TOW #10: Limited English Proficiency (LEP)

Hello Everyone,

As we work with our increasingly wonderfully diverse families in Seattle, we have an imperative to become experts in navigating visits with families who do not speak English as their primary language. One of our very talented gen peds faculty, Casey Lion, has developed this TOW to share her expertise and research in working with families with Limited English Proficiency (LEP). If you would like a moment of humor, check out the Jon Stewart Show's take on language barriers in medicine, (especially 2:24 to 3:03). Here are the resources for this week:

Take-home points in working with families with LEP:

1. Relevance: In the US 15% of children live with at least 1 parent who has LEP; that proportion is much higher in some areas, and it is growing everywhere.

2. Importance: language barriers are associated with decreased adherence, comprehension, and satisfaction with care, as well as poorer outcomes. We have to do all we can to prevent errors by using certified interpreters.

3. The LAW: Under Title VI of the Civil Rights Act of 1964, federal law requires providers or institutions that receive any federal dollars (including Medicaid, Medicare) to provide medical care in a language patients understand. The rule applies to nearly every hospital and private group in the country. Under the Culturally and Linguistically Appropriate Care (CLAS) Standards, we are legally required to provide professional interpretation.

4. How to know when an interpreter is needed: To determine if a patient or caregiver needs an interpreter, ask what language they prefer for discussing medical information. If they want to use a family member or friend to interpret say: “I am so sorry—hospital policy requires me to use a professional interpreter." Teach-back is an excellent strategy to use to assess for parent or patient understanding.

5. What type of interpreter form is best: patients and families tend to report equal degrees of satisfaction with in-person, telephone, and video interpretation, while providers tend to prefer in-person interpretation. All of the above work about equally well. We just need to use them. 

Enjoy getting to work with your families from all over the world!

TOW #9: LGBTQA Youth

This week's topic comes to us thanks to Dr. David Breland, one of our fabulous adolescent medicine docs, and Peter Lam. If you are interested in more on adolescent health, check out the Teenology 101 blog and specifically the LGBTQ articles. David is conducting a research study with parents of transgender youth-check it out.

Materials for this week: 1.  Case and discussion 2.  journal article summarizing practice guidelines for LGBT youth and 3. article summarizing LGBTQ youth health care preferences

Take home points for LGBTQA youth:

1. Most people who identify as LGBQTA are healthy, however, there is a disproportionate number of LGBTQA youth who face barriers to health care and mental health problems, usually as a result of sexual prejudice and lack of family/community support.

2. Recent studies estimate that somewhere between 3 and 10% of the adult population is LGBT. Estimates in teenage years are difficult because the sexual identify is evolving. Around 25% of 12 year olds feel uncertain about their sexual orientation.

3. To support LGBTQA youth, we need to be comfortable asking our patients about their sexual orientation and gender identify. Ask all adolescent patients: “Are you attracted to girls, boys, both or neither”? Asking about gender identity can be as simple as: "do you identify with being male, female, both or neither?"

4. Begin to talk to patients separately from their parents by age 11 or 12 to allow them to speak confidentially with you. Tailor the HEADSSS assessment to their age/development. In the above study on LGBTQ youth health care preferences, provider qualities and interpersonal skills were just as important as provider knowledge and experience, and the youth placed little importance on a provider’s gender and sexual orientation.

5. Recognize that LGBTQA patients have similar or elevated STI risks. We should provide counseling about safe sex and birth control to all adolescents. Female patients that identify as lesbian may still have male partners, so are at risk for STIs and pregnancy and should have PAP smears. Male patients have a higher rates of STI exposure (in King Co in 2015 exposure rate was 44% among 15-19 yo men who have sex with men).

Have a great week!

TOW #8: Immunizations

A huge thanks to our expert Doug Opel for developing materials for next weeks’ TOW on immunizations. This topic is particularly critical for us given relatively low immunization rates for WA state compared to nationally. This is a timely topic as well for back-to-school visits. Many of you may have heard about an unvaccinated child who was diagnosed with tetanus at SCH last year. Hopefully, thanks to our colleagues here, we will continue to make inroads to protect our children. Be sure to attend Dr. Opel's Grand Rounds on Sept 3rd!

Teaching materials for immunizations here: Case and discussion on immunizations and Dr. Opel and colleagues' paper about bringing up vaccine conversations

Additional resources: Responding to vaccine-hesitant parents and summary of chilld/teen recommended immunizations and a great repository of information at

Take-home points on vaccines:

  1. Immunizations are arguably the biggest success story of public health in the 20th century and the most important component of the recommended well child visit schedule. While vaccine safety has been extensively studied, no vaccine is 100% safe or 100% effective. This has contributed to the controversies around vaccines.
  2. While only about 1% of parents are anti-vaccine (choosing no vaccines), about 1/3  are considered vaccine hesitant, and the vast majority (about 2/3) are vaccine accepters.
  3. Vaccine-hesitant parents are the ones where we may have the most influence. As Doug Opel and team identified in a study in Pediatrics last year (see above), choosing a "presumptive stance" (i.e., "today your child is due for these vaccines") rather than a more collaborative approach (e.g. "what vaccines did you want to give today?") was associated with more likelihood of vaccines being accepted by parents.
  4. Vaccines, especially MMR, have been wrongly associated with causing autism. The study that first suggested this association was published in the Lancet and was eventually retracted as people recognized the poor study design and even falsified data. The lead author had his medical license revoked. Unfortunately, the repercussions of this unethical study were incredibly dentrimental and we are still dealing with them.
  5. Among the controversial ingredients in vaccines that have raised concerns are thimerosol (a preservative that was taken out despite lack of evidence that it could cause neurological problems), aluminum (an adjuvant that helps vaccines work better – concentrations are less than what a baby ingests in breastmilk by age 6 months), animal-derived gelatin (used as a stabilizer in some vaccines is objectionable to some people in Muslim faith) and aborted fetal material (used as cell strains to grow MMR, varicella is of special concern to devout Christians or Catholics – the Vatican has said parents could accept these vaccines). 

Have a great week – hopefully some of this review is useful with your vaccine hesitant parents!


TOW #7: Sports physicals

As we hit August, this is primetime for sports physicals! There has been much debate as to what should be included in routine testing and screening. Generally, we follow the AAP guidance for screening, and encourage use of the standardized tool adopted by multiple medical organizations (see below). Remember to refer to our wonderful local sports med experts if you have questions!

Teaching materials for this week: Sports Physicals Case and Discussion and a Pediatrics in Review article

Take-home points for sports physicals:

  1. In addition to routine history and physical, sports physicals should include specific questions: personal and family history, especially cardiac, bone and joint, asthma (and inhaler use), concussion or seizures, sickle cell, and infectious histories. Review weight and diet including attempted weight loss or gain, supplements to gain weight/muscle, and hydration and eating patterns. With females, review menstrual history.
  2. Cardiovascular screening is key: the American Heart Association recommends a 12-element screening tool that encompasses personal history, family history, and physical exam. This tool is incorporated into the Preparticipation Physical Evaluation, Fourth Edition (PPE-4) recommended by the AAP. A positive response or exam finding on any item should prompt referral to cardiology. A goal is to identify risk for and prevent sudden cardiac death, which happens in about 100 young athletes annually in the US. Unlike in other countries we have not adopted routine ECG due to cost and number needed to screen.
  3. Critical parts of the exam include: vision, BP, thorough cardiac exam (murmurs-do valsalva, PMI, pulses, Marfan stigmata), musculoskeletal exam (strength, ROM, functional/sport specific movements), neurologic exam (especially if previous concussion), and skin exam to look for infectious lesions.
  4. Contraindications to full participation include
  • some cardiac disease (discuss with cardiology)
  • Atlanto-axial instability (especially in Down syndrome or JIA),
  • Infectious diarrhea, conjunctivitis, or actively contagious skin lesions (e.g., HSV, MRSA),
  • Fever–increased risk of heat related illness and hypotension,
  • Acute splenic enlargement-increased risk of rupture,
  • Poorly controlled seizure disorder-especially for swimming, weight-lifting, sports involving heights,
  • Hypertension–if> 5mm Hg above 99th percentile for age, avoid heavy lifting & high-static component sports

Have a great week and enjoy seeing all of those athletes in clinic!