Fat kids: the blame and shame game?

Who knew an ad campaign promoting a healthy weight for kids could become the target of so much controversy?

The campaign, called Strong4Life, was rolled out last summer by Children’s Healthcare of Atlanta, Ga., prompted by concern for the future health of overweight children and data suggesting many parents fail to recognize when their child is overweight. Its newest addition is a series of billboards and ads containing photos of fat children, the word “warning” in red letters and messages such as “Fat kids become fat adults,” “It’s hard to be a little girl if you’re not,” and “Big bones didn’t make me this way. Big meals did.”

Public reaction has been swift, to say the least. It’s being blogged and talked about coast to coast this week.

Organizers of the campaign have said the shock tactics are deliberate. “We felt like we needed a very arresting, abrupt campaign that said: ‘Hey, Georgia! Wake up! This is a problem,'” Linda Matzigkeit, a senior vice president at Children’s Healthcare, told the Atlanta Journal-Constitution.

Few would argue we should all just look the other way when it comes to overweight children. But is an in-your-face approach appropriate? More to the point, does it work?

This campaign has drawn a lot of criticism, much of it well placed. (Read more here, here and here.) Public health experts who’ve weighed in say there’s little evidence that shaming is effective in getting either kids or adults to change their behavior. Some worry the harshness of the ads could make children and parents even more reluctant to seek help in losing weight. Others point to the complex influences on children’s weight – family income levels and lifestyle, food availability, the community environment, even the national school lunch policy – and the difficulty of applying simplistic solutions to childhood obesity.

But score at least a couple of successes for this campaign. It has highlighted, rather painfully, the fine line between attacking the problem vs. attacking the person who has the problem. It also has highlighted how difficult it is to have a national conversation about obesity without descending into shrill self-righteousness on one side and angry defensiveness on the other.

The firestorm surrounding the Georgia campaign actually is nothing new. Some years ago, a local medical clinic had to revamp its advertising for a pediatric weight loss program after hearing complaints from parents who objected to the imagery – a sad-looking child sitting alone while his peers played together in the background.

It’s not easy to know how to convey the message in a way that’s constructive. And make no mistake, “constructive” should be the operative concept here.

Since the goal of the Georgia campaign ostensibly is to prod parents of overweight children into taking action, it seems fair to ask: Are these parents genuinely in denial? There’ve been a number of studies examining parents’ perceptions of their child’s weight and most have found that families aren’t very good at recognizing when a child crosses the threshold for being overweight.

I had to look it up online: Among kids ages 2-19, overweight is defined as having a body mass index between the 85th and 95th percentile on the growth chart for children of the same age and gender. Obesity is defined as a BMI above the 95th percentile. I suspect many parents don’t know this formula off the top of their heads. Moreover, they may have trouble accurately applying it, especially for a child who’s actively growing.

Even when parents do recognize their child is overweight, they can be reluctant to add the obesity label (or any label, for that matter) to his or her medical record early in life. There also seems to be a persistent amount of misinformation about childhood obesity, one of the myths being that most kids eventually outgrow it.

It would seem that helpfulness and better information are called for here, rather than judgment or scare tactics.

And let’s not overlook another important fact: The medical community traditionally has had little to offer overweight children and their families other than the standard advice to eat less and be more active. Nor is there much evidence yet that interventions for adults, such as weight-loss surgery, are safe or effective for kids.

For the record, I dislike the Georgia campaign. Kids who are fat already know they’re fat; their peers are telling them so every single day. Harping on it may highlight the symptom but it does little to address the deeper causes. And if the ad campaign is meant to galvanize parents into taking action, why manipulate kids into the position of being a shameful symbol of parental failure?

If we’re going to recognize that the people who designed this campaign were motivated by concern for kids’ health, let’s also recognize that those who object to the ads are motivated too by concern for what’s best for kids. How about dialing down the rhetoric and meeting somewhere in the middle?

Image: Children’s Healthcare of Atlanta

Distracted at the bedside

The patient was seriously sick and in the hospital. The doctors had doubled the dose he was taking of a blood-thinning medication to reduce his risk of stroke. But after evaluating his case a couple of days later, they decided to temporarily discontinue the medication and obtain an echocardiogram to make sure the drug was still needed.

A doctor-in-training took the order. As she began entering it in her smartphone, she was distracted by a text message about an upcoming party. She texted a response, the medical team moved on to the next patient… and the order to stop the medication was never completed.

Four days later the patient was rushed into emergency open-heart surgery to stem internal bleeding caused by too high a dose of blood thinner.

This real-life case appears in the online Morbidity and Mortality Rounds of the U.S. Agency for Healthcare Research and Quality and offers an alarming example of an issue that’s becoming increasingly prevalent in health care: the distractions and multitasking associated with information technology.

If the news coverage lately is any indication, there’s reason for growing concern.

The AHRQ case report is but one instance. Although the patient fortunately survived, it was at the cost of a potentially risky emergency surgery and lengthier hospital stay.

A recent article in the New York Times cited several other examples. In one case, a neurosurgeon apparently got distracted while using a wireless headset to make personal calls in the OR, and the patient wound up partially paralyzed. Other examples included a nurse checking airfare prices online during spinal surgery, intensive care unit staffers using hospital computers to visit eBay and Amazon, and technicians texting or talking on their cell phones during surgery.

It had to happen, I suppose. Smartphones, texting, tablets, Twitter and the like are such a common part of everyday life that it’s inevitable they would spill over into the health care setting. What’s concerning are the implications for patient care, where the stakes are so high.

From the New York Times article:

“You walk around the hospital, and what you see is not funny,” said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

“You justify carrying devices around the hospital to do medical records,” he said. “But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting.”

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. “We’re not educating people about the problem, and it’s getting worse.”

Patient safety is clearly the most critical issue, but technology may also be exacting a toll on the human connection so essential in health care. Josephine Ensign, a nurse practitioner and blogger in Seattle, last week described an encounter outside a hospital elevator with three employees absorbed in their smartphones.

“Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator,” she wrote. “Then all three resumed communing with their smartphones.”

She writes:

When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?

I’m not sure what the answer should be. Outlawing mobile devices and computers is simply not going to happen; after all, there’s a worthwhile place for technology in health care. And when technology is done well, it can enhance care and increase safety, observes Dr. John Halamka, chief information officer at Beth Israel Deaconess Hospital in Boston and chief information officer and dean for technology at Harvard Medical School.

The real issue seems to lie in the day-to-day details, Halamka writes in a commentary accompanying the AHRQ case study. “Mobile devices are becoming an increasingly important part of the clinical workday. Leveraging the benefits while applying technology and policy risk mitigations will result in their optimal use.”

Read more about it here and here.

Photo: Wikimedia Commons

Opening up the doctor’s notebook

If you could see what your doctor is writing about you in your medical record, would this hurt or enhance the doctor-patient relationship?

A new survey on the progress of the OpenNotes project found that the majority of patients – more than 90 percent – are supportive and even enthusiastic about being able to read the doctor’s notes. But among physicians, the reaction was more mixed. Although many believe that sharing their notes can be beneficial, doctors in general have far more reservations about it than patients do.

The findings of the web-based survey appeared a couple of weeks ago in the Annals of Internal Medicine.

I’ve been following the OpenNotes project since it was launched some 18 months ago (I’ve blogged about it here and here). A quick summary: Lab reports, test results and other portions of the medical record increasingly are being shared with patients in the name of helping them become more informed and engaged in their care, not to mention that it’s the patient’s legal right to see their chart. But patients historically have had more difficult access to the doctor’s notes, which typically consist of subjective observations about the encounter – what the patient said, how he or she behaved, the doctor’s thoughts about a potential diagnosis and so on.

Depending on your point of view, sharing the doctor’s notes could enhance patient care or could be downright harmful. So far, however, there’s little actual evidence to support either of these positions. The OpenNotes project, which involves 100 doctors and 21,000 patients in three states, aims to test what happens when patients have increased access to the doctor’s notes.

That there would be mixed feelings about this is no surprise. There’s in fact a rather significant gap in how patients and clinicians perceive the need for information. Patients increasingly want more information but many clinicians question how much should be shared and how well patients will be able to understand it.

Recent debate at the Bioethics Discussion Blog shows just how wide this gap can be. Allowing patients unrestricted access to their full medical record is “a bad idea,” one person wrote. “There’s no reason for most people to have complete, unfettered access to their medical records, whether guaranteed by law or not.”

Others vehemently disagreed. Wrote one commenter:

I believe that providers who don’t think patients should have complete access to their own medical records do so for one of two reasons:

1. They have an irrational fear of “losing control” of the provider/patient relationship by not being able to be the gatekeeper to what the patient sees.

2. They have something to hide.

Worries about sharing the medical record aren’t exclusive to doctors. I once picked up my medical chart only to have a nurse literally grab it out of my hands and tell me I wasn’t supposed to read it. If she thought she was somehow protecting me, she was wrong; it left me wondering what exactly was in my medical record, and it made me trust this particular hospital a whole lot less.

Although the OpenNotes project is, on its surface, about giving patients more access to their medical information, in a deeper sense it’s about something else: the cultural differences that tend to persist between the world of health care and the world of being a patient, between the doctor’s role as keeper of the information and the patient’s growing expectation of being more participatory.

Do providers really need to worry so much about what patients are (and aren’t) allowed to see?

“These fears are overreactions,” writes Dr. Thomas Feeley of the renowned M.D. Anderson Cancer Center in Houston.

M.D. Anderson has been giving patients access to their electronic medical record since 2009, he writes. “While initially doctors complained that they had to explain more to patients about what was written in their records, the doctors soon came to realize the benefit of having patients who are more informed about their care plan and lab results.”

If the topic is volatile, maybe it’s because of the tensions it reveals between providers and patients, writes Stephen Downs at The Health Care Blog. “From my perspective, it appears that many doctors are underestimating their patients and that this underestimation could lead to less patient engagement and ultimately poorer care.”

Many clinicians seem to believe their patients can’t handle the truth, while patients overwhelmingly say otherwise, he wrote. “What do you all make of that gap? How serious an issue is it?”

The OpenNotes project undoubtedly will tell us more when the final results are published. In the meantime, this will continue to be an interesting debate.