. (I thought it was my end.) The crew managed to straighten it out before it came to a halt. Armed with a cane, this time, I resolved to rely on motorcycles, cars, horse-drawn buggies, rickshaws and my two legs to get around. As if that were any safer. At the end of my last trip to Sulawesi, in November of 2007, Stanis and I set out for the trip down to Makassar under gorgeous weather conditions. I am fortunate to have found Stanis Sandarupa through a faculty at the department of Anthropology, at UCLA. Stanis hails from Toraja and received his Ph.D. from the prestigious University of Chicago. He and I have been collaborating on a number of studies during 2006 and 2007. He drives a beat-up jeep that requires frequent visits to the mechanic, but that has managed to take us over hours of potholed back roads to remote hamlets in the mountains where electricity has not penetrated, nor television and other modern appliances. Stanis is an excellent driver, and in even the most hairy traffic situations, I feel remarkably calm. I was truly looking forward to the trip that began auspiciously, along bougainvillea covered mountain roads with vistas of carefully manicured, staggered rice fields along the slopes where an occasional buffalo was tethered to a pole, wading in his private mud pool. Then, a third of the way to Makassar, we suddenly hit a downpour. “Rainy season has arrived,” Stanis muttered. It was still light—although sunset was approaching —and the car roof wasn’t leaking so I did not feel too concerned. The downpour, however, continued under a uniform grey sky in which no break was discernable. “How far are we from the nearest town?” I queried. “Oh, about an hour,” he answered, “and about five hours from home.” The upside was that traffic was minimal; an occasional rickshaw driver, totally covered in plastic, braved this deluge, but otherwise we were making great time. When darkness arrived, I was relieved to see that our headlights turned on; they were weak but working. My relief was of short duration, however, because almost simultaneously, with one sharp beep, the windshield wipers conked out. We went from seeing little to seeing nothing. The first thing that happened was that Stanis slowed us down from 70 to 65 miles per hour. “Any place to stop?” I tried faintly. But I didn’t get an answer. He was glued to the windshield, trying to make out where he was going. There was just enough light outside that I could discern what seemed like lakes, on both sides of the road. We were very nearly hydroplaning. The closer we came to the promised town, the heavier the traffic became. Rickshaws, motorcycles, horse and buggies, ordinary bicycles mingled freely with cars, busses and trucks. To my consternation I noticed that every other oncoming heavy truck, van or sedan had no functioning headlights. In order to make any progress, Stanis had to overtake hundreds of vehicles on that two-way thoroughfare. Continued on Page 20 Senior Bulletin - AAP Section for Senior Members - Spring 2008 19 The Contortionist Continued from Page 19 I can’t say I was praying, but I was pretty uptight. Every time I felt the temptation to grab the dashboard or the door handle, I forced myself back into the seat and relied on some innocuous small talk to calm myself down. The combination of torrential rains, a two-way highway, heavy traffic, unlighted vehicles, all lights amplified and dispersed in a million directions because of the rain, and the knowledge that we had still five hours to go, shattered my confidence in a safe trip home, to put it mildly. Finally, at the edge of Makassar, where it was still raining, Stanis stopped the car on the side of the road, and, for the first time, moved the window wipers manually to clean off the mud and water. I felt my heart rate and blood pressure drop precipitously. Actually, seeing the road for the first time clearly was tantamount to seeing my way home. The field of neuroscience, my area of study, has advanced with incredible speed in parallel with fancy technological discoveries. Genetics, molecular biology and studies of metabolism are particularly challenging. I bravely tackle the literature and try to teach myself the new jargon and concepts with more or less success. The only comfort stems from knowing that I am not alone in this predicament. This February, I presented some results of my Indonesian research at the Western Pediatric Society Meeting in Carmel, California. It was difficult to obtain accurate data of births and infant deaths in Toraja, but after multiple visits I’m inclined to believe the Indonesian physicians and midwives who proclaim that they have never heard of infants dying suddenly and unexpectedly in their sleep. After all, risk factors for SIDS, discovered in the West, are very favorable for infants in Indonesia. The meeting in Carmel tends to be low-key. That’s why young doctors and fellows are encouraged to present their findings there. It is a safe training ground for future presentations at the more demanding national pediatric meetings. Apart from the fact that Carmel itself is a very relaxed and friendly town, the low-key nature of this meeting derives also from the high “grey and shaking quotient” among participants such as myself. This meeting draws a large number of emeritus, retired professors and faculty who probably see an opportunity to meet their contemporaries, have a tax deduction and be wined and dined by pharmaceutical companies or the meeting organizers. A number of these elderly participants dutifully attend the presentations and feign a listening attitude, but in the dimmed light, when the slides are presented, they unapologetically nod off. By doing so, they do not miss a thing; I’m convinced that, just like me, they would have only understood the “but’s,” the “and’s and the “therefore’s” of the hotshot young faculty’s presentations. A few of my contemporaries went so far as to express their delight that they could understand my talk. I was among the youngest of the oldest and I carefully selected the few sessions to attend. Rather than sitting uncomprehendingly in the dim lights, I made sure that my dogs, Intan and Rajata, Balinese names for Silver and Diamond, got to enjoy the most permissive beach in California, a beautiful piece of real estate in the heart of Carmel, free for running off-leash among a hundred canine revelers. I enjoy writing in various places, especially in nature. I don’t hesitate to take my dogs and jump in my van at any moment to drive to places where I can find inspiration. The campground at the North Rim of the Grand Canyon has been one of my yearly destinations. There, Alma, the chief of housekeeping has generously offered me an outside plug for my computer next to the linen cabin, where her electric trolleys ordinarily charge. It’s a good thing, because the only other plug I discovered during a scouting trip was under the flagpole, a rather ostentatious place, where Park rangers would have chased me away, fast. Last year, I woke up to snow. Fortunately, I didn’t immediately pull up stakes because after the snow melted the turquoise, pink and orange of the rocks were deeper than ever. In the meantime, I had found myself an oldfashioned rattan desk in the lodge to use for writing. Continued on Page 21 20 Senior Bulletin - AAP Section for Senior Members - Spring 2008 The Contortionist Continued from Page 20 This sixth decade of my life has been unusually unstructured. It’s a loose patchwork of events, not squeezed in a day, as that trip in the Sixties, but packed nonetheless; not executed in a group, but solo. It feels almost scary, except that I have this reference of the past. The contortionist’s flexibility, applied to life has served me well. I look at myself, amused, thrilled, even, with my daring, the fearlessness that I am graced with, and the knowledge that this may be the prelude to another long or short period of stability— this time not because of responsibility and career building, but because of the inevitable grounding at home that lies ahead, or, if not there, in assisted living. My overflowing present is a last hurrah that I welcome, despite the advent of frailties, such as the replacement of a hip and the loss of a host of English words. The contortionist made his statement by doing, not by talking. Bond Basics by Joel M. Blau, CFP™ and Ronald J. Paprocki, JD, CFP™ MEDIQUS Asset Advisors, Inc. “Results. One client at a time.”(sm) Municipal bonds are debt instruments issued by states, counties, and local government authorities. The proceeds of municipal bond issues are used for a wide range of public purposes, including buildings, highways, airports, schools, or simply to fund general government operations. In general, interest income from municipal bonds is exempt from federal income tax. There are primarily two different types of municipal bonds. General obligation bonds, also known as G.O. bonds, are secured by the full faith and credit of the issuer. Revenue bonds, on the other hand, are issued by agencies such as a port authority, highway commission or water and sewer district, to build specific public works projects. Revenue bonds are backed by the revenues, or expected revenues, generated by these projects for payment of principal as well as interest. Due to the inherent risk associated with uncertain potential revenues, insured municipal bonds have gained in popularity. The issuer actually purchases insurance to protect against the risk of default. The insurer in this situation would be responsible for the payment of interest as well as principal in the event of a default. The insurance, however, does not protect against market or price fluctuation within the bond market. If a municipal bond is held until maturity, the issuer is then obligated and required to repay the full face amount of the bond. If the bond is insured, and is in default, the insurer would then be responsible for the repayment of the face amount. If the bond is sold prior to maturity, the investor would receive the current market value of the bond which may be more or less than the original investment. Bond prices tend to move inversely with interest rates. If interest rates Senior Bulletin - AAP Section for Senior Members - Spring 2008 continue to rise, this would cause pressure on bond prices, moving them downward. Conversely, if interest rates decline, the market values of existing bonds tend to increase in value. The best candidates for municipal bond investments are high tax bracket taxpayers seeking a source of taxadvantaged income, often times to generate income during their retirement years. Municipal bond income can serve as a nice supplement to taxable individual retirement account (IRA) distributions, or pension payouts which are generally taxed at ordinary income tax rates. Municipal bonds can be purchased directly through a securities brokerage account, either through a stock/bond broker or on your own via a brokerage’s website. They can also be purchased as a mutual fund. The main advantage of a mutual fund is the added level of diversification, as well as management expertise. Unfortunately, since most municipal bond funds are open ended, there is never any point in the future where the entire portfolio matures, and then pays back principal. As with all open end mutual funds, shares can be bought or sold at any time, but at the then current value, which may be more or less than your original investment. If this is a concern, but you still want to take advantage of a diversified portfolio of municipal bonds selected by a professional, then a unit investment trust (UIT) may be the answer. With this vehicle, once the bonds are professionally researched and selected, the portfolio remains fixed throughout the life of the bonds. Unlike a mutual fund which replaces bonds on an ongoing basis, the principal of each matured bond Continued on Page 22 21 Bond Basics Continued from Page 21 is paid out to the unit trust investors. The UIT can provide some peace of mind to those who prefer a finite life to their municipal bond portfolio, as well as the ability to essentially lock in an interest rate for the entire period. Keep in mind that while the interest generated is fed- erally tax free, higher after-tax yields may actually be available in taxable bond investments. In addition, municipal bond income may make you subject to the alternative minimum tax (AMT). In light of these potential disadvantages, be sure to consult with your tax advisor to determine if municipal bonds are appropriate for your specific situation. Mr. Blau and Mr. Paprocki welcome readers’ questions. They can be reached at 800-883-8555 or at [email protected]. Securities offered through Joel M. Blau, CFP® and Ronald J. Paprocki, JD, CFP®, registered representatives of Waterstone Financial Group, Member FINRA/SIPC. Waterstone Financial Group and MEDIQUS Asset Advisors, Inc. are independently owned and operated. Please consult your tax advisor regarding any questions you may have with respect to your personal tax liability The opinions expressed in this report are those of the author(s) and are not necessarily those of Waterstone Financial Group. The material has been prepared or distributed solely for information purposes and is not a solicitation or an offer to buy any security. Investors in mutual funds should carefully consider the investment objectives, risks, charges and expenses. This and other important information is contained in the prospectus, which can be obtained from your investment professional and should be read carefully before investing. Investments are not FDIC-insured, nor are they deposits of or guaranteed by a bank or any other entity. LINCOLN AND DOUGLAS The Debates That Defined America by Allen C. Guelzo and Henry R. Luce Professors of the Civil War Era, Gettysburg College. Simon & Schuster, New York, 2008 Reviewed by Avrum L. Katcher, MD, FAAP Why do we wish to read a book about the events of over 150 years ago? Primarily, because of the remarkable skill, without overtly mentioning a specific modern event, with which Professor Guelzo utilizes these history book circumstances to teach us about the significance of the politics of today. He shows us how the interlocking of overt and covert attitudes about race, gender and social class lines, about the institution of slavery, and about the population growth and expansion of the United States came together to mold the politics of those times, and to throw a bright light on how the politics of today are still influenced in the same fashion, if not by the same routes. As a merchant in a small town in Illinois said, “It did not take long before this crowd [realized] that the question that was before them was one that demanded sober, solemn decision, if they were to vote rightly…I tell you that debate (Lincoln v. Douglas) set folks to thinking on these important questions in way[s] they hadn’t dreamed of.” And that quote might be applied to the affairs that arouse us today. Then, we had a short, stocky, fiery debater, described as “a steam engine,” already a United States Senator, running for re-election against a very tall, skinny, inexperienced, well, it is not out of line to say, “hick” from farm country. The lawyer/Senator won that election, but two years later was defeated for President of the United States by the hick. Of the various issues that characterized this rivalry, that of slavery was perhaps the most prominent. Slavery Continued on Page 23 22 Senior Bulletin - AAP Section for Senior Members - Spring 2008 Lincoln and Douglas . . . Continued from Page 22 was a legal, even though repulsive system, in fourteen states. The remainder banned slavery. The issue, and the fight, at first was whether as new territories and states were formed to join the union, would slavery be allowed in them. As for Douglas, “there is no record that Douglas felt any deep pangs of conflict over the toleration of slavery in a republic of liberty.” Meanwhile, Lincoln was farm-raised, with an axe in his hands as early as he could hold one, until in his twenty-third year he became a store clerk. What he also showed, from a very early age, was a devotion to reading, as his father put it, “uncommon natural talents….a constant…and stubborn reader.” And the farm boy entered politics, quickly rose to a good position in the Illinois state legislature, where he was embarrassed because he criticized the war with Mexico instigated by President James Knox Polk, leading to ambush and defeats by the Mexicans. Guelzo deftly and in detail follows both men. Lincoln pursued Douglas’ seat in the United States Senate but lost out following his “House Divided” speech. He was to be nominated to run for the Senate; but when he spoke, he said, relative to slavery: “If we could first know where we are, and whither we are tending, we could then better judge what to do, and how to do it.” Lincoln went on, “A house divided against itself cannot stand. I believe this government cannot endure, permanently half slave and half free.” This came from Mark, II, 27, “If a House be divided against itself, that House cannot stand.” From here, Lincoln went on through the following weeks and months, in order to make plain that the essential issue was the words of the Declaration of Independence, “All men are created equal,” a moral statement, versus the question of the civic rights to which all men were entitled. Lincoln felt that equality had more than one meaning. As mentioned above, there were natural rights, such as “Life, Liberty and the Pursuit of Happiness.” Slavery was an unnatural violation, everywhere and at all times a “moral evil.” Later, during their debates, Lincoln “plunged into a disgraceful catalogue of all, the civic rights, he, fully as much as Douglas, believed blacks could be routinely deprived of.” The list included these sentences: “I am not nor ever have been in favor of making voters or jurors of negroes, nor of qualifying them to hold office, nor to intermarry with white people; and I will say in addition to this that there is a physical difference between the white and black races which I believe will for ever forbid the two races living together on terms of social and political equality.” Guelzo provides us with clear understanding of how it is that a political figure may occupy a belief, a place, which would seem to contradict other positions, and yet feel that his views are consistent. Lincoln taught us the difference between moral standards and civic standards. All men are created equal. All men should have comparable rights under the law. But it is our voice as citizens which makes that moral equality spread to the civic rights which, for many of us, may be of greater importance. Where are we going today, with the questions of the rights of all under the law for health care? Or the right to carry weapons? Or the right to terminate a pregnancy? The right to live in a conjugal way with a person of the same gender? The right to be paid many millions of dollars a year while others do not have enough to eat in healthy fashion? The importance of this volume is the exploration of these seemingly contradictory issues and many others, which we must debate in order to seek out a solution which is fair to all, while expressing a collective sense of what is it that is “fitting and proper.” Guelzo presents no perfect solutions. What he does, that is good for each citizen, is to explore how men of reason, and without reason, attempted to combine personal ambition and the push for what is right in a moral, fitting and proper fashion. Senior Bulletin - AAP Section for Senior Members - Spring 2008 23 Update your Personal Profile An important service is available on the AAP Member Center. A Personal Profile has been added to provide you with an opportunity to view and update your contact information, demographic, and subspecialty information. Simply enter the changes into the form and our database will be updated the following day. The online Member Directory should be your primary resource to locate colleagues. Physician Referral Service (PRS) should be used for patient referrals. These resources have the most accurate, up-to-theminute contact information available. With these new changes and enhancements, we believe we can further improve service to members and the public. 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