Preventing Injury

Physicians Counsel Young Patients About Safety 

 Texas Medicine Logo 

Public Health Feature – October 2012 


 Tex Med. 2012;108(10):35-39.

By Crystal Conde 
Associate Editor 

Whether counseling parents about baby-proofing their homes or discussing bicycle helmet use with young patients, physicians must be able to talk candidly to their patients about child safety and injury prevention.

Understanding the crucial nature of an open dialogue between physicians and patients and their parents, Seth Kaplan, MD, a Frisco pediatrician, convinced the Texas Medical Association House of Delegates at TexMed 2012 in May to oppose laws limiting the type of conversations physicians can have with patients and/or their parents. The house adopted a policy that TMA will "oppose any legislation that would seek to limit the scope of conversations physicians can have with their patients or their patients' parents, when the patient is a child."

Dr. Kaplan is the Texas Pediatric Society (TPS) alternate delegate to TMA and cochair of the TPS Committee on Administration and Practice Management. He felt compelled to speak up after learning of legislation Florida passed last year to restrict physicians from counseling parents and their children about firearm safety. Under the law, patients could report physicians for harassment if patients felt questions about firearms were unnecessary, and physicians could face discipline from the Florida Board of Medicine.

"The political and socioeconomic environment in Texas isn't too different from that of Florida. I thought it would be smart for TMA to have policy on the issue of physician communication with patients in case the Texas Legislature proposes similar legislation in the future," Dr. Kaplan said.

In his practice, Dr. Kaplan counsels patients and parents about gun safety and responsible gun ownership by encouraging the use of trigger locks and locked gun cabinets and by telling them about the Texas hunter education and certification program developed by the Texas Department of Parks and Wildlife. This guidance reflects TMA policy on firearms.

After Florida passed its law, six physicians, along with the Florida chapters of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians, filed suit, alleging it restricts their First Amendment rights to discuss firearm safety with patients. In June, a federal judge agreed. She declared the law unconstitutional and blocked its enforcement.

Many physicians educate young patients and their parents daily about safety and injury prevention based on extensive public health research and recommendations. TMA recognizes it's vital these physicians be able to discuss these topics openly.

Keller pediatrician Jason Terk, MD, chair of the TMA Council on Science and Public Health, says laws and rules that seek to limit the communication physicians can have with their patients are "a basic infringement of the physician-patient relationship."

"Physicians have a duty to counsel their patients or the parents of their patients on those things that should be done to reduce or eliminate preventable injuries. Political leaders should not interfere in the execution of this part of our mission as physicians to score political points," Dr. Terk said.

On a related issue, TMA President Michael E. Speer, MD, urged the Texas Department of State Health Services (DSHS) in August not to adopt rules barring physicians from discussing elective abortion with their patients even if the patients ask about it or if the standard of care indicates the physician and patient should consider it as an option.

DSHS' proposed rules would impose a "gag order" on physicians who participate in the Texas Women's Health Program. "If the state indeed wants doctors to participate in the program, this is a step in the opposite direction," Dr. Speer said in a letter to DSHS. 

"A rule should not compromise a physician's medical judgment regarding what should or should not be discussed with a patient," he said. "The proposed rules would prevent physicians from freely discussing medical care and procedures with patients, and would set a dangerous precedent for future restrictions on patient-physician communications based upon the political agenda of the day."

The American College of Obstetricians and Gynecologists/Texas District, the Texas Association of Obstetricians and Gynecologists, the Texas Academy of Family Physicians, and TPS cosigned the letter.

Ultimately, Dr. Speer said, "the issue of support or opposition to abortion is an individual decision based on personal values and beliefs. Our respective organizations have members on both sides of this issue and are therefore not advocating for or against abortion by this letter. Rather, our organizations are advocating for the preservation of a physician's right and duty to provide his or her patient with truthful and uninhibited medically appropriate information within the patient-physician relationship."

He added that the groups "strongly oppose any interference into a physician's ability to use his or her medical judgment as to the information that is in the best interest of his or her patient."

Many Texas physicians may leave the program because the rules, if enacted, would force them to choose between practicing medicine in accordance with the standard of care and medical ethics or in accordance with a rule created to serve a political ideology, Dr. Speer wrote. 

Talk and Action 

Texas physicians are doing more than just talking to patients about preventing injuries. Many are involved in local and state efforts to prevent them or lessen their impact.

Injury prevention is a priority of TMA's Council on Science and Public Health.

"We know that injuries are a common cause of emergency department visits, hospitalizations, and deaths in Texas," Dr. Terk said. "Prevention of those injuries is manifestly more cost-effective than treating those injuries. Yet we still have far too high a frequency of preventable injuries that arise from motor vehicle collisions, unsafe water recreational activity, unsafely stored firearms, and failure to use proper head protection on bicycles, scooters, and motorcycles, to name just a few."

Drs. Terk and Kaplan believe Texas improved its efforts to protect children by passing automobile safety seat laws and in safeguarding student athletes through concussion management guidelines. While the state doesn't have a child helmet law, TMA's Hard Hats for Little Heads program provides bicycle helmets to children throughout Texas and advocates injury prevention in all wheeled sports and activities through helmet use. (See "Hard Hats Save Heads.")

Proven approaches to preventing childhood injuries, such as helmet use and concussion management, can help reduce the health and economic burden of injuries. A 2006 article titled "Incidence and Lifetime Costs of Injuries in the United States" reports one person dies from an injury every three minutes. Every year, injuries generate $406 billion in lifetime costs for medical care and lost productivity, according to the article, published in Injury Prevention.

The National Federation of State High School Associations reports about 140,000 high school students suffer concussions annually. With TMA backing, the legislature last year passed a bill requiring school districts to create concussion oversight teams that include at least one physician and to establish return-to-play protocols that involve a physician evaluating the athlete. The law also requires the University Interscholastic League and DSHS to approve training courses on concussions for coaches and athletic trainers. (See "Concussion Education Resources.")

Dr. Kaplan says his practice has "gotten more aggressive about following the return-to-play guidelines and with referring patients to sports medicine experts for follow-up testing."

The state helps protect children in automobile accidents, as well. According to the Texas Peace Officer's Crash Reports, 38 percent of children aged 8 and younger killed in car accidents in 2009 were unrestrained, up from 32 percent in 2008. A 2010 Texas Transportation Institute study observed child passengers in 14 cities across the state and found 10.5 percent of them weren't in a safety seat.

Dr. Terk calls the child safety seat law passed by the Texas Legislature in 2009 "one of the most important positive policy changes in recent years." That bill requires that children younger than 8 or shorter than 57 inches be secured in a child passenger safety seat. The initial fine for not doing so is $25, but subsequent fines can reach up to $250.

Helmets Reduce Injury Risk 

As a pediatric neurosurgeon, David Donahue, MD, has seen horrific child head injuries. After witnessing the effects of several preventable injuries and experiencing one himself, the Fort Worth physician got involved in the Hard Hats for Little Heads program.

"I witnessed a helmetless 10-year-old bike rider bounce first off a car's hood, then twice on the pavement on his head. He was hospitalized for weeks," Dr. Donahue said.

He admits he's been the victim of failing to wear a helmet.

"I was rollerblading aside my two sons. They were wearing helmets, but I wasn't. Rolling down a ramp, I lost control and slammed into a cast-iron historical marker head first. I ended up in the emergency room but escaped with a few stitches in my scalp and just a chip out of the outer table of my skull," he said.

Skull fractures, brain hemorrhages, facial lacerations, permanent brain injury, and coma are common injuries Dr. Donahue has seen in children not wearing helmets in an accident.

Dr. Donahue learned of TMA's Hard Hats program when his wife, Angela, was the TMA Alliance's vice president of community health. 

"It appeared an easy project for any medical community to take on. Just order helmets from TMA, find a venue to distribute them, and you can prevent unnecessary injury to a child. The helmets Hard Hats provides are affordable, durable, and the kids consider them 'cool' – half the battle while enticing them to don one," he said.

Hard Hats for Little Heads has made an impact in Dr. Donahue's community.

"Rarely do I see a young child riding a bike without a helmet," he said.

Research to Intervention 

Sharon Huff, MD, says public health research and collaboration among various stakeholders form the basis of injury prevention interventions. Dr. Huff is assistant professor of medicine in the Department of Occupational Health Sciences at The University of Texas Health Science Center at Tyler (UTHSCT) and coauthor of "All-Terrain Vehicle Injuries in Texas, Mapping the Path to Intervention With a Geographic Information System" published in the January 2012 Journal of Agromedicine.  

Researchers found that a 35-county area in East Texas had a statistically higher annual rate of injuries from all-terrain vehicle (ATV) accidents in children younger than 18 than the entire state (10 per 100,000 vs. 38 per 100,000). (See "ATV-Related Injuries in East Texas.")

ATV-related injuries take a large financial toll in the East Texas area. From 2004 to 2010, hospital charges for ATV-related injuries totaled $31.3 million for the region.

The article says helmet use among East Texas children younger than 16 was only 8 percent and cites a National Future Farmers of America survey that notes the median age for first-time ATV riders is 9. Of the East Texas children injured, 2 percent (23 out of 821) died from their injuries, with children younger than 16 accounting for 35 percent of deaths. None of the children who died wore a helmet.

Dr. Huff says the findings are the foundation of evidence-based injury prevention efforts in East Texas. She's a member of the ATeamV community coalition of state and local physicians, health care professionals, and health care facilities working to reduce ATV injuries in counties with the highest rates of accidents.

 "Our coalition is now in the early stages of developing our first intervention, which is a 'train-the-trainer' approach to integrating ATV safety education into hunter safety courses," she said.

In the absence of a statewide helmet law, physicians can do a lot to help increase helmet use among their young patients, Dr. Huff says.

"Physicians are important community members who can help families make safer choices. We are working to bring continuing medical education activities to targeted communities to help physicians do this effectively," she said.

She calls on East Texas physicians to ask patients about their ATV use.

"Physicians also must give families simple messages about the appropriate ATV model, size, and choice for their children's developmental age. Physicians must stress the importance of taking a hands-on ATV safety course, as well as wearing protective gear, including a helmet, while on an ATV. In addition, they must emphasize the dangers of carrying passengers and drinking alcohol before driving an ATV," Dr. Huff said.

 Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email . 

 SIDEBAR 

 Hard Hats Save Heads 

TMA's Hard Hats for Little Heads program urges children to wear the correct helmet for their sport or activity and make sure it fits properly. The program promotes exercise and teaches parents and children about the importance of wearing a helmet.

It has given away more than 125,000 bicycle helmets since its creation in 1994.

Hard Hats has support from physicians, medical students, TMA Alliance members, county and local medical societies, and specialty societies. The TMA Foundation, TMA's philanthropic arm, provides funding, thanks to top donors – Blue Cross and Blue Shield of Texas, Prudential, and an anonymous foundation – and gifts from physicians and their families. The foundation has awarded TMA more than $554,000 for Hard Hats since the program's inception. To make a tax-deductible donation to the TMA Foundation, visit www.tmaf.org or call (800) 880-1300, ext. 1664.

To find out how to give helmets to youth in your community, visit the TMA website; email TMA's outreach coordinator; or call (800) 880-1300, ext. 1470, or (512) 370-1470.

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 SIDEBAR 

Oct 12 TM Public Health Chart 

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RELATED STORY 

Concussion Education Resources  

As young athletes take part in the fall sports season, Texas physicians can participate in continuing medical education (CME) programs on concussions. 

Physicians play a critical role in diagnosing and treating concussions, the brain injuries attracting more and more attention from the sports media and research communities.

Physicians also are playing a more prominent role in their local school districts and communities when it comes to managing concussions. House Bill 2038, passed in 2011, requires school districts to establish concussion management teams that include a physician.  

Texas Medical Association members can learn more about concussions, including diagnosis and treatment, from the following resources: 

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