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My plea to corporate America to help us stop the spread of COVID-19

My plea to corporate America to help us stop the spread of COVID-19

Some of America’s biggest companies should consider leveraging their logistical capabilities—from using drive-thru windows for screening to turning megastores into diagnostic and treatment centers—as part of their corporate social responsibility, during these dire times.

Dear CEOs of McDonalds, Apple, Nike, and Marriott:

As you probably know, the success of both China and South Korea in decreasing the number of new cases of COVID-19 required both social distancing but also widespread testing and isolation of confirmed cases away from their homes. In other instances, testing even more aggressively made a big difference, and the World Health Organization now strongly recommends expanding COVID19 screening as well as isolation. Italy may have waited too long to implement crucial measures and North America has lagged behind for some time: estimates show that the US is now less than two weeks behind Italy and extremely behind in COVID-19 testing.

Testing is not widely available in the US and Canada, with the spread of misinformation leading symptomatic people to head to their local hospital or family doctor to try to get tested (with limited success while overburdening the system). It’s even more dire knowing that, in New York City for instance, an estimated 80% of ICU beds may already be occupied.

As powerful corporations, I hope you consider leveraging your own logistical capabilities, as part of your corporate social responsibility, during these very dire times—particularly in hotspots like Seattle, San Francisco, Toronto, Vancouver, and New York City. Here are some suggestions for what you can do during these perilous times.

Over the past week, McDonald’s announced they are closing seating. There are over 14,000 McDonald’s in the US alone, most of which have drive-thru windows.

So, my first idea involves pausing fast-food manufacturing for a few weeks in some of these outlets and using the existing drive-thru infrastructure for in-person fever screening (window 1) and COVID-9 throat swabs (window 2, if fever is present). These could be staffed with local nurses (wearing personal protective equipment, or PPE) who might typically work in community clinics that are currently closed. The brand recognition of McDonald’s means that most North Americans would easily be able to locate their nearest franchise. These would effectively serve as “Level 1” screening and diagnostic facilities for the next several weeks, with repeat testing weeks later to assess when an infection has cleared.

Second, over the past week, Apple (which has 272 stores in the US) and Nike (which has 350 stores) have closed their stores. Both of these stores, which maximize negative space and average several thousand square feet (so up to 4.5 million square feet of unused space), have design elements that may help reduce transmission during a pandemic. Some of these stores could be refashioned to serve as “Level 2” diagnostic and treatment centers, for more in-depth diagnoses and assessment of confirmed COVID-19–effectively “cohorting” positive cases together. Also, since both Nike and Apple have longstanding manufacturing relationships with China, with independent shipping and warehouse capabilities, they could help store any donated medical supplies from China and the country’s business leaders. Doctors who are not currently skilled to work in an emergency department or intensive care unit (for instance, most general practitioners) could administer the tests and basic treatment at these sites while wearing appropriate PPE, which offloads the burden on hospitals (which in turn serve as “Level 3” treatment sites for more advanced care). This could work better than military tents.

Third, China’s success in reducing transmission was in large part due to effectively quarantining cases away from their family (so as not to infect other family members). Yet building large quarantine centers, as China did, is not logistically feasible in North America. As such, now that there are fewer travelers, Marriott, which has wide reach across North America, could offer designated hotels in which to isolate the confirmed positives for 14 days to help induce “suppression.”

To be sure, North America should still follow the lead of both Britain and France by harnessing local manufacturing capabilities (which requires a Defense Protection Act), specifically for personal protective equipment like N95 masks, gloves, and gowns for first responders–this is even more crucial given the shortage. However, the bigger challenge will remain logistical. We may even end up having enough expensive equipment like ventilators (which may be used to serve multiple patients) if the milder cases are effectively identified and treated early.

I agree that “brands can’t save us” — but companies can leverage their strengths in collaboration with government. In fact, there have been countless examples from history of corporations pivoting to assist in public health challenges. The most prominent one that comes to mind is Coca-Cola. For decades, Coca-Cola offered its cold chain and other logistical capabilities to assist public health programs to deliver vaccines and antiretroviral medications, because donating money, simply put, just isn’t enough.

Through innovation, you’ve been able to place a thousand songs in our pockets, boast the largest market share of footwear, become the biggest hotel chain in the world, and serve as the most popular fast food company. Facilitating widespread screening, diagnostic testing, and facilitating the safe isolation and treatment of mild-moderate cases is not an impossible feat, especially if you work together with the healthcare system. Instead of allowing your brick-and-mortar businesses to sit idle please consider pivoting towards a solution in collaboration with government, as part of a coordinated and effective pandemic response.

Time is running out.

**Originally published in Fast Company on March 19 2020**

How artificial intelligence could improve global health

How artificial intelligence could improve global health

Canadian and international initiatives aim to apply AI to help solve global health conundrums

As we grapple with the coronavirus (COVID-19) pandemic, the pattern of viral spread may have been identified as early as Dec. 31, 2019, by Toronto-based BlueDot.

The group identified an association between a new form of pneumonia in China and a market in Wuhan, China, where animals were being sold and reported the pattern a full week ahead of the World Health Organization (which reported on Jan. 9) and the U.S. Centers for Disease Control and Prevention (which reported it on Jan. 6).

Dr. Kamran Khan, a professor of medicine and public health at the University of Toronto, founded the company in 2014, in large part after his experience as an infectious disease physician during the 2003 SARS epidemic.

The BlueDot team, which consists largely of doctors and programmers, numbering 40 employees, published their work in the Journal of Travel Medicine.

“Our message is that dangerous outbreaks are increasing in frequency, scale, and impact, and infectious diseases spread fast in our highly interconnected world,” Khan wrote via email. “If we want to get in front of these outbreaks, we are going to have to use the resources available to us — data, analytics, and digital technologies — to literally spread knowledge faster than the diseases spread themselves.”

In the past, BlueDot has been able to predict other patterns of disease spread, such as Zika outbreak in south Florida. Now its list of clients includes the Canadian government and health and security departments around the world. They combine AI with human expertise to monitor risk of disease spread for over 150 different diseases and syndromes globally.

BlueDot, as a company, speaks to the emerging trend of using AI for global health.

In India, for instance, Aindra Systems uses AI to assist in screening for cervical cancer. Globally, one woman dies every two minutes due to cervical cancer, and half a million women are newly diagnosed globally each year: 120,000 of these cases occur in India, where rates are increasing in rural areas.

Founded in 2012 by Adarsh Natarajan, the Aindra team recognized that, in India, mortality rates were high in part due to the six-week delay between collecting samples and reading pathology during cervical cancer screening programs. It was also a human resources issue: in India, one pathologist is expected to serve well over 134,000 Indians.

With the aim of reducing the workload burden and fatigue risk (misdiagnosis rates can increase if the reader is tired and overworked), Aindra built CervAstra. The automated program can stain up to 30 slides at a time and then identify, through an AI program called Clustr, the cells that most appear to be cancerous.

The pathologist then spends time on the flagged samples. Much like traditional global health programs, Aindra works closely with several hospitals and local NGOs in India, and hopes their technology may later be adopted by other developing countries.

“Point of care solutions like CervAstra are relevant to a lot of countries who suffer from forms of cancer but don’t have infrastructure or faculties to deal with it in population based screening programs,” Natarajan says.

Natarajan also points to other areas where AI is relevant in global health, such as drug discovery or assisting specific medical specialists in areas like radiology and pathology. Accenture was able to use AI to identify molecules of interest within 10 months as opposed to the typical timeline of up to 10 years.

The Vector Institute, based in Toronto, is also plugging into the potential of AI and global health. It works as an umbrella for several AI startups, some with a health focus and all aiming to have a global impact.

Melissa Judd, director of academic partnerships at Vector Institute, points to the United Nations’ sustainable development goals as a framework upon which to help orient AI towards improving global health. Lyme disease, for instance, is a global health issue that also comes up against the topic of climate change, and recently a Vector-supported AI initiative was able to identify ticks that spread of Lyme disease in Ontario.

Last December, the Vector Institute launched the Global Health and AI Challenge (GHAI) — a collaboration with the Dalla Lana School of Public Health to engage students from across the University of Toronto (from business to epidemiology to engineering) in critical dialogue and problem solving around a global health challenge.

The potential of AI for global health is immense. Major academic journals are also taking note. Last April the Lancet launched the Artificial Intelligence in Global Health report. By looking at 27 cases of how AI has been used in healthcare, editors proposed a framework to help accelerate the cost-effective use of AI in global health, primarily through collaboration between various stakeholders.

As well, a recent commentary in Science identified several key areas of potential for AI and global health, such as low-cost tools powered by AI (for instance an ultrasound powered through a smartphone) and improving data collection during epidemics.

Yet, the authors caution against seeing AI as a panacea and emphasize that empowering local, country-specific, technology talent will be key, as inequitable redistribution of access to AI technology could worsen the rich-poor divide in global health.

This warning aside, Khan with BlueDot is optimistic.

“We are just beginning to scratch the surface as there are many ways that AI can play a key role in global health. As access to data increases in volume, variety and velocity, we will need analytical tools to make sense of these data. AI can play a really important role in augmenting human intelligence,” Khan says.

**Originally published in CBC News**

Uncertainty in a Time of Coronavirus

Uncertainty in a Time of Coronavirus

Here’s why communicating public health risk during an epidemic is so challenging

Ann, a friend and mentor in her 50s, exclaimed over coffee at the end of January: “You know, Amazon is sold out of medical masks. You just can’t get any now. But I’m going upstate this weekend, so I should have better luck there.” I looked at her quizzically. At the time, the World Health Organization (WHO) had not yet announced that the newly named disease COVID-19 (formerly known as 2019-nCoV), caused by the virus SARS-CoV-2 (or simply “coronavirus”) was a Public Health Emergency of International Concern (PHEIC), but this announcement was delayed for several days. Besides, masks should only be reserved for people with symptoms.


Ann is an intellectual, someone who doesn’t easily head into panic mode (this helped her in her law career immensely, and later as a CEO and business leader). But in that moment, she had made up her mind: the masks would be a prudent thing to purchase, despite the lack of indication that they were needed. Effectively, Ann was hedging on the idea that, with the messages she received through the media and her friends, it would be better to be more conservative and overly prepared for the worst, given the potential consequences of being underprepared.

It immediately struck me that, despite being trained in both epidemiology and medicine, I wasn’t entirely sure what to advise Ann at the time: the messages I had received, and articles I had read, were no more consistent. There was still much uncertainty around the coronavirus in terms of how serious it was projected to be and what ordinary citizens could do to minimize risk. We all make decisions every day despite uncertainty, and when emotions come into play it can make things trickier.

But when it comes to public health, where the risks of sending the “wrong” message can have devasting consequences—unnecessary anxiety on the one hand (which can take an immense psychological toll) and thousands of unnecessary deaths on the other. To me, one thing is clear: the messaging around coronavirus thus far has been far from ideal, which suggests that uncertainty in a public health emergency is a wrench that can have devastating consequences if it isn’t harnessed appropriately.

Coronavirus is a moving target, as most epidemics are. As a Canadian, I watched with curiosity when Canadian airports decided on January 17 not to screen travelers for coronavirus (the effectiveness of screening is debatable, but the U.S. had already mandated it). But this then changed a mere one day later. The messaging was all over the place: “We thought it wasn’t necessary, but oops, now it might be.” Initially, the WHO wasn’t as concerned: the information and data about coronavirus wasn’t enough to call it an “emergency,” perhaps in part because the institution was reliant on a whole host of assumptions, such as the accuracy of data from China, a country not exactly known for transparency (with some noting the government may have purposely misled the public).

Gradually, the WHO became more concerned, finally on January 30 labelling coronavirus as a PHEIC, which implies a seriousness and a whole other set of other measures should be taken. Now countries as far and wide as Italy, Iran, Korea, and Spain are reporting a high concentration of cases. As of Wednesday, February 26, over 2,700 people had died worldwide from coronavirus since December and over 81,000 were infected globally. To put that in perspective, the SARS epidemic of 2003, which began in November 2002, infected over 8,000 people and led to 774 deaths in a period of six months.

Today the core messages remain unclear. For instance, the WHO has refused to officially advise no travel to China, but the U.S. State Department made this advisory earlier this month. For weeks we also received mixed messaging about human-human transmission, which is now clear, and more disturbingly that it can occur even when someone isn’t symptomatic (though it is rare). Even epidemiologists had trouble deciding how bad it really is. One reason is that a traditional data point in epidemiology, the R0 value, which is the average number of people an infected person is expected to transmit a disease to, is limited in its predictability.

Still, several doctors and public health professionals have taken to social media to remind the world that the flu kills more, as an attempt to dissuade fears, but COVID-19 is more severe, not just in its the ability to send more affected persons into intensive care (like SARS), and that it can kill even young and healthy hosts (as opposed to the more vulnerable who are more affected by the flu), and by most accounts has a higher case fatality rate (the proportion of those with the virus who die), somewhere around 2 percent (though this rate may be lower—0.7 percent—outside of China’s Hubei province) compared to the flu (which has a case fatality rate of around 0.1 percent).

All of this whiplash points to one perhaps uncomfortable thing: no one really knows how bad COVID-19 is, and how much damage it could eventually lead to. We know from postmortems of how SARS and Ebola were approached—both epidemics that provided an opportunity for bodies like the WHO and the Centers for Disease Control to learn from (the CDC provided a report on their Ebola response, and the WHO released a report on outbreak communication immediately after SARS)—that waiting too long to sound the alarm can be disastrous. We also know that the early predictions were based on assuming that China was being transparent and honest about their situational assessment, something we now understand was not the case.

I recently spoke with Kathryn Bertram, of the Johns Hopkins Center for Communication Programs (JHU CCP), who pointed me to the extended parallel process model as a helpful starting point to examine public health messaging during an epidemic. It considers both our rational reactions and emotional reactions (primarily fear) to help determine the best course of action for behavior. On the rational end, we must ask ourselves about “efficacy”—this refers to the effectiveness of a solution (for instance wearing a face mask or avoiding travel to China) and well as our perceptions on how as individuals we can institute this solution effectively. On the emotional end, we ask ourselves about the severity—how severe might it be if we, as individuals were infected, as well as susceptibility (how likely we might contract it).

Herein lies the issue: the perceived threat rests largely on the information we receive from experts. If the threat is high, we make decisions to take protective action. If we are told that the threat is low or even trivial, we are less motivated to protect ourselves even if we have the resources to do so. When an epidemic is underway, uncertainty can create fertile ground for mixed messages and inconsistency, which in itself can breed mistrust and fear.

Reflecting back to my conversation with Ann, I’m reminded of Annie Duke’s book Thinking in Bets, in which she makes a persuasive argument that, as individuals, we’re often required to make decisions based on having incomplete information. Duke uses the analogy of poker, where decisions are made based on an uncertain future. A good decision, despite this uncertainty, rests on whether we use the right process to come to that decision.

As individuals, we also benefit from thinking back to situations where we may have chosen one way but felt if we had a similar choice again we would choose differently, so our memories play a role as well (and arguably for public health we can rely on our collective memory from other coronavirus epidemics, like SARS). She likens our decisions to bets: given the information available to us, along with our memories of how past decisions panned out, and acknowledging that some of the outcome is due to chance, what might be the best choice to make that would most likely provide the most benefit for our future selves?

Bertram underscores the core risk communication principles, which can also be applied to media covering the epidemic: communicate often, communicate what is and isn’t known clearly, and provide simple action items for individuals to take (so things like handwashing).

Similarly, public health stakeholders should communicate what is and isn’t known, coordinate messages to help ensure consistency, and perhaps most importantly, acknowledge that their views (and thus their messaging) may change quickly; thankfully more recently media organizations are choosing to express this uncertainty and a recent op-ed in the New York Times underscores many of these principles, as “people react more rationally and show greater resilience to a full-blown crisis if they are prepared intellectually and emotionally for it.” The authors also urge that we consider using the term “pandemic” (though the WHO is not yet comfortable with this).

Effectively, while the WHO still presents a hopeful view, it and other organizations played poker on a global scale—and the chips they were playing belonged to entire communities. Their decisions and messages matter, and on balance, it might be best to bet that the consequences of underestimating the severity of the pandemic may be worse than overestimating it. The alternative, which brings to mind the dog meme “this is fine,” could lead to both distrust and potentially thousands of unnecessary deaths. It seems that, despite the WHO finally conceding that COVID-19 continues to poses a “grave threat” to the world and may qualify as the long-dreaded “disease X,” the briefing yesterday remained vague and hesitant, and even domestic messaging about whether the virus is contained or spreading continues to be inconsistent. Some have even suggested we finally accept that COVID-19 may be “unstoppable.” Clearly, we’re still down a few chips.


**Originally published in Scientified American, on February 26 2020**

Worried About That New Medical Study? Read This First.

Worried About That New Medical Study? Read This First.

There’s more than meets the eye — here are some tips to help avoid confusion.

In August 2019, JAMA Pediatrics, a widely respected journal, published a study with a contentious result: Pregnant women in Canada who were exposed to increasing levels of fluoride (such as from drinking water) were more likely to have children with lower I.Q. Some media outlets ran overblown headlines, claiming that fluoride exposure actually lowers I.Q. And while academics and journalists quickly pointed out the study’s many flaws — that it didn’t prove cause and effect; and showed a drop in I.Q. only in boys, not girls — the damage was done. People took to social media, voicing their concerns about the potential harms of fluoride exposure.

We place immense trust in scientific studies, as well as in the journalists who report on them. But deciding whether a study warrants changing the way we live our lives is challenging. Is that extra hour of screen time really devastating? Does feeding processed meat to children increase their risk of cancer?

As a physician and a medical journalist with training in biostatistics and epidemiology, I sought advice from several experts about how parents can gauge the quality of research studies they read about. Here are eight tips to remember the next time you see a story about a scientific study.

1. Wet pavement doesn’t cause rain.
Put another way, correlation does not equal causation. This is one of the most common traps that health journalists fall into with studies that have found associations between two things — like that people who drink coffee live longer lives — but which haven’t definitively shown that one thing (coffee drinking) causes another (a longer life). These types of studies are typically referred to as observational studies.

When designing and analyzing studies, experts must have satisfactory answers to several questions before determining cause and effect, said Elizabeth Platz, Sc.D., a professor of epidemiology and deputy chair of the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health. In smoking and lung cancer studies, for example, researchers needed to show that the chemicals in cigarettes affected lung tissue in ways that resulted in lung cancer, and that those changes came after the exposure. They also needed to show that those results were reproducible. In many studies, cause and effect isn’t proven after many years, or even decades, of study.

2. Mice aren’t men.
Large human clinical studies are expensive, cumbersome and potentially dangerous to humans. This is why researchers often turn to mice or other animals with human-like physiologies (like flies, worms, rats, dogs and monkeys) first.

If you spot a headline that seems way overblown, like that aspirin thwarts bowel cancer in mice, it’s potentially notable, but could take years or even decades (if ever) to test and see the same findings in humans.

3. Study quality matters.
When it comes to study design, not all are created equal. In medicine, randomized clinical trials and systematic reviews are kings. In a randomized clinical trial, researchers typically split people into at least two groups: one that receives or does the thing the study researchers are testing, like a new drug or daily exercise; and another that receives either the current standard of care (like a statin for high cholesterol) or a placebo. To decrease bias, the participant and researcher ideally won’t know which group each participant is in.

Systematic reviews are similarly useful, in that researchers gather anywhere from five to more than 100 randomized controlled trials on a given subject and comb through them, looking for patterns and consistency among their conclusions. These types of studies are important because they help to show potential consensus in a given body of evidence.

Other types of studies, which aren’t as rigorous as the above, include: cohort studies (which follow large groups of people over time to look for the development of disease), case-control studies (which first identify the disease, like cancer, and then trace back in time to figure out what might have caused it) and cross-sectional studies (which are usually surveys that try to identify how a disease and exposure might have been correlated with each other, but not which caused the other).

Next on the quality spectrum come case reports (which describe what happened to a single patient) and case series (a group of case reports), which are both lowest in quality, but which often inspire higher quality studies.

4. Statistics can be misinterpreted.
Statistical significance is one of the most common things that confuses the lay reader. When a study or a journalistic publication says that a study’s finding was “statistically significant,” it means that the results were unlikely to have happened by chance.

But a result that is statistically significant may not be clinically significant, meaning it likely won’t change your day-to-day. Imagine a randomized controlled trial that split 200 women with migraines into two groups of 100. One was given a pill to prevent migraines and another was given a placebo. After six months, 11 women from the pill group and 12 from the placebo group had at least one migraine per week, but the 11 women in the pill group experienced arm tingling as a potential side effect. If women in the pill group were found to be statistically less likely to have migraines than those in the placebo group, the difference may still be too small to recommend the pill for migraines, since just one woman out of 100 had fewer migraines. Also, researchers would have to take potential side effects into account.

The opposite is also true. If a study reports that regular exercise helped relieve chronic pain symptoms in 30 percent of its participants, that might sound like a lot. But if the study included just 10 people, that’s only three people helped. This finding may not be statistically significant, but could be clinically important, since there are limited treatment options for people with chronic pain, and might warrant a larger trial.

5. Bigger is often better.
Scientists arguably can never fully know the truth about a given topic, but they can get close. And one way of doing that is to design a study that has high power.

“Power is telling us what the chances are that a study will detect a signal, if that signal does exist,” John Ioannidis, M.D., a professor of medicine and health research and policy at Stanford Medical School said via email.

The easiest way for researchers to increase a study’s power is to increase its size. A trial of 1,000 people typically has higher power than a trial of 500, and so on. Simply put, larger studies are more likely to help us get closer to the truth than smaller ones.

6. Not all findings apply to you.
If a news article reports that a high-quality study had statistical and clinical significance, the next step might be to determine whether the findings apply to you.

If researchers are testing a hypothetical new drug to relieve arthritis symptoms, they may only include participants who have arthritis and no other conditions. They may eliminate those who take medications that might interfere with the drug they’re studying. Researchers may recruit participants by age, gender or ethnicity. Early studies on heart disease, for instance, were performed primarily on white men.

Each of us is unique, genetically and environmentally, and our lives aren’t highly controlled like a study. So take each study for what it is: information. Over time, it will become clearer whether one conclusion was important enough to change clinical recommendations. Which gets to a related idea …

7. One study is just one study.
If findings from one study were enough to change medical practices and public policies, doctors would be practicing yo-yo medicine, where recommendations would change from day to day. That doesn’t typically happen, so when you see a headline that begins or ends with, “a study found,” it’s best to remember that one study isn’t likely to shift an entire course of medical practice. If a study is done well and has been replicated, it’s certainly possible that it may change medical guidelines down the line. If the topic is relevant to you or your family, it’s worth asking your doctor whether the findings are strong enough to suggest that you make different health choices.

8. Not all journals are created equal.
Legitimate scientific journals tend to publish studies that have been rigorously and objectively peer reviewed, which is the gold standard for scientific research and publishing. A good way to spot a high quality journal is to look for one with a high impact factor — a number that primarily reflects how often the average article from a given journal has been cited by other articles in a given year. (Keep in mind, however, that lower impact journals can still publish quality findings.) Most studies published on PubMed, a database of published scientific research articles and book chapters, are peer-reviewed.

Then there are so-called ‘predatory’ journals, which aren’t produced by legitimate publishers and which will publish almost any study — whether it’s been peer-reviewed or not — in exchange for a fee. (Legitimate journals may also request fees, primarily to cover their costs or to publish a study in front of a paywall, but only if the paper is accepted.) Predatory journals are attractive to some researchers who may feel pressure to ‘publish or perish.’ It’s challenging, however, to distinguish them from legitimate ones, because they often sound or look similar. If an article has grammatical errors and distorted images, or if its journal lacks a clear editorial board and physical address, it might be a predatory journal. But it’s not always obvious and even experienced researchers are occasionally fooled.

Reading about a study can be enlightening and engaging, but very few studies are profound enough to base changes to your daily life. When you see the next dramatic headline, read the story — and if you can find it, read the study, too (PubMed or Google Scholar are good places to start). If you have time, discuss the study with your doctor and see if any reputable organizations like the Centers for Disease Control and Prevention, World Health Organization, American Academy of Pediatrics, American College of Cardiology or National Cancer Institute have commented on the matter.

Medicine is not an exact science, and things change every day. In a field of gray, where headlines sometimes try to force us to see things in black-and-white, start with these tips to guide your curiosity. And hopefully, they’ll help you decide when — and when not to — make certain health and lifestyle choices for yourself and for your family.

**Originally published in the New York Times**

When Exercise Comes to the Hospital’s Intensive Care Unit

When Exercise Comes to the Hospital’s Intensive Care Unit

Even short hospital ICU stays can cause lasting problems for patients. Can early mobility and exercise help?

SAPNA KUDCHADKAR still remembers the morning in 2010 that shaped the trajectory of her scientific research. She was in the midst of a medical fellowship, listening carefully to the hospital’s overnight staff, as they summarized the progress of each child in the pediatric intensive care unit. The staff would comment on how well the patients had slept the night before. “In that moment, I realized that we weren’t really talking about sleep, per se, but really sedation,” says Kudchadkar.

While the terms are sometimes used interchangeably in intensive care, she says, they are not the same. Among other things, real sleep is restorative; upon waking, patients feel energized. The disruptive effects of sedation, Kudchadkar suspected, could have lasting implications for a person’s recovery and long-term health.

Knowing that physical activity enhances sleep, Kudchadkar wondered: Would her young patients do better if they were encouraged to move during their stay in intensive care? At the time, this question was already being investigated in adults, but had largely been avoided in pediatrics due to concerns about patient safety. The intensive care unit (ICU), after all, is widely viewed as a place of rest for the acutely ill or for those recovering from major surgery. And some ICU patients rely on breathing tubes, which are cumbersome and often require sedation to prevent the body from reflexively trying to remove the tubing. Getting exercise broadly into the ICU, then, would require research demonstrating that it is both effective and safe.

Two multi-year initiatives — one directed by Kudchadkar at Johns Hopkins School of Medicine, and one based at McMaster University in Canada — are now providing that kind of evidence for patients of all ages. These initiatives are part of a broader trend toward “ICU liberation.” While intensive care has improved dramatically over the decades, resulting in higher survival rates, there is now a broad recognition that survivors are not walking away unscarred. The ICU liberation movement seeks to reduce the negative effects of intensive care, which can linger for decades, and include everything from lowered muscle strength to depression and anxiety. One way to do this is to decrease sedation and encourage patients to move far sooner than they have in the past.

As with any major culture change, though, “there was some pushback early in the process,” Kudchadkar wrote in an email. Some of her colleagues worried that the new initiative might push sick patients to perform beyond their physical abilities. So she and her team worked to reassure colleagues that patients’ goals would be individualized. “There was a collective sigh of relief that we weren’t trying to get every kid out of bed walking regardless of their acuity of illness,” Kudchadkar recalls. Still, she adds, “illness doesn’t mean stillness,” the program’s catchphrase. That view, according to Kudchadkar, is now shared by a growing number of intensive care specialists across the country.

SEDATION STANDARDS for intensive care units can be traced back to the 1980s, when operating room procedures began being applied in other settings. Sedation causes the brain to take on a semi-conscious or unconscious state, and the drugs include propofol and benzodiazepines. Additional drugs called paralytics are often added to prevent the body from moving. At that time, the focus was largely on using sedation to keep a patient comfortable and able to tolerate pain, without as much regard for the negative long-term effects of prolonged sedation, says Yahya Shehabi, a professor and director of critical care research at Monash University School of Clinical Sciences in Australia.

A pivotal change came in 2000, with a New England Journal of Medicine article that discussed the benefits of interrupting sedation for a brief period each day. Over time, additional research would show that sedation has its own side effects. For one, it has been linked to cognitive issues, typically memory deficits. Additionally, bed rest can lead to muscle deconditioning. A 2014 study found, for example, that each day of ICU bed rest lowered a person’s muscle strength between 3 and 11 percent. Over one third of ICU patients were discharged from the hospital with muscle weakness, and that weakness was associated with substantial impairments in physical function lasting months, and in some cases years.

New research also points to the benefits of physical activity for people dealing with an array of conditions. In August, a systematic review and meta-analysis found that adding physical exercise to standard care may improve quality of life in everything from multiple sclerosis to Parkinson’s disease. When it comes to children, a study in the Journal of the American Medical Association showed that children and adolescents with a concussion may benefit from light activity earlier than traditionally advised. And in June of last year, a systematic review of 15 studies reported that exercise can improve attention and social behavior in children with attention deficit hyperactivity disorder, or ADHD.

Still, Shehabi issues a word of caution regarding the introduction of physical activity into critical care: “Patients who are able to mobilize usually self-select as they get better to achieve ICU liberalization,” he wrote in an email. “As such, many patients will not be able to mobilize before they have recovered substantially from critical illness.” Lakshman Swamy, a pulmonary and critical care fellow at Boston Medical Center, echoes this point: “Early mobilization is critical but difficult — and potentially dangerous without the proper systems and support.” Sick patients may be connected to medical tubes, lines, and drains, all of which can be displaced and serve as major fall risks, says Swamy. “Even one fall can be catastrophic.”

KUDCHADKAR’S INITIAL one-year study, which ended in 2015, was designed to assess the safety of a program that encourages young ICU patients to walk and play. Sydney Pearce was two-and-a-half years old and recovering from open-heart surgery when her parents agreed to let her participate. Within 24 hours of the operation, she was up and walking and driving a cozy coupe car around the ICU. “We had no idea about what the program could do,” said her mother, Ashley. While Sydney was initially reluctant to move about, the young girl soon became determined to try everything she had enjoyed before.

That study, published in 2016 in the journal Pediatric Critical Care Medicine, indicated that the mobility program was safe and appropriate for follow-up testing. As a next step, Kudchadkar is helping lead a multicenter randomized controlled trial to look at the protocol’s effectiveness. It will measure outcomes such as duration of mechanical ventilation, exposure to sedative medications, and length of stay. Johns Hopkins All Children’s Hospital in Florida, Boston Children’s Hospital, Advocate Health Care in Illinois, and Our Lady of the Lake Children’s Hospital in Louisiana are participating in the trial.

Researchers at McMaster University in Canada are also studying ICU mobility. In particular, they are examining whether “in-bed cycling” can help improve outcomes among adult ICU patients. The results of a pilot randomized controlled trial involving seven ICUs, led by Michelle Kho, a physical therapist and professor, were published last year. A larger trial involving 17 ICUs across Canada, the U.S., and Australia, now aims to compare whether adding early in-bed cycling to routine physical therapy among adults in the ICU improves physical function, mental well-being, and mortality, among other factors.

As part of the McMaster-led study, bike pedals mounted on a platform, are wheeled into the patient’s room. A physical therapist then guides the patient — who remains in bed — to use cycling as a strength and rehabilitation program. If patients are physically able, they can pedal the bike unassisted. For patients who are too sedated or weak, the motorized bike passively moves the patient’s legs. Each session typically lasts 30 minutes. “In a lot of ICUs people are on bedrest, which can lead to muscle weakness and general deconditioning,” says Kho. But thanks to the in-bed cycle’s motor, even patients who are sedated and receiving life support can participate.

Physical therapist Kristy Obrovac, who is based at a McMaster-affiliated hospital, St. Joseph’s Health Care, recalls one adult patient who used the in-bed cycle after complex thoracic surgery. The experience provided “an opportunity to focus on something positive,” she says, while offering “a sense of control in the recovery during a very challenging time.”

The in-bed cycling sessions are conducted by physical therapists and engaging them at other hospitals will be key to ensuring that the program can be replicated in different settings, says Kho. “We aren’t looking at the effect of exercise per se, but more at breaking up sedentary behaviors, and the impact that could have for ICU patients, which includes the opportunity to regain some control and hope,” says Kho.

While these new efforts are promising, it may be a few years before the field of intensive care medicine adapts to more formally include them. One challenge could be purely logistical. During the day, ICU patients undergo a range of tests, procedures, and imaging studies, plus they often have visitors. So it could be hard to find a time when clinicians and patients are ready to work on mobility, says Swamy.

Still, he views research like Kudchadkar’s and Kho’s as part of a necessary and important shift in ICU care more generally: “The way we practice medicine needs to be radically reimagined to put the patient — and patient mobility — at the center of the care plan.”


**Originally published in Undark magazine**

Resolving to Be Coached

Resolving to Be Coached

The secret to sticking with your resolutions may be having a coach to help strategize and cheer you on.

My teenage patient looked nervous as I reviewed her glucose readings from her glucometer and her glucose logbook, which people with diabetes use to track their blood-sugar test results. There were a lot of high levels — ranges in the 12’s and 14’s, when the goal was around 7 or 8. The peaks were mostly in the middle of the day and on weekends. (This was in Canada; blood glucose readings of 12 to 14 are equivalent to 216 to 250 mg/dL in the United States.)

“What do you usually eat at home?” I asked. She said that her mother was careful to make her a breakfast that balanced carbohydrates with protein. Her dinners were similar.

“What do you usually eat at lunch?” I asked. My patient started tearing up. She ate whatever her friends were eating in her high school’s cafeteria that day — like spaghetti, hamburgers or pizza, and something like a cupcake for dessert. This was probably what led to her readings being so high.

She had met with diabetes educators before, and she knew what uncontrolled glucose does to a person with diabetes, from speeding up nerve damage in the feet to hastening blood vessel damage in the back of the eyes and the kidneys, to increasing her risk of heart disease.

I knew she could have told me all of that, so lecturing her wasn’t going to help.

Instead my patient needed empathy and the tools to help her make healthier decisions, and part of that required understanding what was important to her, specifically “fitting in” with her friends in high school, the ones who didn’t have a chronic disease. It also would have involved helping her find the motivation within herself to make the change.

But my skill set for helping her was limited, especially on top of everything else I had to cover within our allotted time of 45 minutes.

Research suggests that behavioral and lifestyle factors are a big part of what contributes to chronic disease. In medical training, we learn a lot about the body and how to prevent and treat disease, but little about how we can motivate a patient to change old habits or even stick with a current management plan.

It struck me that what my patient really needed was a coach. At this time of year when many of us have made resolutions to get healthier, working with a health coach might be one way to reach those goals.

A health coach is someone trained in behavior change, who primarily uses an interview style called “motivational interviewing” to help patients see their ability to make change. While some may have clinical training in fields like nursing or medicine, they hail from a wide variety of disciplines or train in health coaching as a secondary career.

As a relatively young field, it’s still finding its footing — for instance, a systematic review found that the definitions of “health coaching” varied widely, though the authors recommended that health coaches take a patient-centered approach to help with goal setting while encouraging self-discovery and accountability.

The evidence that health coaching may spur general lifestyle changes is mounting. A 2018 study looked at clinical trials for coaching for nutrition and weight management and found that over 80 percent of these studies found improvement. And a 2017 study found that coaching can lead to increased physical activity in older adults. Studies suggest that health coaching may also provide benefits for conditions such as obesity and diabetes as well as attention deficit hyperactivity disorder, chronic pain, hypertension and high cholesterol. A recent review found that health coaching can improve quality of life and reduce hospital admissions among patients with chronic obstructive pulmonary disease, and it may help patients to become more engaged in the health care system.

It may even improve health outcomes through encouraging patient adherence to medication.

“Health coaching recognizes that we cannot help people by expecting them to act if that person is not ready to act,” said Leila Finn, a health coach based in Atlanta. “We help people take big goals and break them down into accessible, bite-size pieces — not by telling clients what to do but by helping clients figure out what will work for them.”

Health coaching gets to the heart of what providing good health care is about: acceptance, partnership, compassion, and helping patients feel respected and understood.

Though my clinical training is in pediatric medicine, inspired by what I had read, I recently completed a certificate in health coaching myself. The experience was eye-opening and humbling. I learned new ways of communicating with my patients, specifically ways to encourage them to see their own ability to make lifestyle changes while setting manageable goals. I also learned ways to cheer them on when they reach their goals, without shaming them if they relapse: Both pieces are critical to the process of making sustainable change.

While research is beginning to show the value of health coaching, the principles of communicating with the intent to inspire and motivate are transferable to all health professions — and could reap dividends if taught early on in the training of nursing students, medical students, pharmacy students, and other allied health professionals.

And when I think back to my teenage patient with diabetes, while I was empathetic, that was only half of the solution. The second half could have involved coaching her to see which small changes she could begin to make moving forward. I’m hoping that choosing my words more effectively, even within the pressures of time, may make all the difference for my other patients.

**Originally published in the New York Times**

Scam or Not? Activated Charcoal.

Scam or Not? Activated Charcoal.

Active charcoal comes in many forms: toothpaste; powders, black-colored ice-cream, or “goth lattes.” On Instagram, it is used as a prop. Medically, activated charcoal is used in emergency hospital settings, typically to absorb drugs after an overdose.

What is activated charcoal said to do?
Proponents contend that activated charcoal is a natural detoxifier of the body that can, for example, remove teeth stains and even work as an anti-aging product. After all, if it can medically detoxify the body of poisons, a smaller dose probably works too, right?

Not necessarily. Just to clarify so no one goes sprinkling charcoal in their latte: Activated charcoal is charcoal that has undergone a process in which gases like oxygen are added at high temperatures, resulting in pores that provide a high surface area that allows it to bind to other substances.

Does activated charcoal do anything?
A review in the British Journal of Clinical Pharmacology in 2015 reported that activated charcoal has pores that soak up fluid. It is often derived from burned organic substances, such as coconut shells (as in coconut ash). Dr. Mark Su, a medical toxicologist and director of the New York City Poison Control Center, said that activated charcoal worked by binding to drugs to prevent absorption in the body.

There are side effects in the emergency department setting, like vomiting or pulmonary aspiration. Activated charcoal also doesn’t work on certain alcohols. Some hospitals prefer not to use it in the emergency department and instead opt for more specific antidotes to poisonings and overdoses.

For the rest of us, our liver and our kidneys do a great job of detoxifying things on a day-to-day basis.

If optimal health is the goal, eating healthfully — plenty of green, leafy vegetables — sleeping at least seven to eight hours a day, exercising at least three times a week at an intensity where you sweat (sweat is detoxifying), reducing stress through mindfulness, journaling, and cultivating community and a strong support network are helpful habits to introduce.

Can activated charcoal harm you?

It’s possible that activated charcoal may reduce the effectiveness of certain medications like those for high blood pressure or seizures.

In New York, Morgenstern’s Finest Ice Cream, made with coconut ash, was wildly popular, but in 2018 the company was served “commissioner’s orders” from the New York City Department of Health and Mental Hygiene to stop serving it. The company complied, and the Department of Health and Mental Hygiene has continued to crack down on coconut ash, though Michael Lanza, the assistant press secretary for the department, said in an emailed statement, “Restaurants may serve foods with activated charcoal after securing approval from the F.D.A.” (Stores like Pressed Juicery still sell activated charcoal lemonade in stores outside New York, though not online, citing the ban.)

In the 1960s, the Food and Drug Administration prohibited the use of activated charcoal in food additives or coloring, but an F.D.A. spokeswoman said in an email that the ban was precautionary, as there was a lack of safety data.

What about activated charcoal in health and beauty?
The questions about the use of activated charcoal in foods have not stopped the trend of activated charcoal moving into health and beauty. A study from January 2019, which involved staining cow, goat and sheep teeth with concentrated black tea, found that activated charcoal in toothpaste was not as effective as other whitening agents like hydrogen peroxide or microbeads.

A previous review from 2017 of 118 studies found that there was not enough evidence to support the safety or efficacy of charcoal-based toothpastes and powders and that their safety hadn’t been demonstrated. On balance, given the alternatives, and the risks of ingestion, it is better to stick with safer toothpaste substances, the review suggests.

On the other hand, Dr. Su said there was no clear concern at this time about charcoal’s safety for beauty products for external use.

**Originally published in the New York Times Styles Section**

Addressing the curiosity decline in medicine

Addressing the curiosity decline in medicine

“So, if we’re worried about viral myocarditis, would the patient have similar symptoms as someone with pericarditis?” The astute medical student slipped me his question as we hurriedly made our way across the ward to the next patient’s room.

He had wondered whether inflammation of the heart muscle (as in myocarditis) presents like inflammation of the protective layer around the heart (the pericardium). Classically we are taught that pericarditis-type chest pain is better when sitting up (because the protective layer is kept away from the nerves that transmit pain) compared with lying down or when taking deep breaths.

“Well there is some overlap in clinical signs,” I began. But we were already on to the next patient, and so my attention was redirected. The student had looked eager to hear my response, but that expression quickly slipped away.

These missed opportunities, to explore and address complex questions, are frequent in medical education, and the downstream consequences of not fostering this curiosity are significant.

Curiosity is the necessary fuel to rethink one’s own biases, and it can reap dividends for patient care. When doctors think about a set of symptoms separately, they may reach different conclusions; for example one study found that up to 21% of second opinions differ from the original diagnosis.

Allowing doctors to express their curiosity is crucial and it’s time we encourage all medical trainees to be curious.

The decline in curiosity could be caused, in part, by medical trainees assuming a traditionally passive role in hierarchically organized settings like hospitals, suggests a 2011 paper, coauthored by Ronald Epstein, MD, a professor of family medicine, psychiatry, oncology and medicine at the University of Rochester Medical Center.

“There’s a dynamic tension here. People pursue medicine because they are curious about the human experience and scientific discovery, but early in training they are taught to place things in categories and to pursue certainty,” Epstein told me.

A 2017 McGill University study led by pediatrician Robert Sternzus, MD, took this theme a step further. Sternzus and colleagues surveyed medical students across all four years about two types of curiosity: trait curiosity, which is an inherent tendency to be curious; and state curiosity, defined as the environment in which the trait curiosity can survive. Trait curiosity across all four years was significantly higher than state curiosity. The authors concluded that the medical students’ natural curiosity may not have been supported in their learning environment.

“I had always felt that curiosity was strongly linked to performance in the students I worked with,” Sternzus says. “I also felt, as a learner, that I was at my best when I was most curious. And I certainly could remember periods in my training where that curiosity was suppressed. In our study the trends that we found with regards to curiosity across the years confirmed what I had hypothesized.” Sternzus has since spearheaded a faculty development workshop on promoting curiosity in medical trainees.

So what might be the solution, especially as the move towards competency-based training programs may not reward curiosity, and at a time where companies in places like Silicon Valley — which invest in curious and talented minds — position themselves to be another gatekeeper of health care?

New work led by Jatin Vyas, MD, PhD, an infectious disease physician and researcher who directs the internal medicine residence at Massachusetts General Hospital, offers one idea. His team developed a two-week elective program, called Pathways, which allows an intern to investigate a case where the diagnosis is unknown or the science isn’t quite clear. They then present their findings to a group of up to 80 experienced physicians and trainees.

“What I have found is that many interns and residents have lots of important questions. If our attendings are not in tune with that — and it’s often due to a lack of time or expertise — the residents’ questions are oftentimes never discussed,” Vyas says. “When I was a resident, my mentors helped me articulate these important questions, and I believe this new generation of trainees deserve the same type of stimulation and the Pathways elective is one way to help address this.”

At the end of June, Pathways reached the end of its second year, and Vyas recounts that resident satisfaction, clinical-teacher satisfaction, and patient satisfaction were all high. “Patients have expressed gratitude for having trainees eager to take a fresh look at their case, even though they may not receive a breakthrough answer,” Vyas says.

The job of more experienced clinicians is to nurture curiosity of learners not just for the value it provides for the students, but for the benefits it poses for patients, Faith Fitzgerald, MD, an internist at the University of California Davis, has written. Physicians of the future, and the patients they care for, deserve this.

**Originally published in the Stanford Medicine Scope Blog**

How doctors can help skeptical patients understand vaccines

In 1853, as public health awareness was growing in England, Parliament passed a law requiring all babies to be vaccinated for smallpox, a virulent and deadly disease. The vaccine, developed by physician and scientist Edward Jenner at the turn of the previous century, was an effective way of preventing smallpox. Yet, not everyone was happy about the new law.

Pockets of resistance arose quickly, and in 1867, the National Anti-Compulsory Vaccination League was founded, with concerns not dissimilar to those of today’s vaccine skeptics. The group questioned whether the vaccine might harm its recipients; they believed doctors were somehow profiting from the vaccination law; and they railed against the absence of personal choice.

Today, with the measles epidemic, we are back, effectively, to where Brits found themselves in the 19th century. But there is one big difference. Then, there was incomplete knowledge of how diseases spread and how vaccinations prevent them. Now, the issue isn’t so much a lack of information but the lack of a proper foundation on which to process information. Doctors need to help provide that foundation for their patients.

Not long ago, the father of one of my pediatric patients asked me a simple question about vaccinations: “How is giving a medication to my healthy child supposed to be a good thing?”

It was a eureka moment for me to hear that he considered vaccines to be medicines rather than what they actually are: prevention tools. A vaccine needs to be seen more like a helmet or a seat belt — preventing something from happening rather than treating something that’s there. I tried to clarify how vaccines work by using an analogy. I asked him if he read aloud to his son. He did. I likened vaccines to what happens when he repeatedly points to and identifies an object in a favorite book. Over time, his son learns what the object looks like, and when he sees it in real life, he will recognize it.

Similarly, a vaccine contains protein identifiers of the virus or bacteria it is aimed at preventing. It doesn’t have the complete virus or bacteria itself — just as a book has only a picture of, say, a zebra, not the actual animal. The immune system learns to “recognize” the identifiers, and is thus able to mount a strong response if and when it encounters the actual virus or bacteria, much as a child could recognize a real zebra in the zoo because of exposure to pictures of one.

Two other concepts doctors need to help their patients understand are causality and risk. Causality is tricky. In part, it’s a matter of timing. If your toe hurts immediately after you hit it against the door, it’s reasonable to assume the door caused it. But timing alone isn’t enough; there also must be plausibility — a rational reason to connect one thing with another. There is a rational reason, after years of study, to connect smoking to lung cancer, for example. But even though the symptoms of autism often first emerge in children at around the same age that they are being vaccinated, there’s no biologically plausible basis for a connection — any more than, say, than if a child who prefers to wear yellow every day develops autism, we could establish that yellow clothing caused the condition.

Similarly, and related to this, most of us are poor judges of risk and its role in how we process uncertainty. We fear dying in a plane crash more than in a car accident, though the latter is far more likely. With vaccines, hearing about a rare side effect, especially if coupled with an emotional element (having a close friend who shares the same fear, for example), can make the risk of being vaccinated seem far greater than the risks posed by the disease it would prevent, even though quite the opposite is true.

That said, it’s important for doctors to empathize with parents who express these fears. Whether or not a fear is fully rational, it’s real. One thing that can help is explaining not only the research behind vaccine risk, but also the rigor with which research articles are appraised and reviewed. It was that rigor that exposed, in the end, the fraudulent “research” that suggested a vaccine-autism connection. It was also scientific rigor over decades of meticulous research that has established the safety and efficacy of vaccines. And the inquiry doesn’t stop when a vaccine hits market. The Vaccine Adverse Event Reporting System is a U.S. government-sponsored safety surveillance program aimed at quickly spotting problems with vaccines. In the past, it has been able to rapidly identify potential problems, as it did with a first-generation rotavirus vaccine, for instance.

A final thing doctors might want to share with reluctant patients is something that I myself was surprised to learn: Vaccines are only a tiny fraction of pharmaceutical profit. So the argument in vaccine-hesitant communities that vaccines are promoted largely because they provide huge profits for drug companies simply doesn’t pan out.

Part of the reason there’s such a disconnect between physicians and vaccine-skeptical patients is that they don’t come into the discussion speaking the same language. The more we can learn about each others’ perspectives, the better it will be for children and for public health.

**Originally published in the Los Angeles Times**

Talking to Your Child’s Doctor About Alternative Medicine

Talking to Your Child’s Doctor About Alternative Medicine
[by Drs. Amitha Kalaichandran; Roger Zemek; Sunita Vohra]

A few months ago, the Centers for Disease Control and Prevention published a report about a young boy from Connecticut who developed lead poisoning as a direct result of his parents giving him a magnetic healing bracelet for teething. It seems every few months a story will cover a tragic case of a parent choosing an unconventional medical treatment that causes harm.

More often, the alternative treatments parents choose pose little risk to their kids — anything from massage therapy to mind-body therapies like mindfulness meditation and guided imagery. Research indicates that overall, there are few serious adverse events related to using alternative therapies. But when they do occur, they can be catastrophic, in some cases because caregivers or alternative care providers are poorly informed on how to recognize the signs of serious illness.

The National Center for Complementary and Integrative Health, part of the National Institutes of Health, now refers to these alternative treatments as complementary health approaches, or C.H.A. They are defined as “a group of diverse medical and health care systems, practices and products not presently considered to be part of conventional Western medicine.” In some cases they complement traditional care. In others they are used in place of standard medical practices.

It’s a polarizing subject that unfortunately gets muddled with conversations about anti-vaccination. But while some anti-vaxxers use complementary health approaches, people who use C.H.A. don’t necessarily doubt vaccine effectiveness.

What’s less clear is the proportion of parents choosing complementary health approaches for their children, for what conditions, and their perceptions of effectiveness. We also know very little about parents’ willingness to discuss their use with their child’s doctor, and most doctors receive little training in C.H.A. use, especially in children, and how to counsel parents about it.

To explore these questions, we surveyed parents in a busy emergency room in eastern Ontario, Canada. As reported in our recent study, just over 60 percent said they gave their child a C.H.A. within the last year. Vitamins and minerals (59 percent) were the most common ingested treatment, and half the parents used massage. Our research found that parents with a university-level education were more likely to use a complementary treatment than those with less education.

Parents also perceived most of the C.H.A. that they used — from vitamins and minerals to aromatherapy to massage — as effective. However, less than half of parents felt that homeopathy or special jewelry would be helpful.

As reported in our recent paper, we then asked parents if they had tried a complementary therapy for the problem at hand before they came to the emergency room. Just under one-third reported using C.H.A. for a specific condition, most often for gastrointestinal complaints. Interestingly, in the case of emergency care, there was no correlation with the parents’ level of education.

In work we previously presented at the International Congress of Pediatrics, we asked these parents whether they believed their provider — a nurse practitioner or a doctor — was knowledgeable about complementary medicine. About 70 percent believed their health provider was knowledgeable about C.H.A., although this perception was less likely among parents with a university-level education. Surprisingly, 88 percent said they felt comfortable discussing their use of C.H.A. with their medical provider.

Previous reports have found that only between 40 percent and 76 percent actually disclose C.H.A. use with their doctor. In our study, we were talking to parents who had brought their child to an emergency room, where they would be more likely to talk about whatever treatments they had tried. In many cases, parents may refrain from even taking their child to the doctor if their problem is not a serious one. So it is likely that the overall proportion of parents who use C.H.A. for their children is an underestimate.

Our findings underscore the need for parents and their child’s health providers to have more open conversations about what they are giving to their child for health reasons.

Medical providers also need to be actively asking whether C.H.A. is used and stay up-to-date on current evidence about complementary therapies, including potential interactions with any medications they may also be taking. Much of this information is summarized on the N.C.C.I.H. website.

Here are some ways parents can approach the issue of alternative therapies with their doctors:

■ Write down everything your child is using as though it’s a medication. Include any special diets, teas and visits to other complementary medicine providers.

■ Keep track of any positive and negative results from C.H.A. that you notice —- including no effect — and the cost involved

■ If your child’s health provider doesn’t ask about C.H.A., start the conversation.

Physicians and other medical providers should:

■ Learn more about these treatments and the evidence behind them. The N.C.C.I.H. is a good place to start.

■ Try not to be judgmental; causing a rift with a parent because you might not agree with their choices may cause a breakdown in the therapeutic relationship.

■ Evaluate risks and benefits, and be aware of what is unknown about the specific C.H.A. being used. Make efforts to learn more about the therapy and take action if there are clear side effects and risks, documenting the discussion where appropriate.

Parents and doctors are on the same team when it comes to caring for a child’s health. Taking time to explore what parents and children are using, including any therapies that lie outside the scope of conventional medical practice, provides an opportunity to have open and honest discussions about risk, benefits and safety around complementary health approaches.

**Originally published in the New York Times**