Section on
Osteopathic Pediatricians
Newsletter
Volume 3 • Issue 1
Winter 2011
Comments from the Chair
Section on Osteopathic Pediatricians
Lisa D. Ryan, DO, FAAP, FACOP, Chairperson
H
ello to all and I hope everyone
has had a healthy and joyful holiday season. The AAP Executive
Board approved full section status for
our section at their meeting in May of
this year! This is wonderful news and I
thank all the members for your support
over the last three years. Our membership has grown and we are proud to
have members! At the NCE in San Francisco in October
we had our first section program which you will read
about later in the newsletter! We plan to continue to have
this program at every NCE in the future and would love
IN OUR ISSUE
Comments from the Chair ................................... 1
SOOP Executive Committee ................................. 2
LET’S MOVE IN THE CLINIC ................................. 2
ARTICLES OF INTEREST
2010 AAP NCE: Summary of our first educational
program by the Section on Osteopathic
Pediatricians .................................................... 3
The Accountable Care Organization
and Health Care Reform .................................... 4
AAP International Child Health Network! .............. 5
Summary: Meeting Of The Advisery Committee on
Immunization Practices (ACIP) ............................. 6
International DOs ................................................ 7
Twitter feed . . . .................................................. 8
Join the section . . . ............................................ 8
Counseling High School Wrestlers on
Safe Weight Loss Methods During
the Preparticipating Physical Examination: ............ 9
Contributions to the Newsletter . . . ................... 12
Send in your articles to the Editor .......................
DO First-Ever Section Election 2011 ...................
DO Liaisons - Chapter Level ...............................
Interested in being a DO liaison? .......................
13
14
14
14
Thank You to Mead Johnson Nutrition ............... 14
to hear your input regarding what you would like to see
at these programs.
I wanted to give an update on the Continuing Medical
Education questions that we frequently hear about from
members. I can tell you all that this is quite a “complicated” picture. The requirements for credits vary from
state to state based on state licensing. They also vary
depending on whether the residency program is an AOA
or ACGME approved program. Another factor in the mix
is whether specialty certification is through the American
Osteopathic Board of Pediatrics (AOBP) or American
Board of Pediatrics (ABP). Sounds confusing and I am not
surprised that so many Osteopathic pediatricians struggle with understanding and fulfilling the requirements!
In states with a combined medical licensing board
(Osteopathic and Allopathic) requirements for state
license most likely can be AOA or AAP approved category
1 credits. However, there are fourteen states that have
dual licensing boards. In these states the osteopathic
pediatrician requires AOA approved category 1 credits for
state license and if board certified through the ABP also
requires AAP category 1 credits for maintenance of certification. The states with dual licensing boards include
AZ, CA, FL, ME, MI, NV, NM, OK, PA, TN, VT, UT, WA, WV.
Category 1 AOA credits are received from AOA-accredited
category 1 CME sponsors (ie. state Osteopathic medical
associations, ACOP, AOA). You can also receive category
1 AOA credits for standardized life support courses (i.e.
ATLS, ACLS, GLS, PALS, APLS, NALS). Credits can also be
obtained with delivery of formal osteopathic medical
education on and hour-to-hour basis (i.e. teaching of
students, interns or residents, lectures in osteopathic
medical schools, serving as a preceptor for osteopathic
medical students, interns and residents with approval
from the Osteopathic Medical School). As you can see,
this is not a straight forward process and as we have been
Continued on Page 2
Section on Osteopathic Pediatricians Newsletter
Statements and opinions expressed in this publication are those of the authors and not necessarily those of the American Academy of Pediatrics.
Copyright © 2011 American Academy of Pediatrics
Comments from the Chair Continued from Page 1
looking at this over the last several years, it is my impression that a lot of my colleagues are not aware of all the nuances
in this process.
Your Executive Committee has continued to work with leadership in the American College of Osteopathic Pediatricians
(ACOP) and staff at the AAP to try to look at creative solutions for some of these struggles. By far the most common
questions we have received are related to getting category 1 credits for the Pediatric education we all feel is important to help us maintain our proficiency in delivering quality pediatric care to our patients. In the past the AAP and
ACOP have had combined pediatric meetings where both AOA and AAP credit could be obtained and this continues
to be an appealing option for members. We are also trying to “think out of the box” and come up with other options.
Section on
Osteopathic Pediatricians
Executive Committee
Lisa D. Ryan, DO, FAAP, FACOP
Chairperson; Membership Chairperson
[email protected]
Gary E. Freed, DO, FAAP, FACOP
Member; Newsletter Editor
[email protected]
Gregory L. Gavin, DO, FAAP
Member
[email protected]
Lee J. Herskowitz, DO, FAAP, FACOP
Member
[email protected]
Erik Edward Langenau, DO, FAAP, FACOP
Member
[email protected]
Robert Lee, DO, FAAP
Member
[email protected]
Michael A. Weiss, DO, FAAP
Member
[email protected]
Staff
Jackie Burke
[email protected]
Tracey Coletta
[email protected]
Mark A. Krajecki
Pre-Press Production Specialist
[email protected]
Page 2
It is disappointing to tell you all that our section meeting at the NCE does award category 1 credits but they are
AAP credits at this time. The AAP is not an AOA-accredited CME sponsor. I know membership is concerned
and interested in this topic and I wanted to let you know
that we continue to work on this area and will continue
to keep you informed of our progress.
Please feel free to let me know your thoughts and concerns. I welcome discussion about this complicated issue
and thoughts members may have. I hope this information has been helpful and if you have further questions,
please feel free to contact me. Thank you again for your
support and we are looking for members who are interested in getting more involved with the Section!Please
contact us if you want to get more involved!
Peace and joy in the New Year to all!
Lisa Ryan, DO, FAAP
Chairperson, AAP Section on Osteopathic Pediatricians
LET’S MOVE IN THE CLINIC
An Initiative to Encourage Health Care Providers
in the Clinic
Sign Up Now!
Let’s Move in the Clinic is an initiative to encourage
health care providers to make a clinical commitment to
measuring BMI and counseling patients about optimal
nutrition and physical activity.
Sign up at the link below and move us one step closer
to solving the problem of childhood obesity within a
generation. Pledge your support to the Let’s Move in the
Clinic initiative now and receive a personalized Let’s
Move! Certificate to post in your clinic!
http://www.aap.org/obesity/letsmove/index.cfm
Section on Osteopathic Pediatricians - Winter 2011
The following articles of interest were submitted by members of the AAP’s Section on Osteopathic Pediatricians.
2010 AAP NCE: Summary of our first educational program
by the Section on Osteopathic Pediatricians
Erik Langenau, DO, FAAP, FACOP
Program Chair, 2010 and 2011 AAP NCE
W
ith over 30 participants in attendance, our first
NCE section program was a great success!
Osteopathic and allopathic physicians had the
opportunity to learn about osteopathic principles and
practice, along with current advances in osteopathic
research.
Jane Elizabeth Carreiro, DO (Associate Professor and
Chair of Osteopathic Manipulative Medicine at
University of New England College of Osteopathic
Medicine) started the program with a lively case-based
discussion of how osteopathic principles and OMT can
be incorporated into pediatric practice. Specific presentations included otitis media, torticollis and sinusitis.
Dennis Dowling, DO, MA, FAAO (Practicing osteopathic
physician, Director of Osteopathic Manipulative
Medicine for the National Board of Osteopathic Medical
Examiners, and a supervising attending physician for the
residents at the Physical Medicine and Rehabilitation
department at Nassau University Medical Center) followed with a hands-on presentation of integrating specific OMT techniques for improving lymphatic system
dynamics and treating influenza pneumonia through
hands-on instruction and practice. The presentation was
engaging, interactive, and allowed for practical demonstration of specific techniques.
Gregg Lund, DO, MS, FAAP (Department of Osteopathic
Manipulative Medicine, Touro University - College of
Osteopathic Medicine) kicked off the research presentations with a dynamic presentation entitled “Pediatric
Osteopathic Manipulative Medicine Research Challenges and Opportunities.” The presentation not
only identified the challenges of osteopathic research in
children, but it also provided a great introduction for our
oral scientific abstract presentations.
Two abstracts were selected for oral presentation at this
year’s scientific abstract session.
• Is Osteopathic Dysfunction of Temporal Bone a Risk
Factor for Acute Otitis Media in Young Children?
Chantal Morin, OT, DO, cMSc
• Adjunctive Osteopathic Treatment of Hyper sensitivity and Speech Apraxia in Children with
Autistic Spectrum Disorders. Colleen M. Vallad-Hix,
DO
Both presentations were well received and offered valuable contributions to the field of osteopathic research.
Following the educational and scientific abstract sessions, Lisa Ryan, DO, FAAP, FACOP (Chair, Section on
Osteopathic Pediatricians) concluded the section program with section updates, scientific abstract award presentations, and opportunities to share ideas and
collaborate. All in all, we believe participants left the
session with a clearer understanding of osteopathic medicine, OMT in pediatrics, current osteopathic research,
and opportunities to participate with the Section on
Osteopathic Pediatricians.
Thank you to the faculty who presented, AAP staff who
helped prepare for the program, the researchers who
submitted and presented abstracts, the reviewers who
helped select the abstracts, everyone who helped with
preparing materials for the program, and of course the
workshop participants. And special thanks to Jerel H.
Glassman, DO for providing an exam table for use during the educational program.
Mark your calendars! The 2011 AAP NCE will be held
October 15-18, 2011 in Boston, Massachusetts. The
Section on Osteopathic Pediatricians 2011 NCE program
promises to be equally engaging and enlightening. Also,
please consider submitting research abstracts for this
section program. We are very interested promoting osteopathic research and encourage submitting your projects
for consideration.
Thank you again for the opportunity to put together such
a fun and informative series of educational programs for
the Section on Osteopathic Pediatricians.
Section on Osteopathic Pediatricians - Winter 2011
Page 3
***
The Accountable Care Organization and Health Care Reform
Michael Weiss, DO, FAAP
U
nless you have been living on a remote island
without access to the media, you are keenly
aware that health care reform legislation was
passed by the Unites States Congress earlier this year.
The staggering numbers related to medical spending,
poor quality outcomes, and lack of insurance coverage
drove this effort at a fairly rapid pace (for politics).
President Obama, in his address to Congress last fall,
indicated that we need to “Build on what works and fix
what doesn’t”. He is committed to: “Securing stability for
those with insurance, providing insurance for those without current coverage, and slowing the rise in the cost of
medical care”. The Institute of Medicine’s “Triple Aim”
reinforces this concept: Better Care, Better Patient
Experience, and Lower Cost.
Arguably, the issues surrounding expansion of insurance
coverage were more universally agreed upon. In contrast, the mechanisms whereby we will be able to curtail
medical spending are fraught with debate. Due in large
part to the well publicized article: “The Cost
Conundrum,” written by Dr. Atul Gawande, appearing in
The New Yorker, and oft quoted by President Obama, the
specific issues surrounding wasteful medical spending
have been brought to the forefront of the debate. The
wide variation in the cost, quantity, and quality of care,
as well as the reinforcement for providing MORE care,
was highlighted.
Given this information, our legislators, with guidance
from medical leaders across the country, landed on a
concept that was first coined by Dr. Elliott Fisher from
Dartmouth College: “The Accountable Care
Organization.” This terminology has now been incorporated into the Affordable Care Act passed in Washington,
D.C. earlier this year. Contained within the Reform Bill is
a seventeen page section: “Accountable Care
Organization Pilot Program”, devoted entirely to defining
the ACO and outlining a plan to implement a pilot project to test various reimbursement models for their ability to reduce health care expenditures and improve
medical outcomes.
group to receive and distribute incentive payments
(ability to take risk)
2. Include a sufficient number of primary care physicians to ensure accountability
3. Be comprised of only participating physicians
4. Be able to report on quality measures and other data
as requested by the Secretary of HHS
5. Have the ability to notify applicable beneficiaries
of the program details
6. Be capable of contributing to a best practices network for sharing strategies for quality improvement,
care coordination, and efficiency
7. Use patient-centered processes that emphasize
patient and caregiver involvement in planning and
monitoring of care plans
The Brookings Institute at Dartmouth has simplified the
ACO infrastructure into three major components, each of
which is vital to the success of the model. The first is
local accountability for cost, quality, and capacity. The
ACO must have the ability to manage care across the
entire continuum of an integrated delivery system. The
“local” component is vital to assuring accountability.
Our current reimbursement system does not hold groups
of physicians accountable for the overall quality of care
and outcomes of patients across all care domains. The
ACO structure rewards coordinated care, communication, and smooth facilitation of the fragile transitions of
care that often lead to a breakdown in the system. In
essence, the ACO is the “home for the medical home”.
This should serve as comforting news for pediatricians
who first coined the Medical Home term in the 1960’s.
To qualify as an Accountable Care Organization, according to the Affordable Care Act, an organization must:
The second component is the ability to distribute shared
savings payments. Once care coordination at the local
level has been demonstrated, the ACO must be able to
accurately determine the savings achieved based upon
total patient expenditures and quality targets. The savings are calculated based upon a 3-year historical average of total expenditures for the ACO population and
targets are negotiated between the ACO and payers. The
achieved savings is then “shared” and distributed to the
various providers in the ACO (primary care physicians,
specialists, ancillaries, hospitals, and others).
1. Be enveloped by a legal structure that allows the
Continued on Page 5
Page 4
Section on Osteopathic Pediatricians - Winter 2011
The Accountable Care Organization and Health Care Reform Continued from Page 4
Components of capitation, either partial or global, will
likely be introduced into the equation in the near future.
The third component is the development of accurate,
meaningful, and actionable performance measures.
Investment in health IT will be vital to this aspect of the
ACO. Meaningful measures will shift from individual,
process-related items to population based metrics with
specific outcome goals. Care coordination, shared decision making, capacity control and overall population
health will be emphasized. Additionally, the overall
patient experience will be assessed and reported.
Given the wide variety of delivery system models across
the country, it is important to realize that ACO’s will look
very different in various markets. There is no doubt that
a range of entities will step up claiming their right to be
called an ACO. Testing the various types of delivery systems will be vital as the ACO concept matures. From
large employed physician models to independent practice associations, each will be given the opportunity to
bestow its virtue.
In addition to the Accountable Care Organization, there
are a number of other provisions of The Affordable Care
Act that will, most certainly, benefit children. Rescission
of care and limitations to care based on pre-existing conditions will no longer be allowed, “Children” up to 26
years of age can now be covered by their parents insurance, and many more Americans will qualify for Medicaid
coverage.
Pediatricians are in a unique position to both drive the
new paradigm and prosper in its wake. With many successful years of care coordination, promotion of preventive care, and management of the transitions of care, we
are poised to lead the country in providing high quality
in the most efficient manner possible.
As health care reform unfolds, we can be certain of the
fact that we will need to adapt to whatever comes our
way. The ACO will be part of the future of the healthcare
delivery system structure, so the more we can learn about
the model and prepare, the more likely we are to be successful in the upcoming years. Pediatricians are well prepared to blaze the trail. The hope is that we can,
collectively, “bend the curve” of health care costs, and
provide the high quality care our patients and families
deserve.
AAP International Child Health Network!
www.ichn.org
This dynamic web-based network aims to actively support meaningful collaborations among pediatricians and
others who are working to improve global child health.
What is it?
The ICHN is a free and open service designed to establish connections that foster cooperation on a variety of health
projects. This includes relief and development work, humanitarian service, equipment/supply donation, education, research, fundraising, and visitor exchange. The site is managed by the American Academy of Pediatrics’
Section on International Child Health.
How does it work?
Using the ICHN is simple! After a brief registration process, the network can be used in two ways:
1. You can search the ICHN independently to identify partners who have specific interests and expertise.
2. You can identify collaborators and/or opportunities through a Country Coordinator. Each country around the
world has a designated Country Coordinator who has experience living or working in that country – and who
will happily provide you with assistance or guidance.
Section on Osteopathic Pediatricians - Winter 2011
Page 5
Summary:
Meeting Of The Advisery Committee
on Immunization Practices (ACIP)
October 27-28, 2010
Stanley E, Grogg, DO
Interim Provost/Dean
Professor of Pediatrics
Oklahoma State University Center for Health Sciences
Meningococcal Vaccine: Routine vaccination of adolescents with MenACWY beginning at age 11 through 12 years
and a booster dose at age 16 years.
Pertussis: California experience: 10 infants deaths 2010
- Recommended ages 10 through 64 years, receive a single dose of Tdap in place of one tetanus and diphtheria toxoids (Td) vaccine dose.
- Removal of interval: Adolescents or adults who have not received a dose of Tdap should be immunized as soon
as feasible. Tdap can be administered regardless of interval since the last tetanus or diphtheria containing vaccine.
- Tdap in adults ages 65 years and older:
1. Adults ages 65 years and older who have or who anticipate having close contact with an infant ages less than
12 months (e.g., grandparents, child-care providers, and HCP) should receive a single dose of Tdap (off label),
if not previously immunized with Tdap
2. For adults ages 65 years and older, a single dose of Tdap vaccine (off label) may be given in place of a tetanus
and diphtheria toxoids, (Td) vaccine, in persons who have not previously received Tdap
- For under-vaccinated children ages 7-10 years: Tdap is recommended (off label) as a single-dose. If additional
doses of tetanus and diphtheria toxoid-containing vaccines are needed, then vaccinate according to catch-up guidance.
2011 Immunization Schedule (0-18 years of age)
Continue to have 3 schedules with separate footnotes
1. 0- 6 years
2. 7-18 years
3. “catch up”
a. 4 months through 6 years
b. 7 through 18 years
Publication in MMWR on January 7, 2011 and Pediatrics and American Family Physician in January 2011.
Rotavirus:
1. Severe Combined Immunodeficiency Disease (New Contraindication): Infants with Severe Combined
Immunodeficiency Disease (SCID) should not receive live rotavirus vaccines
2. Intussusception (New warning in PI): Interim postmarketing safety data from a study conducted in Mexico among
a birth cohort of infants suggest an increased risk of intussusception in the 31-day period following administration of the first dose of ROTARIX.
Influenza
1. Routine seasonal influenza vaccination is recommended for all persons aged ≥6 months
2. Two doses, at least four weeks apart, are recommended for all children aged 6 months to 8 years who are receiving seasonal vaccine for the first time
Page 6
Section on Osteopathic Pediatricians - Winter 2011
International DOs
Julia C. Rosebush, DO
A
fter two short weeks of intensive training in the United
States immediately following
graduation from pediatric residency,
I found myself transplanted to
Botswana being regarded as a pediatric HIV specialist. I had been
offered a position as a Pediatric AIDS
Corps physician within Baylor
College of Medicine’s International
Pediatric AIDS Initiative, a unique
program with HIV diagnosis and
treatment centers located in 6 different countries in Sub-Saharan
Africa. The mission of the program is
to send physicians, albeit temporarily, to areas that are overwhelmed by
the HIV/AIDS epidemic to train and
educate local health care professionals in successfully handling the enormous task of diagnosing and treating
all infected and affected individuals.
The academic and personal journey
that I embarked upon would be one
of the most challenging and rewarding periods of my life as a physician.
Just several months into my new
career, I found myself becoming
increasingly interested in and drawn
to the complex management of
pediatric HIV. I discovered a true
affinity for the psychosocial aspects
of medication adherence and the
challenge of treating adolescents,
Botswana’s fastest growing population of HIV-infected individuals. In
addition to both inpatient and outpatient clinical medicine, I also participated as a lead facilitator for
various week-long didactic sessions
focused on basic pediatric HIV management held throughout the country for medical professionals. In
addition to sharing with my peers
the knowledge and skills I have
gained as an osteopath through my
experiences practicing medicine
abroad, I would also like to impart
upon present and future pediatricians the necessity of expanding our
duties as osteopathic physicians to
include the care and protection of
children beyond the borders of the
United States.
According to the American Osteopathic Association’s International
Licensure Summary, most recently
updated in October 2010, “…a few
countries have consistently refused to
grant U.S.-trained DOs full practice
rights, often permitting them to perform only manipulation and sometimes refusing to grant them any type
of practice. Other countries, however,
are simply not educated on the qualifications of U.S.-trained DOs and
their equivalence in education, training and practice to MDs.” The summary goes on to state, “…many
countries that were or continue to be
under British influence adhere to
Britain’s definition of an “osteopath,”
a non-physician health care practitioner who practices only manipulation. Due to the similarity of the titles,
many of these countries refuse to
grant U.S.-trained DOs practice
rights beyond the scope of manipulation. Further, the procedure by which
international countries consider
granting physician licensure to foreigners is not consistent among all
countries.”
What I find most striking about these
statements is the notion that a large
part of the world remains uneducated as to the inherent similarities
and differences between MDs and
DOs and that this apparent lack of
education could be the single largest
barrier to being granted practice
rights abroad as an osteopathic
physician. The misconception that
manipulation is the only major difference between MDs and DOs also
Section on Osteopathic Pediatricians - Winter 2011
needs to be addressed wherein
granting practice rights is concerned, because many osteopathic
medical school graduates do not
choose to perform OMT in daily
practice, but do model their practice
according to the tenets on which
osteopathy was founded, most
notably, the notion that rational
treatment is based on an understanding of body unity, self-regulation, and the interrelationship of
structure and function. What is
encouraging, however, is the fact
that osteopathy is enjoying a period
of substantial growth and that osteopathic medical schools are graduating ever-increasing numbers of
dedicated professionals who are
committed in every way to maintaining awareness of and advancement in our field. It is my belief that
this educational barrier can eventually be overcome with persistence
and participation by osteopathic
physicians in the delivery of health
care beyond our country’s borders. It
is our responsibility, together with
the AOA and the AAP, to educate
those who are uninformed about our
profession and maintain visibility
abroad so that we can secure our
places in medicine and push for full,
unrestricted practice rights wherever
our careers may guide us.
The AOA’s International License
Summary contains a catalog of
countries in which full, unrestricted
licensure for osteopathic physicians
has been investigated. Many of these
listings contain the scope of practice
in that particular country as well as
the contact information for the individual to whom all licensing
inquiries should be addressed. When
comparing this current information
to that which I read just several years
Continued on Page 8
Page 7
International DOs Continued from Page 7
ago, it is apparent that we have made
great strides in obtaining worldwide
recognition and acceptance, however, there is still substantial
progress to be made and it is up to all
of us, as osteopathic physicians, to
promote our profession and the
unique aspects of our training. It is
my sincere hope that my passion for
both pediatric global health and
osteopathy will ignite in you a desire
to pursue international opportunities, if even just for the short-term.
You may just surprise yourself with
not only how much education you
will give, but all that you will receive
in return, making you a stronger,
wiser physician with an even greater
appreciation for the practice of
osteopathic medicine.
For a full listing of the countries in which the AOA has investigated licensure or if you would like to have more information regarding the AOA’s involvement in promoting international recognition for DOs, please contact the AOA
Division of State Government & International Affairs, 142 East Ontario, Chicago IL 60611; (800) 621-1773 ext. 8196 or
visit their website at:
http://www.osteopathic.org/inside-aoa/development/internationl-licensure/Pages/international-osteopathic-medicine.aspx
Twitter feed . . .
The AAP Department of Communications launched the AAP’s main Twitter feed. Twitter is a microblogging service or site that allows quick messages and Web links to be sent to interested “followers” on a regular basis. The
AAP sends several messages or “tweets” each week, including updates about policy statements, Pediatrics studies, public awareness campaigns and more.
Since the launch, we have built a following of 353 pediatricians, reporters, hospitals, nonprofit organizations and
individuals, and this number is growing each week. We invite you to follow the AAP on Twitter. If you already
have a Twitter account, just look for “AmerAcadPeds.” If you have not yet signed up for Twitter, here are a few
easy steps to get you started:
1. Go to www.twitter.com
2. Click “Sign up now.”
3. Fill in the form to create your username and password.
4. Submit to create your account.
5. Log in and search for AmerAcadPeds.
6. On the AmerAcadPeds page, look on the upper left area of the page for a button bar that says “Follow.”
Click on it, and you will be following the AAP!
7. Log in to Twitter regularly to see the latest AAP “tweets.”
If you have any questions, please contact Gina Steiner, Director of Public Information, at 847-434-7945, or
[email protected].
For more information or to join the section . . .
visit our website at:
www.aap.org/sections/osteopathic
Page 8
Section on Osteopathic Pediatricians - Winter 2011
The following is an original article submitted by CPT Lera Liv Fina, DO Brigade Surgeon, 3SB. Thank you Lera!
Counseling High School Wrestlers on Safe Weight Loss
Methods During the Preparticipating Physical Examination:
Too Specialized for the Primary Care Provider?
INTRODUCTION:
Wrestling is a popular high school and college sport. Over
260,000 high school and over 6,000 collegiate athletes
participate in wrestling annually. It ranks eighth in popularity for males and it is growing in popularity for girls1.
Wrestling, like ballet and gymnastics, is a sport that
rewards higher levels of lean body mass. Up to 80% of
wrestlers have been shown to lose weight for wrestling
season2. Of this number, over 70% admit to participating
in at least one unhealthy or even dangerous weight loss
method per week 3. In one study, 11% of wrestlers were
found to have disordered eating.4 45% of wrestlers were
felt to be at risk for the development of an eating disorder in another study5. Such unsafe weight management
practices in wrestlers have led to multiple deaths or illnesses, usually related to poor hydration, at both the
high school and the collegiate level of participation.
Consequently, the National Federation of State High
School Associations (NFHS) now requires schools to
adhere to a minimum weight certification program that
employs urine specific gravity testing and body fat percentage determinations on the day of the wrestlers’ weigh
in as a failsafe against too rapid weight loss or dehydration6. Stated plainly, under the provisions of the minimum weight certification program, a wrestler’s urine
specific gravity must be less than 1.025 for the athlete to
be cleared to participate at the day’s events. Body fat percentage standards must also be met; for male high school
wrestlers, their body fat percentage must be no less than
7% and for female high school wrestlers it must be no less
than 12%7.
PROBLEM and STATEMENT of HYPOTHESIS:
Since 2007, the Washington Interscholastic Activities
Association has been in compliance with using urine
specific gravity measurements and body fat percentages
as determinants of safe minimal wrestling weight for its
high school students who wrestle 8. In leaving it to the
individual coaches to assign minimal wrestling weight
using these aforementioned parameters (via the National
Wrestling Coaches’ Association’s Optimal Performance
Calculator9), the health care provider is released from
this task during the pre participation physical examination. Yet often, health care providers are still called upon
to determine safety in participation for male or female
wrestlers whose body fat percentage is under the established standards. Likewise, the institution of more regulated practices for establishing minimum weight does
not obviate dangers associated with too rapid weight loss
in wrestlers. Primary care providers have a unique role in
counseling high school wrestlers on unsafe weight loss
methods, proper nutrition and fitness.
We report on how regularly primary care providers discuss unsafe weight loss methods with high school
wrestlers during pre-participation physical examinations. We postulate that knowledge about and concern for
the safety of the weight loss practices wrestlers employ,
visit time constraints and overall comfort level with this
topic—and even how it might be received by the athlete—all figure prominently in why a provider would or
would not discuss weight loss practices with wrestlers. It
is our hypothesis that many providers do not feel comfortable certifying minimal weights in wrestlers and that
this issue in particular, while important, is felt by many
primary health care providers to be more specialized,
better delegated to others to manage and not in their
scope of care. The implications of this hypothesis, if
borne out by our results, are discussed in light of the policy statement from the AAP on physician role in promoting healthy weight control practices in young athletes
(PEDIATRICS, Vol. 116, no. 6, December 2005).
METHODS:
We sent out via e-mail an anonymous and original survey to providers in the Family Medicine, Pediatric and
Internal Medicine departments at Madigan Army
Medical Center. The survey was validated by simulated
respondents and ensured to be reliable by test-retest
measurements. We assumed that providers would answer
truthfully. We received a total of 149 responses over a
nine-month long time period. Respondents described
themselves as staff physicians, resident physicians or
nurse practitioners. 73.9% of respondents identified
themselves as staff physicians. 22.2% of respondents
identified themselves as residents. 4% of respondents
identified themselves as nurse practitioners. 28.9% of
responders had been practicing medicine for 3 years or
less. 14.8% of responders had been practicing medicine
for 3-5 years. 14.8% of responders had been practicing
medicine for 6-10years. 37.6% of responders had been
practicing medicine for 11 or more years. 85.2% of
responders said that they considered themselves familiar with pre-participation physical examinations. 88.6%
said that pre-participation physical examinations were
Section on Osteopathic Pediatricians - Winter 2011
Continued on Page 10
Page 9
Counseling High School Wrestlers on Safe Weight Loss . . . Continued from Page 9
part of their practice. To protect against responder bias,
we also queried any personal or family history of
wrestling experience (26.1%) amongst the providers.
There was no statistical difference in answers between
specialties surveyed, in experience with pre-participation
physical examinations, level of training or in overall medical experience (measured by years in practice). There
was also no difference in responses between those
providers with personal or family history of wrestling
experience as opposed to those providers without any
prior wrestling experience.
RESULTS:
We found that during pre-participation physical exams,
the majority of providers surveyed (55%) did provide
nutritional counseling, did discuss weight loss methods
(55%) and the risks for dehydration (67%) with their athletes who wrestle and have to lose weight (Table 1).
Table 1
Providers’ Counseling of High School Wrestlers during
the PPE
Nutritional Counseling
55%
Weight Loss Methods
55%
Risks for Dehydration with
Unsafe weight loss methods
67%
Of the providers that we surveyed, 8.7% understood that
determination of body fat percentage was an acceptable
means of certifying minimum wrestling weights. More
(69%) considered the 50th percentile on standard height,
weight or BMI charts to be the minimum weight that a
teen should be allowed to wrestle (Table 2).
Table 2
Provider Knowledge on Certifying Minimum Wrestling
Weight
Body Fat percentage acceptable
way to determine MWW
8.7%
50th%ile on standard height,
weight or BMI charts
69%
In terms of rating the safety of various weight loss methods used by wrestlers, our surveyed providers were uniform in agreement that reducing caloric intake (60.4%)
and/or increasing physical activity (85.2%) were either
safe or only minimally risky methods of weight loss. They
overwhelmingly rated vomiting (97.3%), use of laxatives
(97.3%), rubber suits (91.9%) or saunas (89.2%) as moderately or very dangerous weight loss methods. Less
(41.6%) considered spitting as an only moderately risky
method of weight loss (Table 3).
Table 3
Safety of Weight Loss methods
• Reducing caloric intake
• Increasing Physical Activity
• Vomiting
• Laxative Use
• Rubber Suits
• Saunas
• Spitting
60.4%
85.2%
2.7%
2.7%
8.1%
10.2%
58.4%
Most (>60%) of providers we surveyed did not feel qualified to certify minimum wrestling weight. The majority
(>60%) felt that they did not receive adequate training to
certify weights and almost 40% said that time constraints
posed too much of an obstacle for them to consider
weight certification a valuable use of their practice time
(Table 4).
Table 4
Providers’ Attitudes Towards MWW Certification
• Feel Qualified to Certify Weight
40%
• Did not receive adequate training
to certify minimum wrestling weight
40%
• Time constraints an obstacle to
certifying weight in the PPE setting
40%
Overall, our surveyed providers felt that they were only
somewhat or rarely effective (87.9%) in influencing a
wrestler’s perception of nutrition and safe versus unsafe
weight loss methods (Table 5).
Table 5
Providers’ Self-Perception of Role in Influencing
Wrestler’s Perception of Safe versus Unsafe Weight Loss
Methods
• Very Effective
4%
• Somewhat Effective
50%
• Rarely Effective
38%
• Ineffective
8%
DISCUSSION:
We reported on primary care provider comfort level in
caring for and capaciousness in counseling the high
school wrestler during pre-participation physical examinations. As we hypothesized, a majority of our surveyed
providers do not feel comfortable or qualified in certifying minimum wrestling weight. Only a minority were
familiar with techniques used to certify minimum weight.
Both the American Academy of Pediatrics and its subcommittee on Sports Medicine have published documents emphasizing the importance of providers
familiarizing themselves with minimal weight and body
composition method determinations.10,11
Continued on Page 11
Page 10
Section on Osteopathic Pediatricians - Winter 2011
Counseling High School Wrestlers on Safe Weight Loss . . . Continued from Page 10
While the determination of minimal wrestling weight
becomes more and more appropriated by the athlete’s
school, the risks involved in unsafe weight loss methods
are not lessened. Understanding how a wrestler’s minimum weight is determined and recognizing that
wrestlers often act dangerously to achieve these weights
form an essential tenet for the provider who certifies
wrestlers for sport participation.
Our surveyed providers do appear to seize upon the
opportunity presented by the pre-participation interview to discuss weight loss methods, healthy nutritional
choices and the dangers in dehydration with wrestlers
despite their belief that such deliberations are greeted at
best apathetically by said wrestlers. A subject for a future
study might address the question of how a wrestler’s decision to engage in unsafe weight loss methods is impacted
by counseling to the contrary provided by his or her
provider during their physical examination.
Distinguishing wrestlers as athletes who face particular
risks is a concept that has been discussed in prior writings12. The identification of providers specifically knowledgeable in minimum weight certification has been
proposed by interscholastic organizations13 and by medical societies14. The majority of providers in our survey,
while appearing to recognize the dangers of unsafe
weight loss methods, feel that visit time constraints
would make learning and utilizing body fat percentage
determination methods an ineffective use of resources.
Yet the more ‘wrestling friendly’ provider, who is competent at certifying minimal wrestling weights, would be
poised to effectively identify the wrestler who is at risk to
lose inordinate amounts of weight in short periods of
time. He or she would also possess the necessary skill set
to assess body composition. Such a skill set would not
only have useable import for wrestlers but for all young
athletes who participate in the so-called weight sensitive
sports. Through such wraparound care, a partnership
can be forged between provider and school and the risks
that wrestlers take to make weight will be at best minimized in the journey from sport physical to certification
to wrestle.
STUDY LIMITATIONS:
As the surveyed group in our sample was general primary
care managers, our study was limited by design in scope
and in care specialty. The questions in our survey did
not specifically address the nature of the nutritional
counseling providers implemented or how they
described safe weight loss practices with their young athletes. At best, our study purports to enlighten primary
care providers on their vital roles in educating young
wrestlers on safe weight loss methods and in familiarizing themselves, as health care providers, with body composition and minimal weight determination methods.
References:
1. A. J. Grove, Hot Topic: Minimum Weight Certification Programs for Wrestling, COSMF Newsletter Fall 2008, p. 8-9
2. American Academy of Pediatrics’ Policy Statement: Promotion of Healthy Weight Control Practices in Young Athletes, Committee
on Sports Medicine and Fitness, PEDIATRICS, Vol. 116, No. 6, December 2005, pp. 1157-1563
3. Periello, Va Jr. Aiming for Healthy Weight in Wrestlers and Other Athletes, Contemporary Pediatrics, 2001, 18:55-74
4. Garner, DM, Rosen LW, Barry D, Eating disorders among athletes: research and recommendations. Child Adolescent Psychiatric
Clinics of North America, 1998, 7:839-857
5. Garner, DM, et.al., op.cit.
6. www.nwcaonline.com
7. American Academy of Pediatrics’ Policy Statement,op.cit,
8. www.tjhswrestling.com/wiaa_weight_management_program.htm
9. Home page of national wrestling coaches’ association; optimal performance calculator
10. American Academy of Pediatrics’ Policy Statement, op. cit.
11. A.J. Grove, op.cit.
12. www.nwcaonline.com
13. Washington state Wrestling Weight Management Program
14. American Academy of Pediatrics’ Policy Statement, op.cit.
“The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department
of Defense or the U.S. Government.”
“The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.”
Section on Osteopathic Pediatricians - Winter 2011
Page 11
Contributions to the Newsletter . . .
The following comments were sent to me in response to my asking if anyone wanted to contribute anything to the
newsletter. Two major topics were addressed by the following comments. First, is the difficulty for DO pediatricians
to get CME credit and the second topic that resulted in several e-mails was about reimbursement for OMT.
Gary Freed, DO, Editor
Continuing medical education (CME) is beneficial for
physicians so they can improve their knowledge in their
specialty as developments in medicine continue to
change at a rapid pace. CME requirements are mandated in most of the fifty states to maintain medical licensure.
As an osteopathic physician on faculty at an allopathic
medical school, the CME requirements are set forth by
the AOA in the state of Florida. Where I practice can be
somewhat challenging. Florida is one of the few states
that limit the number of CME credit hours that osteopathic physicians can obtain from sources approved by
the AMA. Although I can attend grand rounds, teach
many hours a week (including some D.O. residents),
complete the PREP course yearly, attend a university
based pediatric CME conference, this is not sufficient to
complete CME unless I attend a FOMA conference once
every two years. The past four day conference had a total
of 1 out of 22 CME credits related to the field of pediatrics.
Although there is a pediatric AOA conference, it is usually
scheduled once a year, which makes attendance difficult.
CME is important. Physicians need to continue learning,
reading, and perfecting their skills. I am proud to be an
osteopathic physician; one of very few at the allopathic
medical school where I am on faculty. The AOA can mandate certain CME hours, but must allow for excellent
courses that may not be AOA approved to be included in
our CME requirements.
This year, I attended the FOMA conference, completed
my mandatory courses and learned about “pre-operative
education of cataract surgery patients”, “breast cancer
detection”, and “obstructive sleep apnea (in adults)”.
Does this really make me a better pediatrician?
I am most frustrated when it comes to getting AOA 1A
CME credit. It seems as pediatricians we get roped into
family practice osteopathic sponsored conferences in
order to get sufficient 1a CME to keep our licenses and to
be able to maintain membership in the AOA. I would
love to go to more AAP courses and meetings but my job
has limited funding. I am limited to programs offering
AOA approved 1A approved CME. Most of the time I find
myself at family conferences which offer limited pediatric
sessions on very general pediatric topics, which are not
interesting to pediatricians (how many vaccine update
talks can I take!). I do not know how others feel, but even
the topics offered at the national AOA conference this
year on general pediatrics did not excite me. I would like
to see more collaboration of the AAP and its
chapters/societies with osteopathic societies to offer
more local or even national combined CME courses. I
would like to see this discussed or mentioned in the news
letter and get feedback from other members. I imagine
as a pediatric subspecialist this must be even more difficult and frustrating- I find the rules regarding specialists getting 1a credit very confusing. Let me know if I can
help in anyway with the newsletter. I think the AAP DO
section in general is a grand idea. I realize certain AAP
state chapters have identified DO representatives as well.
It would be great to have AAP osteopathic members meet
up at the national conference and discuss more issues.
Sincerely,
Jessica Brown
(In fact, we do have a meeting time at the NCE for
Osteopathic attendees to “meet and greet”
Gary Freed, DO)
***
Randi Sperling
University of Miami/ Miller School of Medicine
***
Continued on Page 13
Page 12
Section on Osteopathic Pediatricians - Winter 2011
Contributions to the Newsletter . . . Continued from Page 12
All I can say is at the Cleveland Clinic they cut our CME
days down to 3 days (from 10). They do not pay for
travel. It is truly an inequity in the institution as other specialties/ primary is are allowed. It is almost impossible to
comply and get credits even here as all of the category 1A
are MD and not accepted by the DO board. This is truly
a detriment to anyone who wants to survive in Peds as a
DO. The small hospitals did not survive this health care
shift and we are stuck. I worry every year how I can take
time and afford to do it all. If we want free credits, we can
go on Sat. morning and get B category. But given that we
work Saturdays and I choose to work some Sundays this
leaves little if almost no family time on the weekends. The
American Academy of Pediatrics would do a service if
they would certify category 1A for DO’s also. That is in the
seminars and Preps.
AM Kalata
***
Commentary on OMT
Dear Colleagues,
I am a new pediatric hospitalist have just learned that
my OMT is not covered under Florida Medicaid. I was
wondering if there is any precedent on this topic. I found
articles (See below) just about insurance companies but
not Medicaid. There are codes but they just don’t pay for
them!
Billing and coding for osteopathic manipulative treatment. Snider KT, Jorgensen DJ. Department of
Osteopathic Manipulative Medicine, Kirksville College of
Osteopathic Medicine-A.T. Still University, Kirksville, MO
63501-1443, USA. [email protected]
I am not from Florida but if you contact the
American College of Osteopathic Pediatricians at
[email protected] I am sure they will have some information on how to get reimbursement in Florida.
Jude Cauwenbergh
***
I think that OMT is on a big list of many things that
Medicaid won’t pay for. And that was before States were
in or nearly in huge budget deficits. Just trying to get
back pain covered is tough when, as our Medicaid likes
to say here in Oregon, “everybody has a backache.” PT is
on that list along with OMT. “Somatic dysfunction of the
ribcage, 739.8, is what I end up using most often.
Certainly worth considering, when your patient may
receive a bill for your OMT if Medicaid won’t cover it, no
matter how much evidence supports its usefulness. At
our clinic, if it’s not paid for, it’s written off. I’m not sure
the AAP would overstep the ACOP in trying to get it
covered, though I’d be thrilled if they did, or perhaps
collaborated on it.
Rich [[email protected]
Feel free to respond to either of these topics or anything
else that you feel is important to DO pediatricians.
I will compile them and include them in the next
newsletter in the Spring. Send all comments to
[email protected]
Erratum in: J Am Osteopath Assoc. 2009 Nov;109(11):574.
If this has not been published I would be interested in
doing a study on the topic and presenting it.
Bahareh Keith DO
University of Florida
***
AAP Section on Osteopathic Pediatricians Members:
Do you have a thought to share with your fellow section members? Please forward any articles
to Gary Freed, DO, FAAP at [email protected]
Thank you!
Section on Osteopathic Pediatricians - Winter 2011
Page 13
Section on Osteopathic Pediatricians
to have First-Ever Section Elections in 2011
The Section will hold elections for executive committee in March 2011. The nominations committee is looking for
DO Section members interested in serving one or two terms on the Section’s executive committee. If you are interested in getting more information about open positions, please e-mail staff at [email protected].
AAP Provisional Section on Osteopathic Pediatricians
Creates DO Liaisons at the Chapter Level
The AAP approved the AAP Provisional Section on
Osteopathic Pediatricians in January 2007. The goals of
the Section are:
1. To develop educational programming, to foster good
working relations between state osteopathic associations and their allopathic counterparts and to unite all
pediatricians in order to become even stronger advocates for children.
2. Educating medical students, osteopathic pediatric
residents, young physicians and all pediatricians on
the resources the AAP has to offer (i.e., education,
publications, policy statements, advocacy efforts, etc.).
3. Education both DO and MD on osteopathic principles.
In order to foster good working relations between state
osteopathic associations and their allopathic counterparts, the Section created DO CHAPTER LIAISONS. DO
Chapter Liaisons:
medical society, especially if they have a pediatric section or deal with pediatric issues.
3. Occasionally write an article for the Section’s and/or
Chapter’s newsletter or web page.
The following individuals are currently serving as DO
liaisons to AAP Chapters:
Chapter
DO Liaison
Maine
Lisa Ryan, DO
Iowa
Greg Garvin, DO
Delaware
Julia Pillsbury, DO
Indiana
Heather Richardson, DO
Illinois
Gene Denning, DO
California Chapter 4
Michael Weiss, DO
1. Communicate with the local AAP chapter and share
information between the Section and the local chapter.
New Mexico
Grace Park, DO
Pennsylvania
Edward Everett, DO
2. Make the chapter aware of the state’s osteopathic
New York 2
Robert Lee, DO
If you are interested in being a DO liaison to your AAP chapter,
please contact Michael Weiss, DO at [email protected].
The AAP Section on Osteopathic Pediatricians would like to thank Mead Johnson Nutrition for their contribution
for the Section on Osteopathic Pediatricians lunch reception at the 2010 NCE.
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Section on Osteopathic Pediatricians - Winter 2011