Vol. 204 December 1, 2018 “Why Doctors Hate Computers”

December 2, 2018

 

Digitization promises to make medical care easier and more efficient. But are
screens coming between doctors and patients?
 – Atul Gawande

I wished I had thought of this title.
I wished I had written the article in the New Yorker that went with it. (1) But, it was written by a better writer, and a surgeon no less; a proceduralist, not a cognitive doctor like us pediatricians and internists. Atul Gawande nailed the reasons for the frustrations of most doctors in dealing with electronic medical records, including graphic points of special irritation with one specific computer behemoth, Epic.

Epic is the $100 million computer software system now in place in the Partners Health Care system serving 70,000 employees in 12 teaching hospitals with dozens of different medical/surgical specialities as well as thousands of office-based providers and their staff. In Epic I have learned the 6 different ways of using 13 different tabs or, worse still, those tiny little icons stuffed into the margin of the screen to get the information I need to see the next patient in a pediatric office. As I traverse the various and varied screens I usually am exposed to too much data and not enough information. It is clear to most of my colleagues and our staff that Epic is chiefly designed as an “optimizer of insurance reimbursement”; probably one reason that large hospital systems and their associated physician networks buy it. A recent Epic “upgrade” was so devoid of any upgrade in clinical relevance that it did nothing to dissuade our view of it as a “reimbursement optimization tool”.

One of Dr. Gawande’s insight as to why doctors have some much trouble liking the new way of computer documentation of everything is that computers do not handle “surprises” very well. In seeking a diagnosis and determining treatment, not all doctor’s questions and certainly not all patients’ answers can be accurately recorded with a simple click in a box. The computer thrives on all those clicks in all those boxes. Doctors do not. We often meander around in our conversations with a patient guided by chance comments or even subtle physical clues. If we elicit a “surprise” we can pursue it much more intelligently and enlightening than the computer can document it. In Gawande’s words computer programs are “brittle, bureaucratic, inflexible, designed for large data bases, rule-based, inflexible, and very difficult to adapt”; in short, unable to handle “surprises” easily. 

Defenders of Epic view their efforts as optimization of the medical care process – “reconfiguring various functions according to feedback from users.” An Epic VP labeled that as the “Revenge of the Ancillaries”. The “users” of an MRI or a X-ray request from a doctor are radiology techs or radiology department secretaries.  The questions they want answered may have little clinical importance but have multiplied within the computer screen requisition that now requires more data entry, more reading, and more in-the-box clicking by the doctor. Some computer programs allow the doctor to delegate ordering tasks, some don’t, and some, like Epic, allow delegating some tasks but not for others. Doctors who are now embracing the delegation of tasks by hiring nurse practitioners and physician assistants are confronting computer programs which are restricting delegation.

Studies have documented that doctors spend two hours in front of a computer for every one hour in front of a patient. In response a new “delegated person”, a medical scribe, has been hired by some doctors. A medical scribe is a non-physician that observes the doctor-patient visit and enters information into the computer freeing the doctor up to maximize the face-to-face patient interaction. (In Quality Management, aka Quality Assurance or Performance Improvement, we call this a “work around” – a human adaptation to bypass a problem in a operating system.)

The Clinical Director of the Partners Epic system defends its as being “for the patients, not the doctors.” Patients gain more access to their medical records like their lab test results, their medications, summary of their visits, and increased opportunity for communication with their physicians. Patient access to their medical record is via a “patient portal”; often touted as a successful way to build a practice and be a modern practitioner. Unfortunately the patient portal has not been the slam dunk it was expected to be. It certainly has not been in our pediatric practice. “Why Are Patient Portals Such Duds?” and other recent reviews describe some of both doctor and patient barriers to their adoption.

The Clinical Director of Partners Epic takes the long view that patients will eventually use the EMR as currently hoped and hyped. We shall see, and in the meantime I hope that fewer practicing primary care doctors experience “burn out” and that fewer new medical school graduates shun primary care practice.

References:
1. New Yorker Magazine, November 12, 2018, Atul Gawande

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Vol. 203 November 15, 2018 Recent Updates

November 15, 2018

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Unsafe Toys for Christmas 2018
World Against Toys Causing Harm or W.A.T.C.H. has just released its 5th annual list of “worst toys for the holiday season” picked for their potential cause of choking, eye injury, or other safety hazard. In 2016 there were 240,000 toy-related injuries. During 2014 to 2016 there were 35 toy-related deaths. The top ten worst toys this year include:

  • Nickelodeon Nella Princess Sleeptime Pet Pillow – choking and suffocation (“DO NOT USE IN CRIB”)
  • Nerf Praxis Blaster- “rapid fire” projectiles could cause eye injuries
  • Marvel Black Panther Slash Claw – “it can actually slash”
  • Power Range Ninja Superstar Blade – “plastic chain saw that can actually cut”
  • Cabbage Patch Dance Time Doll – choking (Is nothing sacred?!)
  • Stomp Ultra Rocket – “fires up to 200 ft. in the air if not stopped by an eye”

Lower Your Prostate Cancer Risk by Riding a Bicycle
Men who did long-term vigorous exercise like biking, swimming, or running had a 25-30% less chance of developing advanced or lethal prostatic cancer. Exercise even lowered the risk for those men who have a specific genetic subtype of prostatic cancer seen in half of the deaths. “The influence of insulin, growth factors, and other metabolic factors” is thought to be the link between exercise and the lower risk according to this Harvard School of Public Health study of 49,000 healthy men between 1986 and 2012.

Many Nutritional Supplements Include Contaminants
Half of U.S, adults take some sort of nutritional supplements spending about $30 billion annually, and the FDA is prohibited by law to evaluate supplements for safety or efficacy PRIOR to marketing. The FDA can issue post-marketing warnings about adulterants. One study from 2007 to 2016 identified 776 supplements, mostly for sexual enhancements, weight loss, or muscle building, with either adverse events or consumer complaints,. Of the 28 products that had received two or more “FDA warnings” 19 continued to be sold. In another study of 21 supplements with “FDA warnings” because of one or more unapproved stimulants, 12 were still available in 2007 and 9 of the 12 still contained the same stimulants. Q.E.D.; FDA warnings have little effect in protecting consumers from potentially harmful effects of contaminants in nutritional supplements.

Does Drinking More Water Reduce Bladder Infections in Women?
Yes, if they had 3 or more bladder infections in the previous year and are drinking LESS than the recommended 1500 ml. (4 water bottles) a day. If they doubled the amount of water to 3000 ml. (8 water bottles) a day the reoccurrence of a bladder infection is reduced from 3.2 a year to 1.7 a year (at least in Bulgarian women). If they were already drinking over the 1500 ml. minimum a day increasing the amount had no effect on recurrence. [All the U.S. women I know, at least in Barnstable county, take a bottle of water with them when they’re just going to the post office.]

One-half of Obese Adolescents Started Being Overweight When 3 – 5 Years Old (at least in 50,000 healthy German children)
Most of the children who were obese at age 6 were obese as adolescents. Rates of obesity were higher in children with overweight or obese mothers. “It is an ominous sign that the number of American children with the most recalcitrant forms of obesity has increased progressively during the past 10 years.” This study suggests that physicians should start nutritional counseling if exaggerated weight gain occurs after age 2! (NEJM October 4, 2018)

Do Not Use Infant Walkers
Despite the fact that the American Academy of Pediatrics has long called for infant walkers to be banned in the U.S. as they are in Canada, infant walkers are still sold here. An average of 9,000 infants a year under 15 months of age are treated in our ERs with head or neck injuries when infant walkers go down household stairs with an infant in them. The AAP says that “there is no advantage of the walker to the infant and parents should not use them.”

A Chilling Aftermath of Our Latest Gun Violence
A friend of mine has a brother who worships at that Pittsburgh synagogue. He was not there for the October massacre, but sat Shemira (literally a bodyguard) for a member who was. After Shemira the brother called my friend to say that he had bought a gun and obtained a carry permit. My friend was incredulous, and asked him, “When are YOU going to carry a gun?” His brother’s answer, “Only when I pray”.

A Prayer for Our Times
The mid-term elections are over, but the political hyperbole and acrimony, especially from the President to the press, is not. On Veterans’ Day we sang “America the Beautiful” in church, and I was struck by the relevance of the unappreciated second verse:

“America! America! mend thine every flaw,
Confirm thy soul in self-control, thy liberty in law.”

Have a Happy Thanksgiving.


Vol. 202 November 1, 2018 Happy Halloween

November 1, 2018

Hub thumbnail 2015 It is the day after Halloween, so I wanted to write a scary blog, and I couldn’t think of anything scarier than a massacre of 11 praying people by someone with an semi-automatic assault rifle.

The Valentine’s Day Massacre of 1929 (only 7 dead)  resulted in a 1934 law restricting the sale, registering the owner (including fingerprints), limiting the transport, and  setting up a federal government record of Tommy guns.  The whole process of buying a Tommy gun took about 4 months.   The law (it was not a ban) worked for Tommy guns. They became too expensive, too scarce, and too much of a hassle to own, and they have  disappeared from our everyday life. Maybe that law happened because a majority of people regarded the Chicago mobsters as criminals.

So why not pass effective federal restrictions on the sale and ownership of assault rifles? Let’s acknowledge that people who use them to kill other people are just criminals.  Lets stop all the noise and emotional overlay about the shooter’s motives and background. Just call him “a criminal” and restrict access for future criminals to his weapon of choice. Such assault rifle restrictions (not a ban) might, at least, successfully reduce the body count for any one particular future rampage. There are plenty of other kinds of guns around that the mentally deranged, political extremist, terrorist, or even just a ticked-off jilted lover can use, so no one’s constitutional right will be abridged.

On the other hand, the October 2018 Philadelphia synagogue massacre somehow doesn’t seem all that scary. After all, we have had similar massacres in night clubs, Southern churches, rock concerts, movie theaters, and elementary schools. Some of us may have kind of “gotten used to it”. Sort of like that old story of the frog sitting in a pot of water getting hotter and hotter on the stove burner, and the frog, not sensing the heat increase by degrees, just sits there until he is boiled up.

By Degrees” is a song written by Mark Erelli that relates that “frog in hot water” story to our epidemic of gun violence. Other famous singer-songwriters, Rosanne Cash, Sheryl Crow, Josh Ritter, Lori McKenna, and Anais Mitchell join him in singing it. Gabby Giffords: Courage to Fight Gun Violence is helping to distribute it as a digital copy. You can go to www.bydegreessong.com to download it while you watch a video of the lyrics. All of the $4.69 and any additional money you wish to donate goes directly to the Gabby Giffords fund.

Go to the By Degrees website, and click the “GET THE SONG” button. This will take you to Giffords’ Act Blue donation page, where you can pay any amount you like for the song, and you will immediately receive a thank you email with a link to download the track.

BY DEGREES by Mark Erelli
When I take a look around me sometimes I wish I was blind
Feels like something sacred’s dying, one headline at a time
I can’t tear myself away, no I just stare in disbelief
You can learn to live with anything when it happens by degrees

I’ve seen every head bowed down as if lost in private prayer
I’ve seen the phones in every hand, seen the long and vacant stares of souls gone numb,
thumbing through each ceaseless, changing feed
You can learn to live with anything when it happens by degrees

I’ve seen talking heads shout back and forth across some great divide
Against a map of red and blue, points of view so cut and dried
But when you look into the mirror what color country do you see?
Where you can learn to live with anything when it happens by degrees

I’ve seen the flags at half-staff as the nation mourned and moaned
I’ve seen the stars and bars a-flyin’ proud above the state house dome
For the Charleston nine we sing “I once was blind, but now I see”
We can learn to live with anything when it happens by degrees

I’ve seen little hands on little shoulders, children in a line
I’ve seen them led away from school as the shots rang out inside
And I thought something had to change but somehow it’s become routine
We can learn to live with anything when it happens by degrees

I’ve seen sadness seep into my heart, each day a little more
This darkness growing so familiar, I can’t recall what came before
My children’s faces filled with questions, looking up expectantly
And I don’t know what to tell them
I can’t bring myself to tell them
That you can learn to live with anything when it happens by degrees.

As Mark says, “I am under no illusions that my song will solve the problem of gun violence. But I have seen what doing nothing does and want to do something. I’m a songwriter and musician, so I did the only thing I knew how to do, as good as I could do it. I appreciate your support and urge you do what you can to support the cause against gun violence.

AND DON’T FORGET TO VOTE!


Vol. 201 October 15, 2018 Medical Facts and Fantasies?

October 15, 2018

Hub thumbnail 2015A baby aspirin a day does not necessarily keep the doctor away.
Daily low dose (81 mg. or a baby tablet) aspirin protects you from having your SECOND heart attack, not your first one. Another recent study confirmed that aspirin gives no such protection to someone who has a normal heart history. A baby aspirin is of NO benefit for primary cardiovascular disease prevention. (Despite these repeated studies many of us continue on our merry way of taking a daily baby aspirin in hopes of preventing “the big one.” )

Ritalin is apparently better than nothing . . . and lots of other things.
ADHD (Attention-Deficit-Hyperactivity-Disorder) in school children is not helped much by non-drug therapy. A 2011 review of 54 studies showed little lasting effectiveness of neurofeedback, child behavioral training, parent training, cognitive behavioral (“talk”) therapy, dietary changes, or herbal and Omega fatty acid supplements when compared to the usual psychostimulant drugs like Ritalin. (This lack of evidence of any benefits from non-drug treatment of this common condition is disappointing. The reviewers themselves call for additional studies.)

There’s An App For It – Among things that your smartphone can do are:

  • Record and transmit a electrocardiogram of your heart rate and rhythm.
  • Ask questions to determine whether you are slipping into a depression, and send a text message to your therapist.
  • Have a trained counselor call you within an hour of you opening up a bluetooth equipped HIV self-test kit to interpret the results for you.
  • Adjust the volume and sound characteristics of the hearing aid in your ear.
  • Operate an automatic pill dispenser filled with your daily medications.
  • Give you a “text neck”. The 60 degree angle of your neck as you text puts about 60 pounds of strain on your spine. (That’s the equivalent of 4 bowling balls).
  • Measure, record, and transmit your blood pressure or blood glucose level.
  • Give you an inaccurate pulse oximetry reading if using a non-FDA approved monitoring app. (In fact, the FDA faced with the existence of about 400,000 health and wellness apps has decided to review 20 apps a year that are directly related to gathering and transmitting clinical data. – FitBits are not included in that category)

Got your flu shot yet?
This year the CDC is recommending the quadrivalent flu vaccine for everyone over 6 months old who does not have a medical contraindication. No particular vaccine brand is recommended over the others. People with egg allergies can safely receive any of the vaccines. ( The Bill and Melinda Gates Foundation is pouring money into research efforts to reduce the potential effects of one of their greatest fear, another flu pandemic.)

Parents know best.
Children sleep better if fed earlier in life. Official pediatric policy used be to start solids at 6 months. Many parents think that starting at 3 months causes longer sleep periods and less sleep problems. A study of 1300 breast-fed infants in England and Wales showed that the parents are right. Duh! (Pediatricians used to recommend starting certain solid foods at even a later age because of potential food allergies. That is no longer true.)

The “other shoe” on probiotics.
The current wisdom that “probiotics are harmless and can benefit everyone” is not necessarily true. The exploding volume of research on our “microbiome” (the bacteria in our intestines) reveals that the bacterial mix in our intestines is unique to each individual (like a fingerprint) and is “good” for us in its natural state. Probiotics can change that mix, and one study shows that some of us have guts that are not only “resistant” to probiotics, but that alteration of our natural mix by probiotics could delay recovery from some illnesses.

Why your visit to your doctor’s office isn’t the same as the “old days”.
It is estimated that a typical primary care physician needs 22 hours a day to address all of the preventive, acute, and chronic needs of an average patient panel of 2,500 patients. This includes all of the insurance-prescribed, electronically embedded (in the electronic medical record – EMR) quality measures tied to the reimbursement of the physician. (This is one reason we patients are filling out more questionnaires, clicking on more boxes on a screen, and spending more time with nurse practitioners and physician assistants when we go to the doctor’s office. “The doc can’t do it all any more.”)

Watch out. More un-immunized children are on their way to school.
A 2017 CDC telephone survey indicates that about 100,000 children in the U.S. born in 2015 and 2016 have not received vaccination against the 14 disease for which shots are recommended. This is an increase from a similar study of children born in 2011.

Too fat? Just take a pill. . . A new kind of pill.
A capsule with a long thin plastic tube is swallowed by the patient. Once in the stomach air is pushed down the thin plastic tube, the capsule expands into a balloon filling 1/3 of the stomach, the patient has sensation of having a full stomach, and the thin tube breaks off and is withdrawn. In about three months the stomach balloon disintegrates, deflates, and is passed out in the stool. It has been approved in Europe and is being tested in the U.S. hoping for FDA approval in 2020. Another start-up company is hoping that their capsule filled with gel that expands in the stomach juices and accomplishes the same thing will also be approved. ( The gel-filled capsule is a bit of deja vu for me. As a chubby pre-teen trying to lose weight, I remember taking a tablespoon of “weight-loss powder” a half-hour before a meal, waiting to let it expand in my stomach, and feeling less hungry  so I ate less. I forget its name, but I do clearly remember the time I was in a particular hurry, ate too soon after the dose, and promptly emptied my over-filling stomach onto my shoes.)

A timely tip for women.
With all the surprise disclosures of “good men” exhibiting past sexual harassment acts and even sexual assaults, how can a woman feel confident that the man she is with is not the aggressive type? A recent study suggests you can just look at his hands. The shorter the index finger is compared to the ring finger, the more aggressive the man may be. This is from a study of 300 Canadian men and women. No correlation of personality to finger lengths was found in women. Researchers associate this finding with “the amount of testosterone that babies are exposed to in utero”. ( Or could it be related to being born North of the 49th parallel?! )


Vol. 200 October 1, 2018 “Memories Are Made Of This” (apologies to Dean Martin)

October 1, 2018

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The man [or woman] with a clear conscience probably has a poor memory. ~Author Unknown

 

 

He said. She said. Which one has the correct memory? That’s a very good question . . . and there are a variety of answers.

Before the memory is made, of course, perception has to occur. As the police, lawyers, and judges know, perceptions of the same event can vary considerably between witnesses. Much has been written about the unreliability and inaccuracy of eyewitnesses to a crime. Extreme stress during a criminal act, presence of weapons, brief time durations, racial disparities, and lack of significant physical characteristics are some of the causes of much different perceptions. But some of it is due to how our brain works.

As an example of perceptual differences in viewing even non-stressful events click here and watch a video of an attentiveness test. It is a variation of the famous 1999 “Invisible Gorilla” perception test.

In the recent confirmation hearing of a Supreme Court judge dominating our current media only the two principals will be telling their story. Since he denies the event as described by her, and no eyewitness is available, we are back to the reliability of memories.

Memories are thought to be reconstructed like a puzzle rather than being played back like a videotape. Other people questioning the memory, challenging details, asking for repeated retelling (as in the “telephone” party game), or unintentionally giving non-verbal clues can actually alter how the puzzle is reconstructed. Police line-ups as a way of identifying criminals has long thought to be rife with such errors.

False memories have intentionally been created in experiments where researchers present to a number of adults four stories of their own early childhood. Three are true memories. The false story contains some true, irrelevant, but known to the reader, details provided by relatives. Each adult is asked to add any other details they can remember to the stories. In the end one-third of the adults believed that the false memory was true. In follow-up interviews 25% still felt that the false memory was true. This, of course, was a highly structured, experimental manipulation not easily mimicked in real life, but it shows that false memories can be created by outside influences.

Mitchell Garabedian, the lawyer that represented victims of Catholic clergy sexual abuse feels that victims often come forward because they feel obligated to for the sake of others. He also notes that both persons believe wholeheartedly that their memory is true, so that both will appear to be equally credible. (1)  This suggests that lie detector test results are irrelevant to characterizing memories as either true or false.

The debate about whether recovered memory in child abuse cases is false or true flared to a peak in the 1990’s. “Recent debates between differing schools of scientific thought, fueled by the media and by lay organizations with varied political agendas, have left the public confused and misinformed regarding the nature of traumatic memories” – ( this was writtenin in 1994!)  In an effort to reconcile the differences of scientific opinion of recovery memory in child abuse cases, a national symposium of all kinds of experts with all kinds of theories was convened in 2012. It did not produce a consensus, but it did produce a 255 page book that you are welcome to read.  (Full disclosure by my true memory: I did not read the whole thing)

“Emotional arousal appears to increase the likelihood of memory consolidation during the retention (storage) stage of memory (the process of creating a permanent record of information). A number of studies show that over time, memories for neutral stimuli decrease but memories for arousing stimuli remain the same or improve. Others have discovered that memory enhancements for emotional information tend to be greater after longer delays than after relatively short ones. This delayed effect is consistent with the proposal that emotionally arousing memories are more likely to be converted into a relatively permanent trace, whereas memories for non-arousing events are more vulnerable to disruption. Several studies have demonstrated that the presentation of emotionally arousing stimuli (compared to neutral stimuli) results in enhanced memory for central details (details central to the appearance or meaning of the emotional stimuli) and impaired memory for peripheral details.  A few studies have even found that emotionally arousing stimuli enhance memory only after a delay.”

We know from PTSD studies that traumatic memories can be either haunting or forgotten. Traumatic memories that are a single event, involve an adult victim, and receive validation and support are more apt to be retained as a “continuous memory”. (i.e.; a rape, assault) Trauma that is repetitive, involving a child victim, and is followed by denial and secrecy is more apt to produce “disassociation/amnesia” (i.e.; incest, abuse, torture).

After reading this you may still be uncertain about who has the correct memory, as well as being undecided about whether the Senate Judicial Committee hearing was a kangaroo court or not. “A kangaroo court is a judicial tribunal or assembly that blatantly disregards recognized standards of law or justice, and often carries little or no official standing in the territory within which it resides. The term may also apply to a court held by a legitimate judicial authority who intentionally disregards the court’s legal or ethical obligations. A kangaroo court is often held to give the appearance of a fair and just trial, even though the verdict has in reality already been decided before the trial has begun. This could be because of the biases of the decision-maker, or because the structure and operation of the forum result in an inferior brand of adjudication.”

HAVE A NICE DAY! If you do, please make sure to remember it.

References:
1. Boston Globe, Sept 23, 2018, B2, Steve Annear

 


Vol. 198 September 1, 2018 A RX for Play

September 1, 2018

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“Unfortunately both the value and the meaning of play are poorly understood in our hurried society.”
The Hurried Child, 1981

“Play for children buffers toxic stress, builds parental relationships,
and improves executive functioning.”
-The Power of Play,  2018

This month the American Academy of Pediatrics (AAP) recommended that all clinicians write a “prescription for play” for all children at each well child visit. The AAP first touted the benefits of play in 2007.  What’s new about this 2018 report, “The Power of Play”,  is 1) the compilation of 139 scientific studies supporting the benefits of childhood play, 2) the specific recommendation that clinicians give a “prescription to play” to the parents of children at every well child visit in the first two years of life, and 3) the inclusion of a list of specific parental actions and behaviors to help parents actually “fill the prescription”.

What is not new is the knowledge that play is very important for children’s cognitive (academic), social, language, and emotional development. In 1981 (almost 40 years ago!) David Elkind, Ph.D. in The Hurried Child, Growing Up Too Fast Too Soon (1) catalogued how play was one of the antidotes to the toxic stresses on our children at that time. His 1981 list of the sources of that stress on children sound still familiar to us in 2018:

  • early pressure to gain academic skills
  • early intervention to help learning in the early years (concept of “readiness” was disputed)
  •  media presentations of adult clothing and behavior as models for children
  •  changes in the traditional family model (dual-career couples, increased single parent families, single parent dating, increased divorce rate )
  • summer camps (and after school programs) becoming competitive training sites for specific skills
  • Cutting of recess, physical education (“gym period”), art, music and drama from school curriculum
  • increasing modes of passive play (no real-time human interaction; media play is passive).

“Play has been transformed into work. Perhaps the best evidence of the extent to which our children are hurried is the lack of opportunities for genuine unstructured play available to them. Genuine play involves human interaction, mostly child to child but also child to adult. Play is nature’s way of dealing with stress for children as well as adults.” – All written in 1981 by Dr. Elkind.

What are some of the specific ingredients listed by the AAP to fill the 2018 “prescription for play”? (2)

Newborn- 6 months

  • talk to your infant, mimic his or her sounds
  • make various faces at the infant so he or she can mimic you
  • let him or her put safe objects in their mouth

7-12 months

  • put infant in different positions so that he or she can view the world from different angles (“tummy time”)
  • use a mirror to show different faces to your infant
  • Peek a boo is a BIGGIE !
  • give him or her more toys to drop (teaches that actions have effects)
  • let infant safely crawl and explore freely

1-3 years

  • give paper, crayons, etc. to encourage scribbling
  • play make-believe with the child
  • read regularly to the child
  • sing and play rhythms to the child

4-6 years

  • allow child to move between make-believe and reality (pretend making biscuits and then tolerate the “spreading of flour all over the kitchen table”; if you can’t tolerate the mess, maybe change this play into ‘actions have effects’?)
  • tell stories and ask your child what she or he remembers about it
  • encourage a variety of safe physical movements (climbing, somersaults, etc.)

“Play with parents and peers is fundamentally important for developing a suite of 21st century skills in a competitive world that requires collaboration and innovation.”(3)

Dr. Elkind won me over completely when he explained why young children are entranced by dinosaurs; something that has perplexed me for years.
“Dinosaurs provide children with a symbolic and safe way of dealing with the giants in their world, namely adults.” (pg. 196)

Refernces:
1. Also “The Power of Play, Learning What Comes Naturally”, 2007, David Elkind, Ph.D
2. from www.pathways.org
3. Michael Yogman, MD, lead author of The Power of Play, AAP, 2018


Vol. 197 August 1, 2018 GMO Tomatoes?

August 1, 2018

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“ The sad reality is that industry is not really committed to making a better tasting tomato.”
– Harry J. Klee, Ph.D., University of Florida

 

It’s August on Cape Cod, and I have yet to taste a big red luscious locally grown tomato! How long do I have to settle for the bland, tasteless, but very red (they gas green tomatoes with ethylene to turn them red) commercially grown ones?! Is there any hope for a better tasting commercial tomato?

GM (genetic modification) has been going on for centuries through selective breeding and artificial selection by the hands of mankind to improve plants and animals. Pre-Columbian natives, by selecting and re-planting those wild scrubby plants that had bigger, redder, and more fruits, started the development of the beefsteak heirloom tomato we know today. There is probably no vegetable or fruit that we eat today, including corn, soybean, and potatoes, that is not the result of mankind’s genetic selection over thousand of years.

But now those initials, GM or GMO, spark great controversy because scientists can do the genetic selections in a much shorter time in the laboratory. The initial GMO crops introduced by Monsanto in the 1990’s were “transgenic” products;. foreign DNA, even from other species, was introduced or “spliced” into the genes of plants to make them more resistant to Monsanto’s herbicides. Corn and soybean which could thrive in the rain of a new, “more effective” herbicide ignited wide-spread concern and speculation about the long-term effects of the “foreign DNA” GMO crops.

In the same year of 2012 the Tomato Genome Project completed its listing of the 900 million DNA base pairs on 12 chromosomes of the tomato AND a gene-cutting technique dubbed CRISPR  was first described.  Scientists from three universities  published their CRISPR research separately in the same year. UC Berkley , MIT, and Harvard continue the legal battles over the patent rights which will be worth billions. CRISPR is basically a pair of biological scissors that allow scientists to precisely snip and delete part of a gene. It is referred to as “gene-editing”. It is not “transgenic”. No “foreign DNA” is involved or inserted.

For example, for the past 60 years growers have been trying to develop a “jointless” tomato. The classic tomato plant develops a swollen knuckle of tissue in its stem just above the fruit. When the tomato is ripe, the stem knuckle gets a signal from the plant for its cells to die, the stem breaks at this “joint”, and the tomato falls to the ground to happily spread its seeds and make new plants. The problem for the tomato grower who is mechanically harvesting tons of tomatoes is that the residual long stem pierces lots of other tomatoes in the picking process. The damage makes them unsellable. By CRISPRing the gene responsible for the knuckle and deleting it, a “jointless” tomato plant results in a bigger, undamaged crop, and more money for the grower.

Other CRISPR experiments are aimed at developing “self-pruning” tomato plants that are half as tall, less bushy, and with more fruits. Some experiments hope to develop plants that flower earlier, that ignore daylight clues, that require a smaller footprint, and that space their fruit on a stem like an accordion. If you discern that these efforts are all aimed at improving the tomato’s financial return in the market place, you are right. One cynic has stated that the “perfect tomato will be one that exactly matches the size of a MacDonald hamburger… A better tasting tomato always plays second fiddle to market economics.”

CRISPR is great at knocking out or deleting genes. It edits genes. The US Department of Agriculture has determined that crops developed with gene editing mutations are “indistinguishable” from those produced by traditional breeding and “do not require regulatory oversight”. It is a long way from the research lab to the market place via the three agricultural mega-conglomerates, but a variety of start-up companies are developing CRISPR-like technologies for getting cheaper, and maybe better tasting, gene-edited produce to market.

So, just when you hoped that life would be getting simpler and choices might become fewer, you now have to ask yourself a new question, “If it’s GMO, is it transgenic (jury is still out) or just gene-edited (approved)?” Although we may be a long way from getting commercially grown tomatoes that taste as good as our locally grown beefsteak heirlooms, do not fear, CRISPR may soon produce a gluten-free wheat!

Reference: “Tomorrow’s Tomato”, Stephen S. Hall, WIRED, August 2018, pg.053-061


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