Born on U.S. Soil: Access to Healthcare for Neonates of Non-Citizens.

INTRODUCTION: The 14th amendment of the United States (US) Constitution guarantees citizenship to infants born in the US. With documentation of citizenship, typically through a birth certificate, neonates gain official identity and the opportunity to qualify for services like healthcare. Most guidance on caring for immigrant children assumes that access to health care is guaranteed for babies born in the US. In practice, some infants born to non-citizen mothers face barriers in obtaining services fundamental to neonatal health. METHODS: We conducted a review of the literature to identify articles on access to care for infants born to non-citizen mothers in the US. Because of the scarcity of relevant peer-reviewed published literature on this topic, the search was broadened to grey literature including news articles, online articles, and legal reviews. Using these aggregated sources, we created a framework for understanding maternal immigration status and barriers to healthcare for neonates born in the US. We discuss risk factors from the public health, historical and ethical perspectives. RESULTS: Barriers exist for some mother-infant dyads in obtaining services such as healthcare, health insurance and supplemental nutrition programs. At-risk dyads include neonates of undocumented immigrants and birth tourists as well as neonates born to women on visas. The impact of these barriers on health-seeking behaviors, access to care, and health outcomes for these neonates is largely unknown. DISCUSSION: The framework for understanding challenges of non-citizen mothers and their infants that we present in this article provides a resource for physicians and public health professionals serving this population. That much of the literature exists outside of healthcare highlights the need for more scholarly work on this problem. Future research will better inform advocacy and public health efforts to protect this vulnerable population of newborn citizens and their mothers.

What Attracts Medical Students to Primary Care? A Nominal Group Evaluation.

OBJECTIVE: To examine the perceptions of first-year medical students on their experiences in primary care. METHODS: Nominal group technique sessions were conducted with first-year medical students for 5 years. Questions were designed to evaluate primary care experiences and the role of primary care physicians. The questions explored what would make them consider primary care, what would detract from it, and what primary care has to offer that no other specialty can. Responses were weighted and ranked. The main outcome was the top five responses to three questions that were obtained at each session. RESULTS: Thirty-four students generated 280 responses to 3 questions. The top 5 responses for each year resulted in 29 experiences that strengthen enthusiasm: patient interactions (weighted sum, 43%), physician interactions/role modeling (22%), community interactions (20%), healthcare system/finances (8%), and other (6%). The top 5 responses resulted in 26 experiences that weaken enthusiasm, including hidden curriculum (45%), poor role models (29%), uncertainties about the healthcare system such as finances and documentation (20%), and patient interactions (6%). The top 5 responses regarding the uniqueness of primary care resulted in 37 experiences, including patient interactions (38%), continuity of care (20%), knowledge base (13%), community impact (10%), lifestyle benefits (10%), and education/prevention (9%). CONCLUSIONS: Medical students highlighted unique relationships with patients and continuity of care as experiences that increase their enthusiasm for primary care. Negative experiences that weakened enthusiasm for primary care included hidden curriculum and poor role models. Programs that provide experiences in primary care can increase student interest in primary care careers.

Visceral Vistas: Basil Hirschowitz and the Birth of Fiberoptic Endoscopy.

Fiberoptic endoscopy was developed at the University of Michigan in the 1950s by gastroenterology fellow Basil Hirschowitz and 2 physicists. Previous methods to visualize the gastrointestinal lumen used rigid instruments that relied on rudimentary optical systems. They were limited in reach and caused patients considerable discomfort. Fiberoptic technology dramatically changed endoscopic practice. The fiberoptic endoscope, or fiberscope, was a flexible instrument that allowed direct inspection of the gastrointestinal lumen. Although many practicing endoscopists initially resisted its adoption, the fiberscope ultimately held sway. Studying the period from the fiberscope's first introduction in the late 1950s to its more widespread acceptance in the late 1960s may help us understand how a new technology makes its way into routine clinical practice.

Hearing screening practices among a national sample of primary care pediatricians.

The objective of this study was to describe variations in hearing screening using a survey mailed to a national sample of primary care pediatricians prior to the 2003 American Academy of Pediatrics (AAP) hearing screening guidelines. Of the 390 primary care respondents, only 303 (78%) performed audiometry, routinely beginning at age 3 (32%), 4 (44%), or 5 (17%); 81% defined abnormal audiometry primarily as failure to hear at a specified decibel level: 15 dB hearing level (HL) (<1%), 16 to 20 dB HL (10%), 21 to 25 dB HL (23%), 26 to 30 dB HL (44%), 31 to 40 dB HL (16%), and more than 40 dB HL (6%). This study serves as a baseline for comparison with postguideline practices.

Hearing screening at well-child visits.

OBJECTIVES: To determine hearing screening failure rates in primary care settings and to examine the referral practices in response to an abnormal screening test. METHODS: We enrolled a convenience sample of children between 3 and 19 years of age who were undergoing hearing screening during a well-child visit. A failure was defined as missing any frequency (1000, 2000, or 4000 Hz) in either ear at 20-dB hearing level. The pediatrician made the decision of whether to refer the patient for further evaluation. RESULTS: Three academic and 5 private practices enrolled 1061 children. Sixty-seven children (7%) were unable to complete the screening. Of the 948 children who completed the screen, a total of 852 children (90%) passed the screening and 96 children (10%) failed. After multivariable logistic regression analysis, the only statistically significant factor predictive of a failed screen was developmental delay (P = .02). Of the 96 children who failed the hearing screening, 57 (59%) had no further evaluation, 12 (13%) were rechecked, and 27 (28%) were referred. Similar percentages were seen with children who could not be screened. CONCLUSIONS: Although 10% of the children failed hearing screening, pediatricians neither rechecked nor referred more than half of these children. Screening that does not result in action for those failing the screening wastes resources and fails to properly identify hearing impairment in children.

The medical discovery of shaken baby syndrome and child physical abuse.

Although child abuse is an age-old problem, it was not configured as a medical problem in the United States until the 1960s. Prior to that time, physician involvement in child abuse cases was limited. In the 1960s doctors began to medicalize child abuse by reporting on constellations of symptoms and radiographic findings that resulted from intentional trauma. Many social, political, and professional forces combined to make physicians more interested in playing a leadership role in identifying and treating abused children.

Compliance with vision-screening guidelines among a national sample of pediatricians.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians. METHODS: We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening. RESULTS: Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models. CONCLUSIONS: Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.