Humanism through the Lens of the Academic Pediatric Association
Article Outline
- What Does Humanism Really Mean?
- Examples of Humanism within the Four Pillars Of the APA
- Why is Humanism Important to Emphasize Now?
- Acknowledging our own Humanism as Medical Providers
- Strategies of Well Being and Self-Care
- References
- Copyright
A year ago today, I remember with vivid clarity standing before you as the Academic Pediatric Association (APA) President Elect while I moderated the Presidential Plenary session. I was quite nervous, hadn’t slept well the previous evening, but a quote by Eleanor Roosevelt kept coming into my mind. “Do something that terrifies you each day.” That sentiment certainly fit the bill for me that day.
I appreciate certain aspects of this quote, which stress the importance of trying new things, extending outside your comfort zone, exposing yourself to new adventures and seeing challenges as opportunities. This past year as President of the APA has been an amazing journey, and this journey has exposed me to new experiences and allowed me to meet an incredible number of new and interesting people. So I thank you for allowing me this opportunity.
My additional disclaimer is that I have been mentored, influenced and inspired by so many members of the APA and many of you in the audience.
The objectives of this presentation are to:
What Does Humanism Really Mean?
I find some people tune out when they hear the word humanism and interpret this word as “just being nice.” But there is more depth and substance behind this concept that I plan to share with you today. There are several definitions of humanism, but the following 2 demonstrate both the variability and common themes. The first was proposed by Edward Pellegrino, a well-known ethicist, who stated that humanism is “[A] set of deep-seated convictions about one’s obligations to others, especially those in need. Encompassing a spirit of sincere concern for the centrality of human values in every aspect of professional activity.”1
The second definition was proposed by Susan Block. She states that humanism is “[T]he attitudes and actions that demonstrate interest in and respect for patients that addresses the patient’s concerns and values. These generally are related to patients’ psychological, social and spiritual domains.”2
Going back in time to another Presidential Plenary session, I remember sitting in the audience and hearing Lucy Osborn given her Armstrong lecture, entitled “The Power of One” (Lucy Osborne, personal communication). With my training as a Robert Wood Johnson general academic pediatric fellow and my research experiences, I had been taught to rely on evidence-based medicine, to develop public health interventions that affect populations, and to strive for large sample sizes. Dr. Osborne’s talk reminded me to look closer. Although having an effect on large populations is a noble goal, it is equally important to know the individuals who compose these populations. As we look at a crowd of people, it is important to look at the individuals who comprise the crowd and ponder what are an individual’s characteristics and perspectives that make him or her unique as a human being. I found that seeking the individual differences and developing those relationships bring the greatest joy and meaning in my work; that is, to focus on humanism.
Humanism has been a cornerstone within medicine since the very beginning of its history. First described by Hippocrates in 400 BC, his concepts continue on in the Hippocratic oath, where the physician’s duty is to benefit the sick and keep them from harm and injustice.3
In 1902, Sir William Osler emphasized the concept of humanism with his quote, “It is more important to know what kind of person has a disease than what kind of disease a person has.”4
In 1927 Francis Peabody published “The Care of the Patient” in the Journal of the American Medical Association. He emphasized that medicine is not a trade to be learned but a profession to be entered. The art of medicine and the science of medicine are not antagonistic but complementary to each other.5
In 1983 a subcommittee of the American Board of Internal Medicine wrote a position paper on the evaluation of humanistic qualities in the internist.6 In their pivotal statement, this subcommittee emphasized that essential humanistic qualities would be required of their candidates, that a major responsibility of resident training includes an emphasis on these qualities, and that methods of assessment were needed to advance the evaluation of these attributes in candidates of internal medicine.
Currently, the Arnold Gold Foundation has a presence at many of your medical schools and emphasizes the importance of humanism within medical education and practice.7, 8 Some examples include acknowledging individuals who demonstrate humanistic qualities and the power of traditions, such as the white coat ceremony, to demonstrate the importance of maintaining humanism within the field of medicine.
I was surprised that there hasn’t been much written on humanism from a pediatric perspective, nor a policy statement from pediatric organizations. I believe policy statements are important because they set expectations and also serve as a compass to guide the direction of a discipline or an organization. I found the lack of a pediatric policy statement surprising because Osler envisioned pediatricians as political beings who are involved in social policy and Dr. Halpern in his book, American Pediatrics, noted that the conceptual roots of pediatrics lie in health-related social problems.9
When I spoke with members of the American Board of Pediatrics and proposed the importance of a pediatric policy statement, it was mentioned that humanism is included under the Accreditation Council for Graduate Medical Education competency of professionalism.10 Although this is true, I see them as distinct and believe there is a need to focus specifically on humanism. The author, Jordan Cohen, in his paper in Academic Medicine, makes a distinction between professionalism and humanism. He discusses that professionalism is a way of acting that includes observable behaviors that meet the expectations of patients. Examples of professionalism include competence, honesty, maintaining patient confidentiality, and responsibility for patients. Humanism is a way of being that comprises a set of deep-seated convictions about obligations to others, in particular helping others in need. Examples of humanism include altruism, integrity, compassion, and respect for others and for the human condition. In summary, Cohen states that “[H]umanism is the passion that animates professionalism.”11
One mechanism by which to promote humanism in medicine is to integrate the humanities into professional training. Although some clinicians may have had exposure during their premedical studies, others may not have had such opportunities. The humanities allow a dialogue between health care providers and their patients by instilling a feeling for the human condition, tapping into our humanistic perspectives and understanding aspects of everyday life, and crossing boundaries of health care hierarchies to help us to better understand our patients.12 The discussion of the humanities, whether it is through art, literature, film, or music, allows the sharing of differing perspectives and allows a community to scrutinize its own values and meanings.13
Osler was an advocate of incorporating the humanities into medical training. He made a practice of reading nonmedical literature for 30 minutes before bed each night and felt that “The wider and freer a man’s general education, the better a practitioner he is likely to be.” This broader education allows health care professionals to better understand the human condition and to include aspects of philosophy and ethics within our medical practice.14
Examples of Humanism within the Four Pillars Of the APA
Let us now explore humanism within the core foundation of the APA. The mission of the APA is to improve the health of all children and adolescents through leadership within these 4 pillars:
As we celebrate the end of the APA’s 50-year anniversary, I have reflected both on the amazing role models who were the early leaders within the APA and how humanism was at the core of their contributions. Although there are countless examples, I would like to acknowledge a few examples of the early leaders.
I will pair examples of the humanities through art work or literature to introduce each of the 4 pillars of the APA.
Humanism in Medical Education
This painting by Robert Hinkley from 1882 (Fig. 1) depicts the first demonstration of surgical anesthesia use at a major institution. Although this painting is present on the cover of many medical education textbooks, I don’t feel it depicts the patient in a very humanistic manner. At first glance I thought the one physician is holding the patient’s hand, yet on closer inspection you can see he is monitoring the pulse. We have come a long way in medical education in ensuring that we respect and address the needs of patients within our educational mission.
Figure 1
First Operation under Ether by Robert C. Hinckley, 1882–1894. From the Boston Medical Library in the Francis A. Countway Library of Medicine. Used with permission.
One of our early APA leaders, Dr. Evan Charney, was pivotal in developing resident education in primary care.15 During the 1970s, residency training was focused on hospital-based patients, with little attention to aspects of prevention, chronic disease, or the joys and satisfaction of general pediatric ambulatory practice. Dr. Charney emphasized the importance of the social aspects of medicine, legitimized primary care medicine, and identified the best ways to ensure that residents received the training they needed. He demonstrated humanism at the level of our trainees and to our patients.
Within education, I must also mention 2 very beloved APA colleagues, Richard Sarkin and Steve Miller, who were role models for humanism and served as scholars for the Gold Foundation. Their premature deaths in a plane crash remain an important reason for us to continue to pursue humanism as part of their legacy.
Dr. Miller, in conjunction with Dr. Schmidt, wrote an article entitled “The Habit of Humanism: A Framework for Making Humanistic Care a Reflexive Clinical Skill.”16 They state that one can develop a habit of humanism that can be taught and emulated at our medical institutions. The first of the 3 essential components is to identify the multiple perspectives in any clinical encounter, which includes the perspectives of the patient, the patient’s loved ones, and the health care provider(s). These perspectives may include those of gender, age, developmental stage, culture, and religion. This component emphasizes the health care provider’s ability to understand the patient’s and family’s concerns when coming to seek care. The second component is to reflect on how these perspectives might converge or conflict. This reflection allows us to become self aware of our own biases that we may bring to a situation. The third component is to choose to act altruistically, which means to incorporate and respect the patient’s perspective. These authors reinforce that humanism can be taught, our curriculum and medical cultures need to emphasize humanism to reinforce these behaviors in everyday opportunities and there must be time for reflection towards habitual humanism.
Humanism in Research
Looking at humanism in research reminded me of the book, The Immortal Life of Henrietta Lacks (Fig. 2).17 This book describes the development of Hela cells and the impact not only on medical research but also on the patient, from whom cervical cells were taken without her knowledge or that of her family. Although these events took place in the 1950s, before the time when institutional review boards had been established or the perspective of the patient as a partner in research was appreciated, the ethical issues presented in this book are fascinating and should be required reading for those who participate in clinical research.
Figure 2
The Immortal Life of Henrietta Lacks by Rebecca Skloot. Crown, 2010. Used with permission.
One example of an early APA leader committed to humanism within research is Dr. Barbara Korsch, one of the founders of the APA. Her vision was to make work in ambulatory care a professional avenue with academic acknowledgement and rewards and she emphasized the power of disseminating research findings to improve patient care. What is a more humanistic venue than to study communication and the doctor patient relationship? By examining 800 videotape encounters, which was a very innovative strategy at the time, Dr. Korsch, along with Vida Frances and Marie Morris, found that the extent to which patients’ expectations from the medical visit were left unmet, the lack of warmth in the doctor–patient relationship, and the parent’s failure to receive an explanation of diagnosis or cause of the child’s illness were key factors in noncompliance of patient.18 These are findings that have served as the basis for subsequent research in adherence and strengthening the doctor–patient relationship.
Dr. Korsch also wrote in an editorial titled, “Issues in Humanizing Care for Children,”19 about the psychological welfare of children and their care in the hospitals. At that time it was considered standard of care for parents to have limited access to their children, with visiting times restricted to once a week. The observation was that children were better behaved and easier to manage when their parents were not present. Staff misinterpreted the increased submissiveness and compliance of young patients as better adjustment to the hospital as opposed to depressed affect. Dr. Korsch remarked on the power of clinical research in disproving those beliefs and helped lead to the active involvement of parents in their children’s care, a precursor to family- and patient-centered care.
Humanism in Public Policy and Advocacy
Figure 3, representing humanism in public policy and advocacy, is a painting by Salvador Dali from 1950 titled “Washington.” Dali was commissioned by the Lasker Foundation, whose sole purpose was victory over disease and death by increasing federal funding, resulting in the development of the National Institutes of Health.
Figure 3
Winged Victory Over Washington by Salvador Dali, 1950.
Courtesy of the Chazen Museum of Art. © Salvador Dalí, Fundació Gala-Salvador Dalí, Artists Rights Society (ARS), New York 2011. Used with permission.
It is easy to connect advocacy with humanism because the core of advocacy often comes from knowledge of harm from individual cases and patient stories, collating these cases, and striving for social justice to protect those in need. Joel Alpert, MD, was such a leader and he was well known for his work in injury prevention. He published an article on “Accidental Poisoning and the Law.”20 Dr. Alpert was concerned about the tragic outcomes of young children who might lick the cap or drink from a bottle of lye, resulting in permanent esophageal strictures and resultant morbidity. Dr. Alpert advocated for a law that mandated that all household substances potentially harmful to children be marketed in special packaging to reduce the likelihood of accidental ingestion. In addition, he went on to create legislature for child resistant containers, and the development of poison centers, visions that became a reality.
Humanism in Patient Care
This portrait entitled, “The Doctor” by Sir Luke Files in 1891 (Fig. 4), is probably one of the best-known paintings of a physician. Sir Fildes had a son who died 14 years before he painted this picture. This represents a profound image of the dedication of the pediatrician towards his patient. The look of concern, vigilance, and caring as this doctor watches over his patient portrays the humanistic characteristics of compassion towards which we should all strive. The doctor’s comforting presence is in his vigil as a healer, in remaining present.
Figure 4
The doctor by Sir Luke Fildes, 1891. Private collection. Used with permission.
For APA leaders in clinical care, I chose to highlight the work of Dr. Robert Haggerty and Dr. Morris Green. Dr. Haggerty is known for the development of the concept, the New Morbidity. Through his work as a hospitalist in the 1960s, he noted that infectious diseases had become less prominent with the dissemination of immunizations and identified the need to address “ the new morbidities,” which included behavioral aspects, psychological components of care, and their impact on the family.21, 22
Dr. Haggerty referred to his good friend, Dr. Morris Green, as the “complete” pediatrician. Dr. Green was known for his attention to the doctor–patient–parent relationship. He taught that listening was the most important tool that one can bring to an encounter. His work in developing the APA Health Supervision Guidelines23 and later Bright Futures24 focused on individual perspectives such as understanding a child’s personality, assessing a family’s agenda, and focused strategies of strength and resilience of families. The emphasis was on the individualized patient, and specific examples of questions are given that are necessary to assess the family, their values, perspectives and beliefs.
Although I have stressed the individual pillars of the APA, the reality is that there is much cross-fertilization and most of these early leaders, just as many generalists today, have devoted their careers to multiple pillars, if not all of them.
The APA continues to address humanism through multiple venues in education, research, public policy and patient care. Current examples include:
Why is Humanism Important to Emphasize Now?
There has been an explosion of new technologies within the past decade. Extracorporeal membrane oxygenation, organ transplantation, and gene therapy are just a few examples. However, concerns exist that increasing technology focuses on science and economic consideration, with less attention to the components of humanism and the doctor–patient relationship.
Also, our world is experiencing changes in communication. We correspond by e-mail and texting even when colleagues are in the next office or across the room. Many of our medical institutions have transitioned to a computerized order entry system so that orders can easily be written far from the patient and the unit where the patient is located. Although efficient, this has influenced relationships both with patients and with other health care providers and disciplines. Work hour reductions have raised similar concerns. While these regulations may lead to a benefit in work life balance, there is more concern about shift work and less time available to spend with patients.
With all these changes, we need to adapt the concept of dual intelligence. We must interact with patients at both the intellectual and emotional level. Although understanding and communicating the intellectual components of disease, physiology, and treatment are important, understanding and connecting at an emotional level demonstrate we respect the values and beliefs of our patients.25 The practice of medicine combines the life sciences with humanism. The science and art are not antagonistic, but rather complementary to each other. Both are essential.
What has become interesting to me is that although humanism has always been important, it seems more apparent in the venues of palliative care and global health. In these venues there is less reliance on technology and more reliance on ourselves, our skills and communication. It makes me wonder whether the resurgence of interest in global health by residents may reflect their desire to get back to the patient, to better understand the meaning of their professional calling, and to rediscover why they pursued this profession.
Yet, I feel it is equally important to emphasize humanism in everyday opportunities. Regardless of the medical setting in which one works, exhibiting humanism is paramount to the human needs of individual patients during everyday encounters. As health care providers, we see many human beings in crisis. We must understand their sense of crisis, address their point of view, respect their past health care beliefs, self-image, and listen to their personal stories that they want to tell.26
Acknowledging our own Humanism as Medical Providers
Our work involves interacting with families and patients in crisis on a daily basis. Did you know that the word patient comes from the Latin, patiens, which means to suffer? The suffering may be physical or emotional.27 Yet the Prayer of Maimonides guides us as health care providers in saying, “In the sufferer, let me only see the human being.”28
For us to work with patients who are suffering, we must also acknowledge our own suffering, hence humanism to self. Just as patients suffer, health care providers also suffer. We suffer by acknowledging our own imperfections, fatigue, medical errors, and discomfort with medical uncertainty. Critical incidents during medical education may impact us and produce emotional and psychological defenses.
Imagine the following. You are an intern during your first month’s rotation. Your 3-year-old patient, Heather, is admitted, secondary to relapse of leukemia. One day during rounds, she coughed one time. She didn’t look sick, but because she was on immunosuppressive therapy, the attending suggested that a chest x-ray (CXR) be ordered and you do so. However, because you were so busy you forgot to check the results. The next morning when you return to the hospital, you see Heather and remember. Much to your distress, the CXR reveals pneumonia and you immediately talk with your team and start antibiotics. However, Heather progressively becomes sicker, and she dies 4 days later while you are on call. You feel so sad and guilty that you are unable to be present for the mother or to comfort her, nor are you able to sleep that night.
The next morning on rounds members of the team ask about Heather, and you inform them she has died. Instead of a discussion about the chain of events, however, the team moves on to the next patient. You fear the chair of your department might call you to fire you. You fear a lot of things, but much to your amazement no one says anything.
It was as if it had never happened.
You have probably figured out by now that I was that intern. I didn’t talk about this with anyone, and no one discussed it with me. I didn’t cry, but I did suffer in silence and isolation.
About 6 months later I was working in the pediatric intensive care unit and a 9-year-old girl presented with relapse of acute lymphoblastic leukemia, the same diagnosis as Heather. She was septic, quite ill, and died 24 hours later. Although I had never spoken with her nor gotten to know her, I ran from her bed crying. I realized then that I was finally mourning Heather’s death and how unhealthy it had been that I had never discussed it with anyone, had never had a forum to gain insight into my actions or emotions.
I reflected on this experience for a long time. I will never know whether the 24-hour delay in antibiotics caused Heather’s death, but I think it did. I didn’t know if my bigger failure was forgetting to check the CXR or being unable to be emotionally present and support Heather’s mother. I failed in my role as a healer. I wrote a narrative on my experience 20 years later.29 After it was published, the person who had been my senior resident during my oncology rotation read it and called me. He was one of the most compassionate people I have ever known. He told me he was sorry. At first I laughed with him and asked whether he was expressing sorrow because he thought it wasn’t a very good article. But rather, he stated he was sorry because he still remembered this experience, now 20 years later. He had known I was suffering but didn’t know how to approach me or what to do. And I hadn’t known how to reach out to others. This is an example of the need for humanism to our patients, to our colleagues and to ourselves.
I know that I am not alone in this journey. From my work with pediatric residents, medical students, faculty, and fellows, these emotions and experiences still occur. Research from Uganda demonstrates that even in environments in which death is a daily event, emotions of sadness, guilt, and self-doubt occur frequently.30 Of note, the AAP Section on students, residents, and fellows has recently stated that finding ways to address their grief and loss is a top priority, so these issues remain important today. It is refreshing to know that addressing these issues has reached a national priority.
We have a duty to address both the physical and emotional pain of our patients and address their suffering. Although in my case it had seemed easier to avoid that pain and distance myself from the patient, to avoid this discomfort is unkind, leaving patients and families alone with their fears and sadness and the perception of abandoning them in a time of need.25 We have an obligation to relieve and address emotional suffering as much as physical suffering. Given that health care professionals should and need to be present and bear witness, we need to develop ways to better support health care providers.
But how do we bridge this continuum, to embrace the suffering of our patients, acknowledge our own imperfections, and maintain the joy and meaning in our work? To do so we must accept and share our own humanity and vulnerability.31 To maintain our work as humanistic providers, we must be nourished ourselves and maintain our resilience. We need to change the medical culture to make it transparent as to how we as heath care providers deal with these issues, and acknowledge that it is normal to feel the pain and suffering, but important not to avoid it, but to embrace it.
As mentioned by Dr. Novack, “[W]e have an obligation as educators to share with learners how we have coped with feelings of anger, anguish, shame or uncertainty in caring for patients.”32
Although my experience had been a painful one at the time, I have also found it in retrospect to be a gift. It allowed me to understand the importance of being present for families, the honor of the service we provide, and the importance of self-care. Some of the most rewarding experiences with patients have involved traveling with them on their journey of suffering. What a privilege when families and patients allow you to travel with them.
Strategies of Well Being and Self-Care
To maintain our work as humanistic providers, we must be nourished ourselves. We need to strive for well being through taking care of ourselves. Wellness goes beyond the absence of distress. It is an active concept that includes being challenged and thriving in various aspects of our personal and professional lives.
I have always found it important to look for evidence and so have searched the literature for evidence about well- being and self-care. Although currently a strong evidence base does not exist for self-care, the surprising finding is that in the 5 manuscripts on the promotion of well-being, the authors emphasize remarkably similar themes. These manuscripts include surveys and individual reflections from internal medicine faculty, primary care providers, hospice workers, residents, and also remarks from the St. Geme address given by Dr. Stephen Ludwig.33, 34, 35, 36, 37
The main domains for well being promotion include the following:
Although these themes are similar, these strategies for well-being and self-care must be individualized. One size does not fit all. This is an individual and personal journey. Each of us must find the strategies that work for us.
I am sure my husband is laughing by now because I have not been a good example of self-care during these past few busy months. Perhaps the main point is not to do this perfectly but rather to develop self-awareness when you are not in balance and to use the strategies that work for you to get back into balance. Let us use as a motto this quote by Cadib, “The secret of the care of the patient is caring for oneself while caring for the patient.”
In conclusion, humanism has been at the core of the APA mission. Humanism is essential to our work as health care professionals, and we should strive to demonstrate humanism everyday towards our patients, colleagues, and ourselves. There are several ways to advance the humanism agenda. These include the development of an APA policy statement on humanism, the development of a curriculum for health care professionals on addressing grief and loss to better care for ourselves, and to develop research to determine the benefits of wellness and self-care on health care providers, productivity, patient care and patient satisfaction.
I would like to offer my thanks to so many: to my colleagues at my institution who have supported me, to the APA Board and the APA Administrative staff, who brought such pleasure to the job of President, to the members of the Continuity SIG and CORNET, who remain at my core, to my many mentors, many of whom are residents and fellows with whom I have worked, and to Modena Wilson and Henry Seidel, who demonstrated such amazing examples of what it meant to demonstrate humanism every day.
And finally thanks to my husband, Mal, my power of one. He is the one who deserves a great deal of thanks today because he has supported my work within the APA. To be able to journey through life and through the world with him as my partner is my greatest joy.
References
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- . Nurturing humanism through teaching palliative care. Acad Med. 1998;73:763–765
- . The Hippocratic Oath and the Ethics of Medicine. New York, NY: Oxford University Press; 2004;
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- . Evaluation of humanistic qualities in the internist. Position paper. Ann Intern Med. 1983;99:720–724
- . Humanism in medicine from the perspective of the Arnold Gold Foundation: challenges to maintaining the care in health care. J Child Neurol. 2006;21:546–549
- Gold Foundation website. Available at: http://humanism-in-medicine.org/. Accessed August 25, 2011.
- Halpern, Sydney A. American Pediatrics: The Social Dynamics of Professionalism 1880-1980. Berkeley, CA: University of California Press; 1988.
- Accreditation Council for Graduate Medical Education. Available at: www.acgme.org/acWebsite/home/home/asp. Accessed November 23, 2011.
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- . Accidental poisoning and the law. N Eng J Med. 1971;284:611–612
- . The “new morbidity.”. In: Haggerty RJ editors. Child Health and the Community. New York, NY: John Wiley and Sons; 1975;p. 461–486
- . The child, his family and illness. Postgrad Med. 1963;Sept;228–233
- . Guidelines for Health Supervision. II. Elk Grove Village, IL: American Academy of Pediatrics; 1988;
- In: Green M, Palfrey JS, Clark EM editor. Bright Futures: Guidelines For Health Supervision Of Infants, Children, And Adolescents: Pocket Guide. 2nd ed.. Arlington, VA: American Academy of Pediatrics; 2007;
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- . Humanism in emergency medicine. Am J Emerg Med. 1993;11:556–559
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- The Prayer of Maimonides. Available at: http://www.library.dal.ca/kellogg/Bioethics/codes/maimonides.htm. Accessed August 25, 2011.
- Serwint JR. Physicians must address emotional toll of patient’s death. AAP News, August 2004. Available at: http://aapnews.aappublications.org/content/25/2/81.full. [Subscription required]. Accessed August 25, 2011.
- Serwint JR, Howard CR, Musoke P. When death is a daily event: pediatric residents’ experiences and reactions to patient deaths in Uganda Africa. Platform presentation at the PAS Meeting, San Francisco, CA, May 1, 2004.
- . Viewpoint: professionalism and humanism beyond the academic health center. Acad Med. 2007;82:1022–1028
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- . Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857–1861
- A qualitative study of physicians’ own wellness-promotion practices. West J Med. 2001;174:19–23
- . The well-being of physicians. The Am J Med. 2003;4:513–519
- . The Joseph W. St. Geme Jr. Lecture: striving for “Polygamy.”. Acad Pediatr. 2011;11:5–8
- . A self-care plan for hospice workers. Am J Hospice Palliative Med. 2005;22:125–128
PII: S1876-2859(11)00285-3
doi:10.1016/j.acap.2011.09.007
© 2012 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
