Letters

2. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988-995. 3. Schechter NL. Functional pain: time for a new name. JAMA Pediatr. 2014;168 (8):693-694.

Corresponding Author: Josephine Johnston, LLB, MBHL, The Hastings Center, 21 Malcolm Gordon Rd, Garrison, NY 10524 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Chambers GM, Hoang VP, Lee E, et al. Hospital costs of multiple-birth and singleton-birth children during the first 5 years of life and the role of assisted reproductive technology. JAMA Pediatr. 2014;168(11):1045-1053.

4. Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S; American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004;63(12):2215-2224.

2. Johnston J, Gusmano MK, Patrizio P. Preterm births, multiples, and fertility treatment: recommendations for changes to policy and clinical practices. Fertil Steril. 2014;102(1):36-39.

5. Gaskell H, Moore RA, Derry S, Stannard C. Oxycodone for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014;6(6):CD010692.

4. Fertility Clinic Success Rate and Certification, 42 US C § 263a–7 (1992).

Reducing Rate of Fertility Multiples Requires Policy Changes To the Editor The Chambers et al1 study recently published in JAMA Pediatrics assesses the financial burden associated with multiple births and concludes that the increased use of singleembryo transfer during in vitro fertilization (IVF) could significantly reduce health care costs, not to mention morbidity and mortality. We cannot agree more. However, as we found in our ethical and policy analysis of the relationship between fertility treatment and multiple births,2 clinicians and patients in the United States are under considerable financial pressure to eschew single-embryo transfer. These pressures are primarily the result of decisions by insurers, employers, and state governments to exclude many fertility treatments, particularly IVF, from insurance plans. The problem has several components. First, lack of insurance coverage for IVF encourages prolonged use of ovarian stimulation treatments, which are more often covered by insurance and less expensive per intervention, but which can be difficult to control and result in more multiple births than IVF.3 Second, when patients do undergo IVF, limited or no insurance coverage provides a very strong disincentive to elect singleembryo transfer because the transfer of 2 embryos still yields slightly higher pregnancy rates than transfer of 1. Third, fertility clinics’ success rates are calculated on a per-transfer basis. Since 1992, IVF clinics have been required to report to the Centers for Disease Control and Prevention,4 which publishes a report allowing patients to compare clinics. Because fertility treatment is a competitive business, clinics (like patients) have a financial interest in achieving high pregnancy rates per transfer, further disincentivizing single-embryo transfer. There are a number of arguments for (and some against) including fertility treatments in basic packages of health benefits. The cost of prematurity and other complications associated with multiple births is a powerful reason for covering these treatments. All clinicians who treat women, babies, and children should advocate for this change. Josephine Johnston, LLB, MBHL Michael K. Gusmano, PhD Pasquale Patrizio, MD, MBE, HCLD Author Affiliations: The Hastings Center, Garrison, New York (Johnston, Gusmano); Yale Fertility Center, Yale School of Medicine, New Haven, Connecticut (Patrizio).

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3. Kulkarni AD, Jamieson DJ, Jones HW Jr, et al. Fertility treatments and multiple births in the United States. N Engl J Med. 2013;369(23):2218-2225.

The American Board of Pediatrics Should Close Up Shop To the Editor The Nichols1 Viewpoint recently published in JAMA Pediatrics on the American Board of Pediatrics (ABP) begs the question of whether the ABP should have a future. I think not. When the ABP was formed in 1933, it was important for the public to have a means to identify physicians with special competence in the care of children. Now, numerous bodies (public and private) perform background checks. Patients are even able to discover what their physician eats for breakfast. Assessing physician competency interests all medical educators, especially those involved in board certification. The hitch has always been centering the search on items that can be measured, such as factual knowledge, rather than qualities that help make physicians special, like empathy and integrity. Today’s wired world diminishes the value of memorized facts. With the help of a telephone, a clinician can instantly enter a constellation of symptoms and generate a differential diagnosis. The real measure of value added by an accrediting body has to be measured by comparing it with what is widely available. Nichols envisions data captured by electronic medical records as useful to monitor quality improvement and patient outcomes. Because health supervision and treatment of viral illnesses constitute a large part of primary care practice, it is hard to contemplate what outcomes would be assessed: when a seborrheic dermatitis rash clears? The proportion of parents of infants with colic who retain their sanity? He also advocates greater emphasis on mental health content in the ABP examination. What kind of content? Probably not the skills I look for, such as providing end-of-life care, understanding the social determinants of health, empowering immigrant parents to get involved in their kids’ schools, or most importantly, being good listeners. Nichols even sees the ABP becoming involved with assessing professionalism, a quality that used to be called integrity. Other than lie detectors, finding assessment tools remains a work in progress. Long ago, while involved in studies on the relevance of residency training to pediatric practice, Steven Dassel, Ralph Wedgwood, and I came up with highly subjective measures for identifying good pediatricians. Our participants had to be respected by their peers, hold clinical appointments in pediatric departments, and care for an appreciable number of children of physicians in their practices.2 Of course, the ABP’s measures for identifying good pediatricians are much more extensive and (Reprinted) JAMA Pediatrics March 2015 Volume 169, Number 3

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Letters

1. Nichols DG. The future of board certification: learning is competency. JAMA Pediatr. 2014;168(9):789-790.

which precisely addresses those examples that Dr Bergman lists, namely, end-of-life care, empowering immigrant families to be involved in their child’s school, or understanding the social determinants of health.1 The ABP is continuing to develop examination content, life-long learning activities, and quality improvement projects around these and other professionalism topics. Parents, practices, and payers rely on the ABP certificate as a marker of pediatrician competence. Even if the ABP were to close up shop, these individuals would still seek external validation based on national standards that a pediatrician is competent, safe, and improving the quality of her or his care. Perhaps payers or the government could perform these functions, but if pediatricians hope to maintain the public’s trust, I believe it is better for us to continue to accept the responsibilities of a self-regulating profession just as we have for more than 80 years.

2. Bergman AB, Dassel SW, Wedgwood RJ. Time-motion study of practicing pediatricians. Pediatrics. 1966;38(2):254-263.

David G. Nichols, MD, MBA

expensive. Residents currently pay $2265 to take a computerized examination administered by a commercial company, Prometric. In accredited pediatric residency programs, trainees have 3 years to learn, during which their competencies are assessed. There is no longer a need for an outside body to get involved. The ABP should close up shop. Abraham B. Bergman, MD Author Affiliation: Department of Pediatrics, Harborview Medical Center, Seattle, Washington. Corresponding Author: Abraham B. Bergman, MD, Department of Pediatrics, Harborview Medical Center, 325 Ninth Ave, Box 359774, Seattle, WA 98104 ([email protected]). Conflict of Interest Disclosures: None reported.

In Reply I thank Dr Bergman for his letter and welcome the opportunity to respond to his suggestion that the American Board of Pediatrics (ABP) should close up shop. Dr Bergman frames his major arguments from the perspectives of history, technology, and professionalism. History | He writes, “When the ABP was formed in 1933, it was important for the public to have a means to identify physicians with special competence in the care of children. Now, numerous bodies (public and private) perform background checks.” In 1933, physicians could rely on a fairly stable knowledge base acquired during training to last a professional lifetime. In contrast, today’s parents are fully aware that medical knowledge changes much more rapidly. Hence, there is a public expectation of life-long learning, self-assessments, and the periodic demonstration of competence throughout a career. Technology | Dr Bergman correctly asserts that “today’s wired world diminishes the value of memorized facts.” However, the instantaneous availability of information does not obviate the public’s need for an assessment of physician competence. If compassion combined with an Internet connection were all that were needed to care for sick children, then there would be little to distinguish a pediatrician from other members of the health care team or even parents, all of whom also research medical information on the Internet. The difference lies in the physician’s ability to apply extensive clinical, biological, and often sociocultural knowledge to rapidly analyze complex information, judge its applicability to a specific patient, and decide on the most appropriate therapy. The vast majority of current ABP examination content assesses these analytical and decisionmaking skills rather than just memorization. Professionalism | Dr Bergman writes, “Nichols even sees the ABP becoming involved with assessing professionalism, a quality that used to be called integrity.” Professionalism is more than integrity. The ABP, the American Academy of Pediatrics, and more than 130 other medical organizations have endorsed a definition of professionalism contained in the Physician Charter, 288

Author Affiliation: The American Board of Pediatrics, Chapel Hill, North Carolina. Corresponding Author: David G. Nichols, MD, MBA, the American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514-1513 (dnichols@abpeds .org). Conflict of Interest Disclosures: Dr Nichols serves on the Data Commons Board of Directors, as committee cochair of the American Board of Medical Specialties Special Committee on the Physician Scientist, and is chair of the Medbiquitous Board of Directors. Additional Information: Dr Nichols serves as president and CEO of the American Board of Pediatrics. 1. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.

Physical Activity and Depression: Type of Exercise Matters To the Editor In the longitudinal study by Toseeb et al1 recently published in JAMA Pediatrics, the authors showed no association between objectively assessed physical activity (PA) and the development of depression symptoms in 736 adolescents across a 3-year period. These important findings are in apparent disagreement with previous interventional research relying mostly on short-term interventions with smaller cohorts and that use self-reported measures of PA.2 Notwithstanding the merit and methodological strengths of the study by Toseeb et al, we believe some clarifications are needed regarding a few potential confounding factors that were not controlled for. Tosseb et al assessed PA using heart rate and PA was expressed as energy expenditure (kilojoules per kilogram per day) or moderate and vigorous PA (minutes per day) and was divided into weekend and weekdays.1 This method is undoubtedly objective and provides relevant information. Yet the type of PA, ie, the different types of activities and exercises that make up the total daily PA, was not assessed. A recent meta-analysis showed that PA is beneficial for patients with depression, with aerobic activities (vs more power-oriented or strengthoriented exercises) providing the highest benefits.3 The type of PA also influences exercise induction of the brain-derived neu-

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