The Athlete’s Foot & Health Literacy – PediaCast 354
- October is Health Literacy Month! What exactly is health literacy and why is it important? Dr Mary Ann Abrams and Dr Alex Rakowsky stop by the studio to share their experience and perspective. The Sports Doctor, Bob Weil, also visits this week as we consider common problems of the athlete’s foot. We hope you can join us!
- The Sports Doctor Radio
- The Athlete’s Foot
- Foot Injuries
- Foot Problems
- Ingrown Toenails
- Health Literacy
- Plain Language
- Sports Doctor Radio – Dr Bob Weil
- Healthy Life Radio presents The Sports Doctor
- Ask Me 3 (NPSF)
- Questions are the Answer (AHRQ)
- Helping Hands (NCH)
- Pediatric Patient Handouts (AAP)
- KidsHealth (Nemours)
- Patient Care and Health Info (Mayo Clinic)
- MedlinePlus (USNLM)
- Health Literacy – PediaCast CME 020 (FREE Category 1 CME Credit)
- Plain Language Landing Site (CDC)
- Plain Language Thesaurus (CDC)
- Plain Language Medical Dictionary (U of M)
- NC Program on Health Literacy (UNC Chapel Hill)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It is Episode 354 for October 5th, 2016. We're calling this one "The Athlete's Foot and Health Literacy". I want to welcome everyone to the program.
I have a couple more great interviews for you this week. Now, I know we've been heavy on the interviews the last few episodes. I do have more pediatric news coming your way, and the always popular answers to listener questions. More of those in upcoming episode. In fact, we'll include news and answers to your questions in our next episode.
We've had some really good questions coming lately, and we always have room for more good questions. Now, you may be asking yourself, what constitute a good question for PediaCast. And the correct answer is, it's a good question if it's your question, right? No silly questions here, we consider everything. So if there's something that you really have on your mind, you're wondering about it, don't feel silly asking, even something that may seem pretty simple. If you have that question, it's like that many other parents have the same question. So we love to answer those.
And, it's easy to get in touch with me to ask a question. Just head over to PediaCast.org. Click on the Contact link and ask away and we'll try to get your question on the program.
In our last episode, we considered neck injuries. It's an important consideration given that football and other autumn sports are in full swing. Today, we're going to consider the other end of the body, the athlete's foot — what injuries can student athletes expect in the foot region, how are these injuries treated, how can they be prevented. We'll also consider skin conditions including athlete's foot, of course, but other skin problems of the athlete's foot — what can you expect? Also in-grown toenails, which is both a skin and a nail condition. And, of course, we'll talk about treatment and prevention of all these problems involving the athlete's foot.
So you get your neck issues, you get your foot issues, and of course, there's everything in between which we can't cover it all. So we just picked the neck and the foot for this fall. Maybe next fall, as the school sports season gets underway, we'll have consider other injuries. Forearm and wrist injuries, those are pretty common, too. Ankle injuries, of course.
By the way, to help me cover the athlete's foot, I do have a fantastic special guest with me today, The Sports Doctor, Dr. Bob Weil. He's been doing radio for over 20 years from Chicagoland. You'll find him these days broadcasting his live column sports medicine show at HealthyLife.net. You'll also find him here today on PediaCast as we consider the athlete's foot. So stick around for that.
And then, October is Health Literacy Month. Just about every ailment has a month these days. It's easy to miss one or another of them. But this is one that really does affect everyone, because it doesn't matter which disease or condition your family faces. Health literacy is important to all of us.
So what exactly is health literacy? It boils down to understanding — how well do patients and families really understand what is going on as it relates to their health. Understanding is important, that's why most of you tune in to PediaCast because you want to understand. It's not dumbing down the information.
Health literacy really involves explaining the science in terms the listener can understand, or the reader can understand. Because understanding, when you understand something, it's tied to adherence and compliance, also satisfaction and quality and safety, and ultimately health outcomes.
So what can providers do to increase health literacy? We have a lot of providers in the audience, so we want to talk about that. What can health organizations do? And most importantly, what can you do as a mom or dad or a patient to improve your own or your family's health literacy?
Sure, you can listen to PediaCast, that's great start. But you're already doing that. You can tell other parents about the program. Of course we love when you do that. But we have lots more practical ideas for you as a couple of primary care docs from Nationwide Children's join us to share their experiences and perspectives. Dr. Mary Ann Abrams and Dr. Alex Rakowsky will be joining us as we talk about healthy literacy for Health Literacy Month. So stay tuned for that.
All right, again, the way to contact me to ask your questions or suggest show topics, it's easy to get in touch with me. Just head over to PediaCast.org. Again, click on the Contact link. I do read each and every one of those that come through, and we'll try to get your comments or your topic idea or your question on the program. So be sure to ask away, and we do have more episodes coming up where we'll answer your questions.
Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's take a quick break. And, I will be back to talk about the athlete's foot and health literacy. It's coming up right after this.
Dr. Mike Patrick: Dr. Bob Weil is a sports podiatrist in Chicago. That means he's a foot specialist who takes care of athletes including student athletes. That's what he's here to talk about today, the athlete's foot. So let's give a warm PediaCast welcome to The Sports Doctor from Healthy Life Radio at HealthyLife.net. Dr. Bob Weil, thanks for joining us today.
Dr. Bob Weil: Hey, Dr. Mike, it's a pleasure to be with you. Congratulations on the great work you do with PediaCast. There's so many super important topics, but hey, my friend, The Sports Doc is in. How can I help you?
Dr. Mike Patrick: I am so glad that you're joining me today. You are in Chicago, correct?
Dr. Bob Weil: I am in Chicago, yes. I am from New York. I'm a New Yorker. I practice my New York accent at least once a week, but I've been in Chicago area, gosh, going four decades.
Dr. Mike Patrick: That's fantastic. And you have a weekly radio program. Tell us about that.
Dr. Bob Weil: Yes, my show is called The Sports Doctor. I've got a long history on the radio, Dr. Mike. I did 20 years in a local blues jazz station, WDCB, great Chicago station that had some specialty shows, public radio. The Sports Doctor was one of them. I think I followed The Lawnmower Show, if I can recall.
Dr. Mike Patrick: Yeah, 90.9fm, right?
Dr. Bob Weil: 90.9fm, yes.
Dr. Mike Patrick: See, I did my homework.
Dr. Bob Weil: …Station. And then, I've been involved with all positive talk radio, if you could believe it — Healthy Life Radio, which is a great station. They've been around about 14 years out of Manhattan Beach, California. They have 30, 35 hosts, all sorts of different topics — holistic medicine, relationships, astrology, just the idea of all positive talk radio is a great moniker.
On my show, Dr. Mike, we discuss everything from concussions, to what's the local… Whether it's Adrian Peterson's knee injury, whether it is Peyton Manning's foot injury. We discuss current events.
The theme of the show is the role of the foot in sports, where we talk a lot about what's the best shoe, how important it is, the foot. Like the song, the foot bones is connected to the leg bones and that's connected with the knee bone is really where it's at in sports medicine. But we talk nutrition. I like to think that the sports doctor is all things sports medicine, fitness and wellness with the various topics and pediatrics is a big one.
Dr. Mike Patrick: Yeah, sure. And we'll include links to Healthy Life Radio, HealthyLife.net, over on our Show Notes page for this episode, 354, over at PediaCast.org, so that folks can find you easily. But it sounds like you cover all sorts of topics that parents, moms and dad — especially if you have student athletes at home — would be interested in.
So let's start with what are the most common foot injuries seen in young athletes?
Dr. Bob Weil: Well, there's a couple of categories, Dr. Mike, that are up front and personal. One is acute injuries — injuries that just happened. You fell, you sprained an ankle. You twisted your knee. You had some sort of traumatic episodes, stepped in a hole. And the far more common, more problematic many times are the overuse or repetitive motion injuries that we see. The shin splints in the cross country runner, the knee discomfort in the young athlete who's doing everything the same every day, I call them the prodigy sports.
We just watched the Olympics. Wasn't that fantastic?
Dr. Mike Patrick: Yeah, that was a lot of fun.
Dr. Bob Weil: When you see 17-, 18-year-olds that are the best in the world, how long do you think they've been doing it? Since they're four, five years old, maybe younger. So the challenges of specialization is a big one. And common problems in growing kids are heel problems, what we call apophysitis. There's a big growth cell in the back of the heel. So repetitive running, jumping, soccer with the cleats on the bottom of the heel, heel pain is a common foot problem that we see.
Again, ankle sprains are the most common sports-related injury still today. We take all ankle injury seriously. All of them should be identified and rehabilitated. Those are more in the acute type injury that just happened. Many times, we're talking about the old RICE principles, Dr. Mike. Rest, ice, compression, elevation can't go wrong on an injury that just happened.
Overuse injuries many times are a different animal. Again, "You know I don't know what it is with my son's ankles but every time he gets into four and five days a week in soccer, his ankles are hurting." Or, "His Achilles tendons are hurting him." Or, "They got this shin discomforts."
So overuse problems often are related to foot mechanics. Is that boy or girl flat-footed? Do they have high arches? Are they bow-legged? Are they knock-kneed? All of these things go into, big time, these kinds of problems are with children as they're growing, as they're playing sometimes a little bit of too much in the way of… There are a lot of pressure on these kids.
Dr. Mike Patrick: And I think, as adults, we experience overuse injuries and a lot of times we just say "Ah, we're getting old. We're not quite as fit as we used to be," but kids have the same issues, right?
Dr. Bob Weil: They do, and again, sometimes we push kids a lot. Everybody's familiar with the old Little League parent screaming on the sidelines and getting over-involved and too involved many times in the kinds of pressure on these kids. Club sports are again a big deal, where you have adolescents already very serious about the sports they play.
And one of our concerns — we talk about it a lot on The Sports Doctor, Dr. Mike — is drugs and sports. "You know, the kid needs one or two Advil just to participate." Or, "You know, this is bothering him but they've got a game this week and a game next week." So we try to pay a lot of attention to the demands that adults put on growing kids in competitive sports. It's a lot.
Dr. Mike Patrick: And one of the important things to differentiate is, is this a sprain or strain or a repetitive use type of injury? Or, is there something more worrisome going on like a fracture or a growth plate injury? How do we tell the difference acutely between those two groups of things?
Dr. Bob Weil: Well, we can get very sophisticated. Again, we might take an X-ray, number one. If something's of a stress fracture relationship, for example, it might not show up on an initial X-ray, so an MRI might be something that is indicated. There's a test called diagnostic ultrasound which is the same technology that look in a mommy's tummy at the developing little fetus or baby. And diagnostic ultrasound could show us tendons and ligaments in real time, "Hey, it's torn" or it isn't.
So we can get sophisticated. The point you're making is a very important one. Get a diagnosis. Get evaluated. And we tell parents all the time, if however, you're dealing with problems that seem to be repetitive or seem to be ongoing, that's when many times we say "Look to the feet." Look at the mechanics of the feet that many times are oriented towards excessive stresses above many times.
For example, I would let you know, all your listeners, that 90% of so-called shin splints, shin pain that's repetitive is related to foot mechanics that causes us to overuse certain muscles. So we tell moms and dads, if you're looking at problems that seem to be repetitive or seem to be ongoing, then you really want to get evaluated in order to be able to determine, you know, is son and daughter in the best shoe for the foot mechanics? Great question.
So many times we're talking about the proper fit of shoes and being in the right shoe for the particular sport. That's no less important for me and you or our kids or great grandmas when you're talking about are you in the best type of shoe? As general rule, running shoes are made for one step in front of the other, going in one direction. So we don't want to be in running shoes if we're playing side to side sport like soccer or lacrosse or whatever it happens to be.
So again, I also tell parent another big thing, Dr. Mike — if your son or daughter needs over-the-counter pain medicine to participate, you're over the line. You're pushing it.
Dr. Mike Patrick: Sure. And it's going to be important that if they are experiencing those kind of things, physical therapy or some kind of training program, conditioning program, stay active between sports seasons. So they're not just all of a sudden exerting their muscles and pulling on those tendons and ligaments and stretching things when they weren't used to being used.
Dr. Bob Weil: Well, this is a challenge, you see, because again in the prodigy sports… One of my exciting times in the past besides seeing the Superbowl Chicago Bears and the great athletes in so many sports, the John Mckenrose, the Tracy Austin… Growing up in Illinois, one of my specialties is figure skating. My real specialty is orthotics, whatever the sports happens to be, we'll talk more about prescription inserts that go in your shoes. But the 2010 Men's Olympic Gold Medal figure skating champion Evan Lysacek grew up in Napleville, Illinois. He was ten years, Dr. Mike, when I put orthotics in his skates. Fifteen years later, he was the best in the world.
And skating every day and jumping every day and these kind of challenges, both mentally and physically, so the reality is there are a lot of kids, who no matter how many times we tell the parents or them, "I wish you would play different sports, use different parts of the body…"
I use term called 'intelligent rest' a lot, which is you got to have some recovery time mixed in. But again, if you're going to be a great swimmer, you're going to be a great gymnast, you're going to be a great figure skating, you're going to show up in soccer, then a lot of times, by the time you're 10, 11, 12 years old, that's all you're doing. Real challenge, and that when we try to mix in a good personal trainer, a physical therapist, that could show your son and daughter how to stay as a free of injury as possible. And a little luck is always appreciated along the line, right?
Dr. Mike Patrick: Yes, definitely. Now, in addition to injuries of the foot, athletes also can have skin problems associated with the foot. What are some of the more common skin problems they can come across?
Dr. Bob Weil: Hey, you know, pun. You know, athlete's foot skin fungus is common. It could be everything from a nuisance to a real nightmare. So we try to tell whoever you are, if you're in and out of a locker room, in and out of a shower, wear pool shoes. You can be susceptible to fungus, and all of a sudden athlete's foot could be raw, itchy, blistering, potentially setting you up for skin infections. It also could be dry and more of a nuisance than a real problem.
So skin fungus, athlete's foot, between the toes as a common condition. It loves moisture. We were in socks and shoes, there's lots of sweating that's involved. Sometimes there's skin odor that's involved. So we try to tell athletes of all ages especially the kids, if you've got a rash, skin in inflammation, redness, itchy, et cetera. Let's check it out, see podiatry, check with the pediatricians.
Planus warts we also see in kids. Planus warts are caused by a virus. You could be the cleanest kid in the world. You still could be susceptible. Sometimes they are a transient problem that we don't have to make a big deal out of. Other times, they're a real nightmare. They're under weight-bearing surfaces, the heel, the ball of the foot. Sometimes, they treat it topically with different creams, different acids, padding, et cetera. Occasionally, we might super cold them or spark them.
Most skin conditions of the athlete's foot type variety, we're dealing with antifungal creams, sprays, different kinds of powders. And for the most part, that's the gamut of skin conditions in kids. Again, dealing with skin fungus athlete's foot type situations.
You'll see corns and calluses, much more common in adults, but we see them also. Foot type, Dr. Mike, is inherited very often. So many times, we'll see, "Gee, you know, she's got bunions and hammer toes just like her mom, just like her grandma." So, this is something that surprises people in many instances. If you see something suspicious, you're uncomfortable, again, podiatry is a great profession to add to your repertoire, especially if your son and daughter is athletic. Because then, you could really get into getting in the best shoe.
Dr. Mike Patrick: And speaking of the right shoe and a good fit, pressure sores and blisters can be a problem for lots of kids.
Dr. Bob Weil: Absolutely. Again, anybody can get blisters, pressure sores. Let's say the season's new. You're not used to being in your new shoes. The ground is super hard, et cetera, et cetera, and you can get some blistering. And blisters are never pleasant and they can be a real difficult scenario, need to be treated preventing infection.
Sometimes when we use emollients like Vaseline, other kinds of emollients to prevent friction but often persistent blisters in certain locations can be related again to the mechanics of the foot. Which is, for example, "No wonder Mike's getting blisters under the ball of foot. He's got high arch. This is where he's putting in all the pressure." And many times then we'll see, orthotics to redistribute weight, properly control position is one of our biggest weapons.
Dr. Mike Patrick: Yeah, absolutely. So, it's a good idea when kids are having problems of any kind, whether it's pain from recurrent injuries, whether there's something going on with the skin. As you had mentioned, you need to get the right diagnosis first in order to figure out exactly what it is that you're going to do.
Dr. Bob Weil: I think that's a good rule of thumb regardless. We also have scenarios that are very important. Number one is prevention. Also, number two, maybe not the most important to everybody is enhancing performance. So many times again, we're talking about how important is your young athlete's alignment? Do they have proper structural integrity? A lot of that starts with the feet. It's hard to do anything without starting with the feet.
So an understanding of the role of the foot, whether it's as your first major shock absorber, every step you take coming down from a jump, running in one direction or another or your ability to adapt to different surfaces. We tell parents, "Your son or daughter regardless of sports should include, so should you, strengthening your feet and ankles." I like rubber bands a lot. I like balance boards. I'm a big advocate of balance exercise, roughly of all ages, of all types.
Dr. Mike Patrick: And here in Ohio, a lot of schools have athletic trainers. And here at Nationwide Children's, we have a great sports medicine program for kids with athletic trainers. They can really help out with that conditioning in kind of pre-season sort of work to get kids ready.
Dr. Bob Weil: Yes, that's interesting. They become a… Not that they never were always. They always have. These are the geniuses. The individuals who whether it's a catastrophe of injury that they're on top of, whether it's again what we mike call pre-hab or getting ready for the season — unfortunately not every school has access to athletic trainers — but they are tremendous asset to be able again to work with these young athletes.
What are the areas you should be paying attention to? What type of balance training? What type of strengthening should you be doing as well as dealing with the everyday kinds of injuries? Again, whether it's someone who broke an ankle because they've a bad injury right on the field, or whether or not that's trainer talking to this young girl who says, "You know, I don't know what it is, my knees are always bothering me." Of course, she might be jumping 300 times a week because she's playing volleyball.
Dr. Mike Patrick: Right, yeah, yeah. And I think, you had mentioned, a lot of parents have those questions, like how exactly do we get ready for this sports season? How do we prevent injuries? And it's hard to find the right answer but if you'd work with an athletic trainer, they can really point you in the right direction.
Dr. Bob Weil: They absolutely can. So can physical therapy, and so can sports medicine. Again, if somebody says I'm going to go to Dr. Mike's hospital, and I'm going to go meet with this sports medicine staff to say, "You know, my son and daughter's a serious figure skater, and I'd love to do two things — stay out of injury trouble and enhance her balance and performance," and many times, they'll put that boy or girl through an evaluation. Again, taking a look at the structure, how well do they balance, what type of stability, how strong are they, these kinds of things and be able to give a smart program to try to stay out of trouble. And I think that type of information is really, really available. And I think it should be routinely taken advantage of especially if we're talking about a young boy or girl who's a serious athlete.
And let's not fool ourselves, even junior high school today, we're talking serious athletes, let alone high school and above, especially at the club level, where you might have again 11, 12-year-old figure skater who's already doing double jumps, who's skating ten days a week and who were really trying to stay out of trouble and enhance their balance and stability.
Dr. Mike Patrick: Yeah, absolutely. Another issue that we see frequently in student athletes are in-grown toenails. Tell us about those, what causes an in-grown toenail?
Dr. Bob Weil: Sometimes you have them, sometimes you don't. As a rule, we can easily clip out offending in-grown toenails once in awhile, keep somebody comfortable, show that boy or girl. I like sports pedicure where they don't have an ingrown nail. It's not infected. That's many times that podiatrist sees, "Boy, it hurts." It's red and inflamed.
There are simple office procedures, Dr. Mike, to permanently get rid of in-grown toenail problems. For instance, if we see a young boy or girl, this is a third in-grown toenail infection… They're common on the big toe, on either edge. Some people have curved-in nails, inherently. Others don't have that kind of problem.
So if we see that we've got discomfort in those areas, then see a podiatry where you can get an expert opinion on it. Is this something that I can every few months clip out quite easily without any pain and keep you comfortable? Or, is this something that requires numbing the edge of the toe off, removing just the edge of the in-grown toe nail, cauterizing the growth area, and that edge never grows back to cause trouble?
Dr. Mike Patrick: So you're making the nail thinner or more narrow…
Dr. Bob Weil: Yeah, yeah. So slightly that you can't even see it. Now, again, if you have a flat-type foot that's rolling in excessively, then you might be pinching that skin up against the big toe and your shoe mechanically. So in many instances, we'll start to see real early, we'll tell parents all the time, "If your son or daughter is picking at their toenails, bring them in. Let's take a look. Let's stay out of trouble."
Usually, we don't see these kids till we've got a red or inflamed area that might be infected and those areas hurt. Those things are uncomfortable. So it's not an unusual problem. It's very, very simple to number one, control, and very very simple also to get rid of the problem permanently if we see, "Wow, this is the third or fourth episode that these kids are dealing with."
In-grown toenails common as adults? Absolutely, also.
Dr. Mike Patrick: Yeah, yeah, definitely. In terms of preventing them from happening in the first place, is it just a matter of letting the nails grow a little long or can you still get them even if you are cutting them too short?
Dr. Bob Weil: I think it depends, you can always aggravate something if you're looking to clipped nails. As it is sometimes, it's a difficult position even to get down there and see what you're doing and do it properly. As a general rule, I tell people, cut your nail through a comfortable length. Round off the edges slightly, don't dig at any particular edges. If you got to dig in an edge, see podiatry. They might be able to really help you out.
If it's painful, I don't like pedicures. Otherwise, maintenance nail care pedicure are fine, as long as you're dealing with a facility that has sterile instrumentation, et cetera and something like that.
So, usually, we'll see cut the nail to a comfortable length, don't dig at the corners. Maybe round them off slightly and you should be ready for another thousand miles, you know.
Dr. Mike Patrick: And again, proper fitting equipment is going to go a long way to keeping that from happening as well.
Dr. Bob Weil: I'll tell you, Dr. Mike, before we're done, believe it or not, statistics tell us that even athletes, 75% or 80% of them are ill-fitted with the shoes. If that's even close, it's astounding. So many people are not fit, "Well, I'm nine or nine and a half, so I'm buying off the shelf and are ordering them online." If we take ten pairs of shoes off the shelf, all size ten, they're all different.
So we really tell people to be, especially for your children, get them properly fit. And, many times, it's hard to be a good walking running shoe store as far as getting some good information regarding what type of shoe is best for you, what's the best fit. Even we've seen athletes who they were in the wrong width. And again, if you're in a shoe that is slightly tight, you might be much more susceptible to blistering, to toenail concerns, et cetera, et cetera, rubbing whatever bony prominence is like in the back of the heel or in the inside of the arch.
But again, one of our real bottom lines, Dr. Mike, whether you're talking about the skin, whether you're talking about the nails, whether you're talking about muscles and joints, arches, et cetera, if again we see in these kids that problems are recurrent or persistent, pay attention to foot mechanics. Because many times, that's the area that we're looking to correct. And this is when we get into the whole role of costumed orthotics or inserts for shoes, which is 95% of what I do in sports medicine.
Dr. Mike Patrick: Where do parents start with getting a good fit? You had mentioned like a running shoe store.
Dr. Bob Weil: I think that Stride Rites and children's shoe stores usually are very very good place with young children to have confidence that they fit properly. It's hard to beat the good sneaker. It's got a bendable ball. The foot is got a rigid counter around the heel.
For adolescents and adults, a running shoe store. They're usually very knowledgeable. New Balance has its chain of stores. There are many others that carry all the named brands, Nike, Adidas, Puma, New Balances, many, many good brands. But, usually, in the running shoe store, they can give you a little bit further information, which is "I think, Mike, you could go to a neutral shoe that doesn't look to correct anything." Or, "You know, with your feet, kind of flat-footed, I think we want to go in a motion control shoe." Or, "Maybe a stability shoe."
Still, running is the only sport that we get that kind of sophistication when it comes to the particular… It's hard to get a motion control or stability shoe if you're looking for a football or soccer shoe. This is why I recommend again in parents that you at least pass by podiatry and find out what is the real things you want to be paying attention to regarding your son or daughter in a sport shoe. That's just smart sports medicine.
Dr. Mike Patrick: Yeah, absolutely. Well, Dr. Bob Weil, The Sports Doctor on The Sports Doctor Radio, we really appreciate you taking time out of your day to talk with us today. Tell us again about your radio program.
Dr. Bob Weil: Okay, again, people can go to my website, Dr. Mike, SportsDoctorRadio.com, written out. And they can see a lot of my past guests. They can see lots of different topics, listen to whatever they choose, read a lot of articles on everything from footballs that are safe for any age, to women in high heels, to children specializing in sports, lots of shoe information, and they could find all about the show.
And I am on live. Our show is live every Wednesday. As a matter of fact, you're my guest on the 28th which will be past by the time the show comes on. We're going to be talking about the PediaCast, changed roles.
But I'm on live every Wednesday, HealthyLife.net. The name of the show is The Sports Doctor, three o'clock, Central Standard Time. We're on for an hour, usually two guests a show. You also could follow me on Twitter. Twitter is a great world. I get a lot of guests on Twitter. I got about 25,000 followers from all over the world and people can follow me @SportsDocRadio. It's been a pleasure, Dr. Mike, really. I found you on Twitter.
Dr. Mike Patrick: Yeah, yeah. That's how we got connected. And I will put links to all of those links that you've talked about in the Show Notes for this episode, 354, over at PediaCast.org, so folks can find you very easily.
Dr. Bob Weil: Wonderful. It's been my pleasure. And again, congratulations on the great work that you do in your hospital. And I look forward to you joining me.
Dr. Mike Patrick: Great. I'm looking forward to it as well. We'll talk soon.
Dr. Bob Weil: Thank you very much everybody.
Dr. Mike Patrick: Dr. Mary Ann Abrams is an ambulatory physician at Nationwide Children's Hospital and a clinical assistant professor of Pediatrics at the Ohio State University College of Medicine. She's board certified in pediatrics and preventive medicine and holds a masters degree in public health. However, her passion is awareness of and empowerment through health literacy. That's where she's here to talk about today. So let's give a warm PediaCast welcome to Dr. Mary Ann Abrams.
Thanks for joining us today.
Dr. Mary Ann Abrams: Hi, Dr. Mike. Great to be here.
Dr. Mike Patrick: Really appreciate you stopping by.
Our second guest as we consider health literacy is Dr. Alex Rakowsky. He is also an ambulatory physician at Nationwide Children's Hospital and an assistant professor of Clinical Pediatrics at the Ohio State University College of Medicine. Dr. Rakowsky also serves as program director for the Dual Residency Program, which is a partnership between the Nationwide Children's and the Ohio University College of Osteopathic Medicine.
Health literacy is one of Dr. Rakowsky's passion. He talks about it frequently with medical students and residents and patients and families. It's a pleasure having him with us today, so let's say hello to Dr. Alex Rakowsky.
Dr. Alex Rakowsky: Thanks, Dr. Mike. How are you?
Dr. Mike Patrick: Yeah, thanks for stopping by, really.
Dr. Alex Rakowsky: Sure.
Dr. Mike Patrick: Really do appreciate both of you taking time out of your busy schedules. So Dr. Abrams, what is meant by the term 'health literacy'?
Mary Ann Abrams: Well, there is an official definition, which is the degree to which individuals have the capacity to obtain process and understand basic health information and services to make appropriate health decisions. But what that really means for everyone is the ability to find, read, understand and use health information in order to take care of themselves or their loved ones.
Dr. Mike Patrick: So really just the capacity to understand what's going on and what the directions are that your physician or your medical provider having you do and why it's important to follow those recommendations.
Dr. Mary Ann Abrams: Yeah, to find it, to use it, to remember it, to be able to apply it when you need to.
Dr. Mike Patrick: Yeah, absolutely. October, as it turns out, is Health Literacy Month, which is one of the reasons that we're promoting it. Although, this is something that's important for folks all throughout the year, isn't it?
Dr. Mary Ann Abrams: Absolutely. We know that more than a third of US adults have limited health literacy, 21 million parents. And that means they have trouble with reading directions and actually giving medications safely to their children. That means they struggle with knowing when to come in for an appointment and what shots their children need and filling out all the forms that we give them in healthcare.
Dr. Mike Patrick: Yeah, absolutely. Health literacy is also associated with health outcomes, isn't it?
Dr. Mary Ann Abrams: It is. While we know that some people have limited health literacy, we know that almost 90% of US adults struggle with some part of our healthcare system. And we also know that anyone can have trouble depending on the circumstances, if you're tired, if you're sick, if you've been up all night with the sick child and you're worried about them. And what does that mean when you have low health literacy? A lot of studies have shown that it is associated with less use of healthy preventive services like making sure you got a flu shot, taking care of your chronic illnesses like diabetes or asthma, being in the hospital more, more emergency room visits and higher cost.
Dr. Mike Patrick: And when providers pay attention to health literacy, there are studies out there to show that it improves the quality of care, safety issues, health equity issues. So what that means is that we're really giving the same care to everyone that we see but realizing that some patients may need more time, more explanation, maybe a different way of explaining some things so that they truly understand what's going on.
Dr. Mary Ann Abrams: Yeah, there's a set of things that we can do as providers that we'll be talking about in a little bit in this podcast that can really help us as a healthcare system make those healthcare encounters more successful for providers and for patients and families. Then, there are things that also touch on what people can do as they come in to the healthcare environment to be more prepared.
Dr. Mike Patrick: Yeah, absolutely. Dr. Rakowsky, what sort of factors contribute to low health literacy?
Dr. Alex Rakowsky: I think as you would think of any human interaction, when you have a communication between a provider and a family, it's a two-way street. So I actually want to start off first with the providers and things that kind of impact health literacy, that the providers may not be doing or doing. The first is that we tend to forget health literacy. We tend to be very focused on health outcomes, or we tend to very sort of work driven. So sometimes, I think we're very busy and don't think about these things.
Another issue is that we don't put ourselves in the patient's shoes. So we kind of walk in assuming that they already have some basic knowledge about what we think are basic topics. So I think a lot of the communications is lost right there and then because we're not even thinking about these things.
As far as their families are concerned, I think the main factor is just uncertainty or fear about the medical system in general, and that's because of several things. The first is the family may not speak English, and the clinic for example that I'm at, 40% of the number of patients don't speak English. So it isn't just having an interpreter in the room. It may be social issues as well, in terms of how they actually view healthcare to begin with.
The second issue, if you do speak English, is how comfortable are you with the words that are being used? How comfortable are you with the concepts that are out there? So you can even say words that are easier to understand but if you're not comfortable with the concepts, then health literacy kind of has an impact.
The third I think is emotions, which Dr. Abrams brought up a little bit. We all had bad days when we're tired or a child was sick, or we're worried about something. It's hard to kind of focus when you're sort of in an emotionally-charged state. And I think that place a huge impact as far as you walking with some anxiety, you're working on some kind of stress. It's hard for you to hear what's going on or for you to kind of express your concerns.
And then, two other things that you want to bring up. One is the busyness in the room. As pediatricians, we commonly see multi-child families that come in to the office. It may be just one child who's sick but if the other child's climbing on a table or spinning around on a doctor's chair, it's hard to focus. But things we tend to forget about the busyness in the room to begin with.
And then, also busyness of the patient's life. So it may be financial concerns that they have. They may need to get out of the office by a certain time to pick up another child at the bus stop. They may just be so busy at home that they don't think about things in the same way that you do. So if I tell somebody, for kids, you need to go to the YMCA every day for an hour, I might as well tell him to swim across the Atlantic, because it's just so difficult for them to do this. So you lost communication right there and then.
Dr. Mike Patrick: Speaking of busyness, also sort of outside the exam room, just the general office busyness, there's a pressure to see patients during the day, got a waiting room full of people who may be been there quite awhile. So as you had mentioned, it can become easy to be just sort of task-oriented like, "This is what I need you to do," and just sort of assume that they understand why those instructions are important. But we really need to take, kind of slow down even when we're busy and take the time to kind of explain things to folks so they understand why our recommendation are important, why we're recommending it. So that they'll be more serious about adhering to those recommendations.
Dr. Alex Rakowsky: And I think slowing down for providers probably the first step you can do.
Dr. Mike Patrick: Yeah. And then, that requires patients to be a little bit more patient, because the idea is okay, you might have to wait a little longer in the waiting room, which no one really likes to do, but realize that when you do finally get into the exam room, we're going to take as much time with you as we did with everyone in front of you to really try to explain things so that you understand.
Dr. Alex Rakowsky: Yes.
Dr. Mike Patrick: Other factors that contribute to low health literacy?
Dr. Alex Rakowsky: I think a lot of it also kind of goes with this comfort level and the ease that we have in explaining things to families where families have been asking us questions. And a lot of it to what I'm going to kind of recommend when it comes to things that we can help with health literacy is to kind of make sure that there's a better connect between what people are actually expecting out of the visit.
I think in general, we tend not to think about the patient's perspective or the family's concern walking in to the room. We tend to think "What's the diagnosis? What am I going to do?" instead of "Diagnosis, what am I going to do? But what's the family actually concerned about and how am I going to explain it in way that kind of address that concern?" I think there's a major disconnect a lot of times with clinic.
Dr. Mike Patrick: So what can health care providers do when interacting with patients and family in the exam room to improve health literacy?
Dr. Alex Rakowsky: Let me start off with the priorities again. I think number one is slow down. Number two is put yourself in that family's shoes. My mom used to have some healthcare concerns, and I'm not an adult doctor, but it was kind of neat to kind of see the perspective of now a patient family member and try and having a doctor kind of explain things to her.
The doctor did a great job of walking and saying, "What are your concern about this diagnosis? What are your concerns about the management plan?" And I thought it was so brilliantly done because my mom had different concerns as a non-medical person than I did as a physician who had some basic knowledge about this disease. And then, she was able to actually communicate with both of us in a way that really made sense. So I think the doctor did a great job just stopping for 30 seconds, "What are these people going to be asking me about? And what's your concern walking through the door?"
Dr. Mike Patrick: Because everyone does have concerns when they walk through the door. We can look at them as "Okay, I've got so many patients I have to see today. Here's number two, number three, number four, number five," and we read what the chief complaint is without understanding that these folks were so concerned about this particular problem, that they did wait for awhile. They went through making the appointment, coming in. I mean, this is a really important thing to this family, so we do want to find out why it's a concern, why they're here and show them that we do care.
I think the third thing is just to kind of preempt the next visit. So as a general pediatrician, if I see for example a nine-month-old, I can tell the parents, "Here's the handout in terms of what to expect at the one-year visit. And this is what's going to happen over the next three months. And here are things about feeding et cetera." So, when you walk in the parents already have some basic sort of knowledge and they're sharing the same knowledge that I have as far as expectations for development.
If you're a subspecialist, you're an endocrinologist, "Here are the things that I'm going to check on you six months from now." "Here are things that you should be looking for, because this is what I'll be looking for." I think that really kind of helps connect between you and the family. So, that's on a provider perspective.
From the patient's family perspective, I just want to start off with the basic expectation that we're not being slow on purpose. Like we had mentioned in the past, I think a lot of families were sort of "You're so slow, why are you so slow?" because it's going to build in some time if you want to do a better job explaining. So I like what you said about telling the family that "I may be running a little late at this time, but I will spend the time to make sure that you understand this as best as I can."
And then, come prepared. Come prepared to ask questions and come prepared to ask your concerns. Because for a lot of things, we tend not to think about the concerns. I have an example where I recently saw a family for the sixth time for a head cold on an infant who's now 18 months. And Mom's concern that this child had either cancer or some immune problem. Well, I just kept on thinking head cold, head cold, head cold. And every time as we kind of went through visit by visit every two or three months, mom just seem more and more disgruntled with us hearing it's a virus.
So if asked mom, "Is there a concern you have about the number of colds that this child is having?" and she said, "Yes, I read on the Internet that this could be a sign of leukemia. This could be a sign of an immune problem," so just stopping for 45 seconds and just explaining, "Johnny's in daycare. Most kids in daycare, at first you're going to have six to nine colds." This is what you expect. This is what I'm worried about — if he loses weight, if he doesn't develop right, if he got several pneumonias.
So mom walked out of there a lot happier. It didn't change my diagnosis, it didn't change the way I thought about that patient, but it sure changed the way mom and I connected.
Dr. Mike Patrick: And even just a quick explanation of how the immune system works, that you have to catch every single virus that comes along so that you have protection against that virus in the future, which means he may be sick more often now, but a few years from now, he's not going to be sick as often because he's building immunity. I mean, taking that time to explain sort of how our body works can be quite helpful.
Dr. Alex Rakowsky: And then, they came in very recently for his two-year visit. And mom's like, "He had head cold number seven and eight at home, but I knew what's going on. So I wasn't concerned about it." She really started of focusing on, "Instead of worrying about my child having cancer, I sort of like seeing all these developmental milestones, which is just great to see as a parent if you're not worried."
Dr. Mike Patrick: Yeah, yeah, absolutely. Kind of moving up hierarchy to the healthcare organization that providers work under that umbrella, Dr. Abrams what are some things that healthcare organizations can do to help with this idea of health literacy.
Dr. Mary Ann Abrams: Well, I really liked what Alex said about being patient-centered and really focusing with what's going on with the patient from their perspective. So, on top of that, there are several things that individual providers and the healthcare system can do to support those providers to really help clarify and communicate effectively.
First, we take the universal approach. We don't single out people and say "Oh, I don't think you understand. You probably do. We just assumed everybody needs clear communication techniques. Then, we try to create an environment that encourages questions. There is a program called Ask Me 3 and we would invite families and parents to think about these three questions. We want to make sure they know the answer before they leave, and we want them to make sure they have the answer before they leave — what is my child's main problem? What do I have to do about it? And why is it important? So that's the three core messages.
And then the third piece, probably one of the most important is that we use plain language, which means we used living room language. We think about it as though we're explaining things to our grandmother in the living room, not another medical colleague. So we use plain language and at the end of the whole encounter, we circle back and we make sure they really understood.
And that technique is a very special technique called teach-back, where we ask patients to explain back using their own words what they need to know or do about whatever we've been discussing. It's very important that we ask that question in a non-threatening way, not to say, "Well, tell me what I just said or repeat back to me," because that puts them on the spot. We take that burden on and say "I've given you a lot of complicated information, I want to make sure I explained it correctly and clearly. Can you tell me what you're going to tell your son's father or your daycare provider or your mother-in-law about what we're going to do about his asthma?" or his changing the diet or whatever, the food that he eats.
That circle, closing the loop with teach-back is probably one of the most important pieces.
Dr. Mike Patrick: Really just to ensure that they're understanding the instructions. And then, that gives you the opportunity to reinforce the importance of it or why it is that we're having you do this, or what difference is it going to make.
Dr. Mary Ann Abrams: And to clarify if they don't understand. Otherwise, we'll never know.
Dr. Mike Patrick: Yeah, I also like the universal precautions kind of approach that we're just going to use plain language and think about health literacy for every patient.
Just as an example, I recently had an encounter where moms and internal medicine and dad is a cardiologist, but this is a pediatric problem. And so, that's not something that they're used to seeing in their world. And so, even though they're physicians they really still were appreciative of things being explained sort of a basic level. I could use a little more maybe anatomical correct words, and they appreciated that. And in fact that's how I found out they were physicians because I wasn't using those terms.
But still, in terms of the actual problem, I think that they really appreciated that sort of basic level of talk. But that's still not dumbing down the science, is it?
Dr. Mary Ann Abrams: Not at all and it's a perfect example because we would make assumptions that they would understand, and they might be embarrassed to admit they don't understand. So we end up cross-talking across each other. So just to assume that everyone benefits, even good reader like clear, concise information, what they need to know and they can learn more about what is nice to know later.
Dr. Mike Patrick: Yeah, absolutely. What are some resources that patients and families can use to help improve health literacy? So, let's say their child is dealing with a specific problem. Folks, the tendency is just okay, I'm going to Google it. But then, you're going to get some good resources and you're going to get some not so good resources, things that are evidence-based and things that are misinformation or based on myths. So, rather than just sort of throwing it out to Google, what are some specific places that folks can go to get evidence-based trustworthy health information where they can read up on a particular issue?
Dr. Mary Ann Abrams: They can look at several resources. They can look at professional organizations like the American Academy of Pediatrics, KidsHealth. The US federal government has the Medline Plus website. Those have a variety of good quality variety of presentations. Some things are in multiple languages. Some things are with video and easy to read formats.
So looking for those sorts of organizations, seeing how frequently those sites are reviewed and who their sources are, how they get their funding and who is on their board — those are guides for when you're looking at online information.
But I'd also suggests going to the Ask Me 3 website. You can also go to the Agency for Healthcare Research & Quality. They have a variety of questions that you can look at before you go to a visit. So you can think about some of those questions that you don't want to kick yourself later and say, "Why didn't I ask that?"
And, the other thing, I want to circle back to the teach-back piece. Not every doctor, not every nurse, not every social worker, not every respiratory therapist is going to be using teach-back. So we want patients to start asking for a teach-back. Now, you're going to say, "Please teach that back," but you can say things like "Just a minute, I want to make sure I understood what you told me, because I need to tell our daycare provider." Or, "Just a moment, this is what I heard you say," and then say what you heard them say.
And that will make the doctor, the nurse, the provider stop and say, "Oh, no, this is what I indeed said." And that can be incredibly eye-opening, because until we really know what patient heard or the parent heard, we don't really know that we were clear.
Dr. Mike Patrick: Yeah, yeah, absolutely. So really be an advocate for your own health literacy and think about these things before you go to a visit. Because in the heat of the moment, you may not think about this. You're just sort of trying to absorb it all. But if you think about it intentionally before you actually have the visit then, it may be more likely that you will seek a teach-back or make sure that you've understood something by repeating it back to the provider.
Dr. Mary Ann Abrams: And don't be afraid to ask question. Even though the health care settings seems a very busy place, we want questions. We welcome questions. So please be sure to ask if you want to invite someone else to come with you to a visit to help you remember, that's always good. Write things down. If you don't speak English well, we have an interpreters available. So ask for an interpreter, and take advantage of that opportunity to have someone really help foster clear communication.
Dr. Alex Rakowsky: Yeah. And just to follow up on what Mary Ann said, parents shouldn't think that they have to walk in to every visit being well-versed on the child's development or some disease process. But at least know that you can always ask questions. At least know you can always stop and say, "Can you just explain this to me better?" And I definitely recommend to parents to ask for resources at the time of their visit.
And all of us have resources about, "This is what's going to be happen by 12 months. This is the food that you should be introducing. This is basic care of your diabetes." So, even if you don't know what to ask upfront, ask for the resources, so by the next week, you can read some of these things and you can call back in.
Dr. Mike Patrick: And I love the answer to the question in terms of what are resources that you can use rather than just Google something. And instead of digital resources, let's use human resources. And sort of getting together what questions you're going to ask, instead of asking Google, ask those questions to your provider the next time you go in. That's a great advice.
Some of the websites that Dr. Abrams had talked about, Ask Me 3 is from the National Patient Safety Foundation. And it just gets you thinking about how to ask about the main problem, what you need to do and why is it important for you to do this, which really speaks toward understanding the disease process and why we are recommending various treatments for it. So if you understand sort of the underlying science, then it's easier to see why it's important and be invested in following those recommendations.
And then, the other was the Agency for Health Care Research & Quality, which is part of the US Department of Health and Human Services, Questions Are The Answer which just gives you some sort of work-through, some ideas on what to ask before a visit, during a visit, and after your appointment.
So those are great resources. I'll put links to both of those in the Show Notes for this episode, PediaCast 354, over at PediaCast.org.
And then, in terms of just general health information that would be evidence-based and trustworthy that you had mentioned, the American Academy of Pediatrics and HealthyChildren.org is a great place to go. They also have pediatric patient handouts which families can look for, but also providers can use that as a resource for helping folks understand.
Here at Nationwide Children's Hospital, we have a program called Helping Hands which are also patient handouts on a variety of conditions. I'll put a link to both of those resources.
And then, Nemours, they have KidsHealth out there for quite awhile. And Mayo Clinic also has a great patient care and health information resource. And of course, the government has Medline Plus, which is another trustworthy evidence-based resource. And again, links to all of these are in the Show Notes for this episode.
We've kind of hinted around this concept of plain language as we've talked about health literacy. Dr. Rakowsky, what is plain language? And then, we'll take it a step further and tell folks about the plain language pledge.
Dr. Alex Rakowsky: So plain language is something that Mary Ann had brought up. It's not dumbing down the science. It's using terminologies that people are more comfortable understanding. So it's essentially using terms that are more commonly used instead of scientific or medically used terms.
Dr. Mike Patrick: Yeah, so we can explain something that's complex. But by using plain language, again we're not dumbing down the science, we're just explaining it in terms folks can understand, but they're still getting the science behind what we're saying.
Dr. Mary Ann Abrams: It's no different than as a healthcare provider going to talk to your car mechanic or your accountant or your lawyer. We don't understand that technical language. We have education, et cetera, but we still need that to be in plain language for us. So, it's a trade-off between being clear and… It's not really a trade-off. It is a way of translating what we're saying into words that people understand.
Dr. Mike Patrick: So as an example instead of saying, you may have an adverse reaction, just say, "Well, here's the side effects." Or, instead of hypoglycemia, we're going to say low blood sugar. Or instead of topical, "This is something you're going to apply to the skin," that sort of thing.
And then, what is the plain language pledge?
Dr. Alex Rakowsky: So it's essentially finding a few words that you "know", that you use over and over again. And I'll put "know" in quotation marks, because sometimes you have no idea that you're using this. I love ID, infectious disease, so I use cellulitis a lot and it wasn't until one of the interpreters looked at me who had no idea what cellulitis was and said, "What is that before I translate into English?" So it made me realize that maybe I use this term instead of skin infection.
So, as one of the residents doc actually tagged along when I was talking to the next patient. She's like, "P3 the… through that term like five times." So it was essentially a self-acknowledgment that I use a term that patients probably have no idea what I'm saying. So the pledge is essentially you take the terms that you know that you're using or ask somebody else to kind of just tag along with you a couple of visits, that they noticed that you're using and try to use a term that you think people are going to understand.
Dr. Mike Patrick: Or use the bigger term but then explain what that is in language folks can understand. Because then, you might build their vocabulary a little bit. But still, don't go just with that technical term.
Dr. Alex Rakowsky: I think it's an important point, because when you discharge them, the diagnosis is there. And, of course, it's a cellulitis. So, if you say it's a skin infection, they walk out, "So it was a goo. You hid something from me." So I think you can say, "Yeah, this is a skin infection which we technically call cellulitis." So they'll at least know what's that term.
Dr. Mike Patrick: And impetigo, that sounds even worse than cellulitis, right? But it's not as bad, usually.
Dr. Alex Rakowsky: Or erythema toxicum neonatorum, that's scares a lot, yeah.
Dr. Mike Patrick: Which is just in plain language…
Dr. Alex Rakowsky: Baby acne.
Dr. Mike Patrick: Yeah, right. Exactly.
And especially for providers who would like to get in on this, for Health Literacy Month, you can take a selfie of a poster that says "I pledge to use… " and then the plain language term, instead of and then the technical term with a red circle and a line through it. And then, put it on Twitter, #plainpledge. If you want to know exactly what I'm talking about just do a search for #plainpledge and you'll see more of these.
Also #nchplainpledge and that will get you one that are specific that folks here at Nationwide Children's are doing during the month of October. And then join in with your own because you may have some great ideas of plain language.
And then, there are also some sites that both providers could use to help if you're searching for plain language terms. But I think these sites are also helpful for patients and parents and families, because you can search the reverse way if you see a term and you want to know what does this mean. There's a plain language medical dictionary from the University of Michigan that has a searchable online database that kind of converts technical terms to plain language. And we'll put a link to that in the Show Notes for this episode, PediaCast 354, over at PediaCast.org, along with all of the links that we've been talking about.
Also, if you're interested in health literacy, and especially for the providers out there in the audience, I do want to mention that we did also a PediaCast CME on health literacy. And we offer free Category 1 Continuing Medical Education and faculty development credit for those who listen. It's really an hour-long presentation for Health Literacy Month. And we not only talk about health literacy from a providers' point of view and from patients and families, but also from a system point of view, from health organization point of view, and also what are some examples of health literacy projects that are going on in the world of research with health literacy.
So if you're interested in a deeper presentation of this topic, check out PediaCast CME and that is Episode 20. PediaCast CME 20 over at PediaCastCME. org.
All right, well, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, really thank you both for being with us today.
Dr. Alex Rakowsky: Thanks also, Mike.
Mary Ann Abrams: My pleasure. Thanks.
Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Bob Weil, The Sports Doctor from the Sports Doctor Radio at HealthyLife.net. Also, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both of them ambulatory pediatricians here at Nationwide Children's Hospital.
That is all the time we have today. PediaCast is a production of Nationwide Children's Hospital.
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Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast. time on PediaCast.