Corner Clinic

1. My child has outgrown a pediatrician, now what?
2. What is computer vision syndrome and how can I prevent it?
3. Does every woman get hot flashes and how long do they last?

My child has outgrown a pediatrician, now what?

The summer before I left for college, I visited my physician for my “last check up.” There were no prolonged good-byes or discussions about transferring my medical records, but it was clear that I was finished seeing my doctor. In retrospect, it was akin to walking out the door of my “medical home” with my bags packed and having no idea where I might be headed. Since I was relatively healthy, I only saw a physician two or three times for acute visits during my undergraduate and medical school years; and it was not until my pediatric residency that I established care with a gynecologist.

One would hope that a few decades later, we are doing a better job of assisting emerging young adults in their transition to adult health care providers. In speaking to my own children (ages 23, 20 and 17-years-old) and others in this age group, however, it is clear that we have more work to do. While there is not a one-size-fits-all way to make this transition, there are ways to think about this move ahead of time.

In 2011, The American Academy of Pediatrics (AAP) partnered with the American Academy of Family Physicians and American College of Physicians to release a report titled “Clinical Report—Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home.” In it, they state that the goal is to “…maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood.”

Although the document is geared toward physicians, the steps of transition from pediatric to adult medicine are ones that can also be considered by teenagers and their parents.

1. Discuss the medical transition policy in your provider’s office. Some offices have a formal policy regarding when and how patients are transitioned out of the practice. If you don’t see anything posted, ask your physician if such a plan exists. This discussion could begin as early as 12 to 13 years of age.
2. Initiate a transition plan. If you or your child has chronic health care conditions or disabilities, this may need to begin earlier rather than later. Your pediatrician should be aware or can help research adult health care providers who are able to care for the specific health conditions that you or your child has. Conversations can then begin with your family, as well as the adult providers about the process and timing of transitioning. For teens that are healthy, the initiation of a transition plan can occur later (early high school years).
3. Review and update the transition plan at each annual check-up. In the early teenage years, this will likely be a brief discussion; but as one moves into the later years of high school, discussing young adult health care providers who are available along with ways to contact or meet them should be a part of this review.
4. Implement an adult care model. This means that the patient assumes all or nearly all of the responsibility for their health care, including interactions with office staff about appointments, tests and follow up care. This should happen somewhere between the age of 18 to 21-years-old for the majority of patients who do not have complicated medical conditions.

Because the Affordable Care Act allows the majority of dependents to remain on their parents’ insurance until age 26, some pediatric offices are transitioning to the adult care model for their emerging young adults using adolescent medicine physicians, adult mid-level providers or physicians trained in both pediatrics and internal medicine. If this is not the case in your pediatric office, implementing this model means making the move to a new office and new provider. The AAP recommends that if a student is going away to college, the transition to an adult care model should happen prior to leaving for college. If this cannot be done in the current provider’s office, the transition to an adult provider should happen early enough to feel established in the new office prior to leaving home.

What is computer vision syndrome and how can I prevent it?

Over the last few decades, computers have become a part of daily life both in the workplace and at home for millions of people. With prolonged use of computers, an increasing amount of patients could experience computer vision syndrome (CVS). CVS refers to a collection of symptoms associated with the use of computers and other screens, such as phones and tablets. These symptoms can include any combination of internal ocular symptoms (eye strain or ache), external ocular symptoms (burning, irritation, tearing or dryness) or even visual symptoms (blurry vision or double vision).

Studies suggest that dry eyes may be a result of a reduced blink rate as we stare at screens and increase the exposure of the cornea. Other studies show that eye strain may be the result of our visual system constantly focusing and refocusing based on the pixelated screen, which does not happen when reading printed material.

More studies are being conducted as to which methods can best help relieve CVS. Some propose positioning the top of a monitor at eye level so that the observer’s gaze is downward in order to minimize dryness. Eye care practitioners commonly recommend the “20-20-20 rule.” For every 20 minutes of computer work, take 20 seconds to look at least 20 feet away before resuming your computer work. To help with dry eyes, using over-the-counter, preservative-free artificial tears can also help. Computer prescription glasses can help relieve some fatigue and an amber or yellow tint in the lenses can help improve the contrast on the screen. Since symptoms of CVS can vary, it is important to have an annual eye exam with an optometrist or ophthalmologist to check for refractive error and general eye health.

Does every woman get hot flashes during menopause and how long can they last?

Hot flashes are one of the most common symptoms associated with the menopause transition, occurring in up to 75 percent of women. Hot flashes are recurrent, transient sensations of heat, occurring in the upper body and face and can be associated with flushing (redness) and sweating. Typically, an individual hot flash lasts for a few minutes and can recur during the day with variable frequency. When occurring during sleep, hot flashes are experienced by women as night sweats and can be disruptive to sleep, causing frequent awakenings.

While hot flashes are a common experience during menopause, the severity and frequency of the symptom varies among women. Many women find their hot flashes tolerable and minor lifestyle adjustments (dressing in layers, keeping room temperature cool and avoiding hot flash triggers) are often sufficient in keeping flashes controlled.

However, 10 to 15 percent of women will have more frequent and severe symptoms and will seek treatment. FDA approved treatment options for menopausal hot flashes include hormone therapy (estrogen, progesterone) and selective serotonin reuptake inhibitors (low dose paroxetine, brand name Brisdelle). Gabapentin can also be used (off label) for women desiring to avoid estrogen therapy. Over the counter herbal therapies tend to be less effective for moderate to severe hot flashes and are generally not recommended.

While older studies suggested that hot flashes tended to taper off over a short duration of one to two years, more recent studies suggests a longer duration of hot flashes. The Study of Women Across the Nations (SWAN) found that among the cohort of 1,449 US women, the median duration of hot flashes was 7.4 years. Understanding that hot flashes can last for more than just a few years is very important for clinicians who care for midlife women. For some women, medication for hot flashes may need to be continued for several years and stopping therapy prematurely can result in a significant decline in quality of life.

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