Atlanta Anti-Child Obesity Campaign Risks Stigma - Slate

A leading child health expert at the National Institutes of Health has lent his support to an effort to end a controversial anti-child obesity campaign that includes such taglines as "Chubby isn't cute if it leads to type two diabetes."

In a letter to the activist leading the counter-campaign, NIH's Alan Guttmacher said that the ads carry "a great risk of increasing stigma" around childhood obesity and, as a result, pose "risks to the psychological health" of obese adolescents.

The ads in question (two of which are pictured below) come from Georgia-based Strong4Life, which is run by Children's Healthcare of Atlanta. The group began putting up billboards in the Atlanta area this past August that couple stark black-and-white images of overweight children with warnings of health risks linked to obesity. The posters are accompanied by messages such as: "Being fat takes the fun out of being a kid," and "Fat prevention begins at home. And the buffet line." The group has also put out similarly-themed videos, which can be viewed here.

The aggressive campaign has sparked its fare share of debate, with online activists urging the group to take the ads down. As part of its counter-push, one of the activists reached out to a number of health experts to solicit their opinions, including Guttmacher, whose response was passed along to the BBC.

Strong4Life contends that the ads were meant to be controversial as a means of sparking debate, and were modeled after a recent anti-methamphetamine campaign deemed successful. Most of the billboards have been taken down as the anti-obesity campaign moves into its next phase, although the group says that some still remain in neighborhoods with particularly high child obesity rates.

Georgia has the second-highest child obesity rate in the nation. Mississippi, the southern state's western neighbor, nabs the top spot.

http://slatest.slate.com/posts/2012/02/09/atlanta_anti_child_obesity_campaign_risks_stigma.html?

What Doctors Can Learn From Musicians - NYTimes.com

Last week in my cello lesson, I spent an hour and a half on a single line of music. It was a snarly line, and I botched it heroically for 90 solid minutes. My teacher was patient, but uncompromising; I was met with blunt feedback at every step and left feeling wholly dispirited.

At home I plowed through that line for the next week, painstakingly dissecting each infuriating dotted-sixteenth note and every nasty double-sharp. On my teacher's advice, I recorded each attempt, then listened back to repair my errors. It was excruciating for me (to say nothing of the suffering of innocent household bystanders).

There was no eureka moment, but slowly, grindingly, the dissonant cacophony coalesced into a recognizable melody. It was only one measly line, but I'd successfully navigated it. I was one tiny step better than I'd been before.

It made me think about an unusual essay in The Annals of Internal Medicine called "Music Lessons: What Musicians Can Teach Doctors." The author, Dr. Frank Davidoff, an internist and former editor of the Annals, makes the interesting point that although medicine is learned over many years, the actual practice of clinical medicine is a performance, "in the best and deepest sense of the word."

Doctors spend much of their energy keeping up with the vast medical knowledge, but scant attention is paid to how this knowledge is dispensed in actual practice, or what Dr. Davidoff would call the performing of medicine.

Musicians, on the other hand, focus intensely on the performing of music. My experience was but a snippet of what musicians spend a lifetime doing — relentlessly practicing, constantly bathed in critical feedback from teachers, audiences, critics and their own ears.

Dr. Davidoff points out that the greatest music teachers are coaches, not lecturers. In contrast, most of our teachers in medicine are lecturers, and information is simply shoveled at the student.

In a recent piece in The New Yorker called "Personal Best," Dr. Atul Gawande probed the idea of coaches for physicians who would observe doctors in the process of practicing medicine, then give detailed feedback, much like my cello teacher did with me.

The midcareer plateau Dr. Gawande wrote about resonates with me. At this point, I feel comfortable treating most of what crosses my desk, but I'm not really learning much. This is in contrast to the exponential learning I experience as an amateur musician. The exhilaration — even with its implacable frustrations — pulls me to practice cello with a vigor that can't quite be mustered when I read my weekly medical journals.

This exhilaration, in fact, recalls what I felt as a beginning medical student. The loss of this excitement may be a large component of burnout and plateaus in midcareer doctors.

In music, plateaus are flatly unaccepted. When complacency creeps into my cello practice, my teacher exhorts me, "If you aren't improving, you are getting worse!" Could a medical coach bring back the intellectual vibrancy from medical school days, spur that constant growth?

Dr. Gawande decided to try, and invited an esteemed surgeon to observe him and give blunt feedback. There were many uncomfortable moments of feeling awkward under observation, of worrying what his colleague would think of him. These are all familiar emotions to me from my cello lessons, where I present the fruits of each week's practice to my teacher. There is always that painfully long moment after I put down the bow, the deep breath in which my teacher searches for a charitable way to catalog my blunders. Criticism, no matter how softly couched or solidly constructive, is always hard to take. But without fail, I improve after these critiques, once I've scraped my battered ego off the floor.

Would doctors actually want a coach observing their work and offering critiques? It's not a comfortable experience, for sure, but if done in a spirit of self-improvement, without the threats and penalties of the current quality-measures movement, many might be open to it. I surely would. I'm probably a "good enough" doctor now, but it would be hubris to think that I couldn't be better.

Picking the right coach is paramount. I initially tried several cello teachers. All were excellent, but when I took a lesson with the last one, I knew immediately that I'd found the right mentor. The combination of exacting standards — whether for Suzuki's "Twinkle Twinkle" or Bach's suites — and unflinchingly honest criticism, laced with an unfailing optimism that I would succeed if I kept at it, is perfect for me. We've been sweating it out together for six years. It's the hardest, most sustained, most gratifying work I've done in the last decade; nothing I've done in medicine in these same years comes close.

The main stumbling block, honestly, is time. As I read through Dr. Gawande's experience — detailed discussions, reviewing videos, observing other doctors — I kept waiting for him to reveal where that time came from. Was it his own free time? Or did the hospital exempt him from some clinical duties (that is, take a revenue loss)?

If doctors are told that coaching is a fabulous idea — go ahead and squeeze it into your schedule! — there will be very few takers. But if we allot some resources (as we do for continuing medical education) and ensure that this will not be used punitively, many doctors would be eager for an experienced clinician to offer feedback. The next step would be to incorporate suggestions from patients. Then the orchestration might really get interesting.

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Danielle Ofri is the author of three books, including "Medicine in Translation: Journeys With My Patients." She is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review.

http://well.blogs.nytimes.com/2012/02/03/what-doctors-can-learn-from-musicians/

On HealthTap, Advice for You and Points for Doctors - NYTimes.com

EVERY sphere of life, it seems, can be turned into a game — including the way physicians offer medical advice and build a public reputation. HealthTap, a start-up based in Palo Alto, Calif., has brought the vocabulary and mechanics of games to medicine.

At the company's Web site, users post questions and doctors post brief answers. The service is free, and the doctors aren't paid. Instead, they engage in gamelike competitions, earning points and climbing numbered levels. They can also receive nonmonetary awards — many of them whimsically named, like the "It's Not Brain Surgery" prize, earned for answering 21 questions at the site.

Fellow physicians can show that they concur with the advice offered by clicking "Agree," and users can show their appreciation with a "Thank" button. These clicks bring recognition to the contributors, too. Receiving 25 thanks gives a doctor a "Doogie Howser Award"; for 50, it's a "Dr. Heathcliff Huxtable Award."

Here's an example of a question on HealthTap: "What does it mean when ur right side of ur body goes num?" The top-rated answer last week was as follows: "Stroke is likely. If that occurs at any time, anywhere, immediate emergency room evaluation should be done and the person should get there by ambulance. The earlier the intervention the better the result." Five other doctors agreed.

By participating, doctors who want to attract new patients have a chance to gain visibility. When searching for answers to a particular question, users can add a geographic filter, narrowing the search to doctors who are nearby. But doctors who already have busy practices and can't accept new patients are less likely to be interested in participating on the site.

HealthTap started its Web site last May. It says that it has signed up more than 9,000 physicians and that it is adding 100 a day. The site does not carry advertising, and the company declines to comment about how it plans to generate revenue.

Aside from the badgelike awards, the site offers some social network features. Users can follow particular doctors and topics of interest; new answers related to these are displayed in an "activity feed" shown when users log on to the site.

"Twitter, Facebook, Quora and Zynga have invented social and game mechanics for broad markets," says Tim Chang, a managing director at the Mayfield Fund, one of HealthTap's venture capital backers. "If you can take the best of those mechanics and apply them to a single vertical, that can be very powerful."

The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a "reputation level," which is built by accumulating HealthTap awards, "Agrees" from fellow physicians and other measurable activities at the site.

Neither the doctors' specialties nor the levels are displayed next to doctors' answers, but by clicking, the curious user can see that one answer was submitted, say, by a psychiatrist listed as "Level 7 Leading" and a dissenting one from an internist who had reached "Level 14 Distinguished."

Ron Gutman, the chief executive of HealthTap, says this of its system: "In academic or big hospitals, a physician's reputation is known only to fellow physicians. At HealthTap, professional reputation is transparent to patients as well as to peers."

But patients have long been able to check on one part of their doctors' background: whether they are board-certified. That certification, administered by physician peers, requires continuing education after one collects a medical degree and license and passes a famously difficult board exam. The American Board of Medical Specialties works with 24 member boards, covering internal medicine, family medicine and specialties. It offers a Web page that makes it easy for patients to learn a particular physician's certification status.

HealthTap requires only that its physicians be licensed in the United States and in good standing — that is, not accused of malfeasance. Lamentably, it does not use board certification to establish a floor for qualifications required for physicians to participate. The company says it does not require board certification because this "is not required in the U.S. to see and care for patients."

Another worrisome aspect is the breeziness of HealthTap's answers, which are limited to 400 characters, a length hardly well-suited for providing nuanced answers to some medical questions.

A disclaimer at the foot of every page says that the site "does not provide medical advice, diagnosis or treatment."

DR. PETER W. CARMEL, president of the American Medical Association, says he is concerned about the use of online medical information, which should "complement, not replace, the communication between a patient and their physician," he wrote in an e-mail.

With online health information sites, "a medical history is not taken, a physical exam does not occur and any suggested treatment is not monitored or assessed," he said. "Using this information in isolation could pose a threat to patients."

In response, Mr. Gutman said, "We respect the A.M.A. and would welcome collaboration with them and any other forward-thinking medical organizations looking to improve the quality of care."

Many doctors just out of medical school, like other people in their 20s, are accustomed to texting as a primary mode of communication, so they may embrace HealthTap's exchange of bare-bones information. But other physicians may find the context-free, short-question, short-answer approach problematic. The Doogie Howser Award will go to others.

http://www.nytimes.com/2012/02/05/business/on-healthtap-advice-for-you-and-points-for-doctors.html?src=recg&pagewanted=print