Writer's block

If anyone who reads my blog is wondering why I haven't posted in a while, let's just say I just haven't had anything to say.  I know you are supposed to keep the posts coming regularly so that people will keep checking the blog, but I just have not been able to come up with anything I really wanted to write.  The one topic that did come to me recently turned out to become irrelevant practically as soon as it was written, so it was never posted.

I do have a couple of themes in mind that I will be probably be developing over the next few months when I have time to write.  For the time being, I will mention that one of the themes relates to fatherhood and the impact of absent fathers.  I presented this topic about 8 years ago at a grand rounds in residency, so I need to update some of the data before I post.

That's it for now.  Hopefully I'll produce some more interesting posts in the near future.

Oops. Shouldn't have hired George.

I have discovered what is wrong with the health insurance industry.  It appears that George Costanza is working at one of the major insurance companies.  See the photo below of actual correspondence from one of our insurance companies.



  "Oh, no!  I'm sorry.  It's the Moops.  The correct answer is the Moops."
Thanks to Dr. Carrie Kelly for finding this.

"Disinfecting" pacifiers

No offense to parents who have done this, but:  When your child's pacifier falls on the floor, putting it in your own mouth to "clean" it is probably not helping the situation.  I recommend soap and water.

Newest Insurance Outrage

While I am on the topic of bad behavior by insurance companies, check this out:

A preteen girl in my practice needed antibiotics for a urinary tract infection.  The antibiotic was chosen based on the sensitivities reported by the lab (this means I was choosing an antibiotic to which this child's bacteria was know to be sensitive).  Of all the choices, I chose the antibiotic with the least side effects, which also happened to be one that has existed for quite a while and therefore has a generic version.  In the real world (meaning the world in which someone pays the pharmacy directly for their medicine at the full price), this should be the cheapest medicine.

So, I am practicing really good medicine here, right?  I chose the cheapest antibiotic with the fewest side effects, and I know from the culture that this medicine will work.

To borrow from Lee Corso:  Not so fast, my friend.  The insurance company, who will remain nameless, apparently doesn't have a special deal with the maker of GoodCheapMed, so they deny the med.  Unfortunately for the child, the insurance company decides this at 6:45 p.m. on Friday evening and notifies us by fax only.  No call to the on call physician for the weekend.  No call to the off call, but prescribing, physician.  The only notice is by a fax to an office that the insurance company KNOWS will be closed until Monday.  The child then goes the entire weekend without an antibiotic because of the misbehavior of her insurance company.  The situation is discovered on Monday and the child receives a different, but still effective, antibiotic and finally receives the needed treatment.

Two general lessons from this story:
1.  Do not EVER think that your health insurance company cares about your health.
2.  If your doctor prescribes a medicine for you that gets denied, call your doctor (even if it is the on call doctor) so that they can address the situation.

Insurance Company Logic: Reject First, Then Overdose

I have not often talked about the myriad ways that insurance companies interfere with the practice of good medicine, in part because I don't have enough time to recount every story.  I had an infuriating dealing with a company this past week, though, that I think speaks volumes.

The short story is this:  The patient is a two-month-old breastfed baby with gastroesophageal reflux which has not been controlled with "reflux precautions" (feed smaller volumes, burp well, keep upright after feeds, and elevate head of bed to 30 degrees) or with Med A.  Med B has a number of negatives as an alternative or adjunctive medicine, so the next most appropriate medicine is Med C.

Since this is a young infant, I prescribe a dose appropriate to the baby's size and, surprise of all surprises, the insurance company denies the prescription because it will cost them more money.  Never mind that it is the appropriate medicine at the appropriate dose in an appropriate form for an infant.

So, what is the insco's reasoning?  The patient must first try OTC Med C.

Oh, you say, that's not so bad.  Shouldn't patients try OTC meds first anyway?

Well, maybe in some situations, but the OTC med in this situation would be a dose about 8 times higher than the patient should have (and would require the two month old to swallow pills).

To bypass the INSURANCE COMPANY'S RECOMMENDED OVERDOSE of my infant patient, I have to spend my time waiting on hold with the insurance company, so that I can eventually talk to their employed physician, who does not actively practice medicine and is most likely not a pediatrician, and try to convince him or her that it is bad medicine to overdose my patient.

Oh, the joys of practicing medicine in the U.S.

One Year

It has now been little over a year since we left the U.S. for the month in Kenya.  We were hoping to make it back there by now so we could serve again while Amy's cousin was still there and are disappointed (though not surprised) that we have not been able to do so.  We still find ourselves longing to go back and serve in a place where there is such great need.  As demanding and difficult as our trip was, we knew that what we were doing was meaningful and needed.  Though the medical work was often stressful, it was still enjoyable.

There is much that we miss about Kijabe specifically and Kenya in general.  We definitely miss the pace of life that we had there.  We had a lot of family time and few extracurricular activities.  I was able to eat lunch with Amy and the kids on most days and was usually home by 6 for dinner and family time in the evening.  Rift Valley Academy was a short walk up the hill if we wanted to play on the playground or make use of their beautiful campus.  

We miss the fact that life was relatively "unplugged".  We had electricity, a cell phone, and limited dial-up internet access.  It was just enough to communicate with those at home, but too frustratingly slow to waste a lot of time on the internet.  The kids played with each other a lot and used much creativity in their play.  Very little time was spent around a screen, and that was refreshing.

Medically speaking, I miss the opportunities I had to use a greater proportion of my training than I get to use here.  I miss the opportunity to help train the residents there.  Nothing makes you learn a topic as well as having to teach it.  I miss the opportunity to learn from some of the most talented physicians and devoted believers I have ever been around.  I miss working in a place where I know that what I am doing facilitates bringing others to Christ and discipling them.  I am very happy with my practice here and am blessed with a great partner and great staff, but I do miss many things about working at Kijabe.

Kenyans value relationship greatly and sincerely want to converse and get to know you.  A quick, obligatory "fine" in response to being asked how you are just won't suffice.  You must shake hands, make eye contact, and actually speak thoughtfully.  

We miss the opportunity to worship with the Kenyan believers.  Attending hospital chapel was one of the highlights of my time there.  We miss the joy with which the Kenyan believers live their lives.  Though many suffer hardship and (at least in American terms) poverty, their faith and joy shine through.  

Oh, if life here could be more like life there.  

Ill with want...

Those of you who are Avett Brothers fans will recognize the title of this post as the the title of one of their songs. As I listen to the song again tonight, I am struck again by the profound truth of their lyrics.  That phrase, ill with want, is an accurate description of what plagues us here in America.  We have a nearly insatiable appetite for things.  Our happiness seems to depend on whether we are able to accumulate as much stuff as our neighbors.  Because there is always someone else with more, we are never really happy.  Meanwhile, our more distant neighbors around the globe are suffering from exposure, hunger, and oppression.

We are unhappy if we can't get away for a round of golf once in a while.  Many in this world are hoping to have a full plate once in a while.  We NEED the latest iGadget (I am guilty here, myself), the latest fashion, or the latest adjustable driver that corrects for our uncorrectable slice.  Meanwhile, a large minority of the world NEEDS food, clothing, and shelter.  We plan to retire at 65 and hope to retire earlier.  They hope to be able to work until they die so they can feed themselves and keep themselves clothed.

We are indeed ill with want.

A Day in the Life...

Ever wonder what your pediatrician does all day?  Ever wonder why you sometimes have to wait to be seen (or, in my case, many times)?  Doesn't he or she just spend 8 hours a day at the office and then go home?  Why does he sometimes seem a little tired?  How can she be tired if she only works 4 days a week in the office?

If you have ever wondered about those things, I am going to give you a peek into what my typical work day looks like.

6:00 a.m. - Get up and get ready for the day. (If I am really disciplined, I will get up at 5:00 or 5:30 so I can exercise.)
6:45 - Leave for the hospital
7:05 - Arrive at first hospital, make rounds in newborn nursery, then move on to the pediatric ward to round on inpatients.
8:00 - Leave first hospital and go to second hospital.  Repeat the above.
8:45 - Leave second hospital and drive to office.

Note:  I do not always have patients at both nurseries and both pediatric wards.  I do often have to go to both hospitals, though.  If I don't have patients at both hospitals, I go get some coffee and spend some quiet time before the office.

9:00 - Arrive at the office to start the office day.  I am usually met with multiple questions that relate to patients who might need to come in immediately but don't want to, or who must have this form now or they won't be able to go to football practice (but they didn't bring it in until this morning), or I find out that a staff member won't be at work today because they are sick or something urgent happened.  Or, if it is winter, "The schedule is full already, where do you want to add sick patients?".

9:05 - Start seeing morning patients.  I will generally see an average of 4 patients per hour.  In winter I may see 6 per hour.  In summer, I may see 3 per hour, depending on the type of visits.  Between patients, I am usually greeted with more questions about where to fit someone in, presented with more forms to sign, forced to be cordial to the drug rep who is bringing in the samples that we need and has her boss with her, have to call back to the hospital about a patient, or have to argue with an insurance company about approving the MRI that our patient desperately needs to prove she does not have a brain tumor or spinal injury.  Along the way, I do have the great privilege of conversing and playing with lots of fun little kids while making the best medical decisions for them that I am able.  The relationship with the kids and their parents is what makes all the other hassles worthwhile.

1:30 - I finish my "morning" after 6 1/2 hours of work.  I then move on to my lunch "hour", which is usually less than 30 minutes and is spent reviewing labs, returning phone calls, and signing forms while shoveling in whatever I happen to have available for lunch that day.

2:00 - I start the afternoon and do more of what I did from 9:00-1:30.  The after school phone calls begin and we work to try to fit in those kids who got picked up from school sick.  If our schedule for the afternoon is already full, we usually add those kids on anyway and stay late to see them, unless I have a firm evening commitment that requires me to leave by a certain time.  Right before closing is when the asthmatic in severe respiratory distress walks in and must be urgently treated in the office while arranging for admission to the pediatric ward.

5:00-7:00 - I will finish seeing patients somewhere between 5 and 7, depending on the time of year and day of the week.  Once all patients have left the office, I will usually still be at the office for another hour or two finishing documentation and making phone calls.  If I admitted someone, I will also dictate the admission note and follow up on any admission orders that I have done.

6:00-8:30 - I finally make it home somewhere between these hours, depending on time of year.  My family has usually eaten dinner already, so I will either eat quickly and start hanging out with the kids, or I will hang out with the kids and then eat dinner once they have gone to bed.

9:00-11:00 or 12:00 - The kids have made it to bed and I can then start handling the personal responsibilities that I have that are not directly related to seeing patients, like paying bills, catching up on medical reading, working on "maintenance" of my board certification, and, oh yeah, actually having a conversation with my wife.

11:00 or 12:00 - Finally I go to bed so I can repeat the above tomorrow.  I will probably get about 6 hours of sleep, though I need about 8.

Not every day is this way, but many are.  Once the kids are in bed, I may do some kind of leisure activity instead of the work-related things mentioned above, but this is a fairly decent representation of my average day.  Since my partner joined the practice last year, I do have more time for leisure activities since she splits the hospital duties and phone calls with me.  My days and weekends off are usually spent hanging out with the kids and taking care of office planning activities that I can usually not accomplish if I am scheduled to see patients.

So there you have it.  A typical pediatric work day for me.  Some pediatricians will work longer hours than I work.  Some will work fewer days and fewer hours than I do.  Most will have a similar set of responsibilities that they must somehow manage while seeing patients in the office, making the right medical decisions, and not getting too far behind schedule.

Despite how hectic things can sometimes be, I am glad to be a pediatrician and I don't know what else I would do with my life.  The whole professional athlete plan just didn't pan out, although some of those NFL kickers manage to keep kicking until they are 50...

Good from Bad

I had the opportunity recently to view "Soul Surfer", the film that tells the true story of the teenage surfer who lost her left arm to a tiger shark while surfing near her home in Hawaii.  I would venture to say that it tells one of the most remarkable "overcoming the odds" sports stories you will ever come across, and is worth watching just for that.

Spoiler Alert:  If you intend to see the movie, watch it before you read further.

The plot centers around a girl named Bethany Hamilton, who is one of the top-ranked junior surfers in the world at the time of her accident.  The fact that she did not die from the attack is miraculous in and of itself, since they were quite a distance from medical care when the accident happened.  Quick action on the part of those who were surfing with her at the time allowed them to get to the hospital in time to save her life.  She reportedly lost about 60% of her blood volume before she reached the hospital, making her survival even more remarkable.

The film then follows her return to life and the trials of learning to do everything one-handed.  

I won't rehash the entire movie here, but I did want to share a few thoughts.

First:  To be able to surf one-handed is an impressive accomplishment.  My appreciation for Bethany's achievement is heightened by the fact that I had my first opportunity to surf this past January at Pismo Beach, California.  I would equate this to the way that you gain a greater respect for what a professional golfer can do with a golf ball once you have played for a while and realize how difficult it is to put the ball where you want it and to intentionally hit a draw or a fade or put backspin on the ball.  It took quite a while for me to get up on a long board using two arms, though I did manage to have a few decent (for me) rides before it was all said and done.  I can't imagine how difficult it would be to paddle out and then catch the wave and get up using only one hand.  Having had this experience recently, Bethany's achievement in not only learning to ride again, but becoming a competitive professional surfer, is truly extraordinary.  

Second:  Although the film focuses on Bethany's return to competitive surfing, it makes the point that life is about far more than surfing.  Although Bethany was "born to surf", surfing is not God's primary purpose for her.  After her first unsuccessful attempt to return to competitive surfing, Bethany is discouraged and wants to stop surfing.  She participates in a mission trip to Thailand to help tsunami victims and discovers that she can use her surfing to  point others to God.  This trip rekindles her desire to return to surfing as she can finally grasp how Romans 8:28 applies to her situation:  God can cause all things (even shark attacks) to work together for the good of those that love Him and are called according to His purpose.  Her return to surfing inspires multitudes around the world, including many who are also disabled, and she points them to God.  That is God's purpose for her.

The correlation in our lives is that even the struggles and tragic events with which we are faced can be used for our good by God if we love Him and seek His purposes.  What disability in your life does God want to use for good?  What might his purpose be?

Anticipatory Silence

Wow.  I am flabbergasted and disappointed by what has happened in Florida and what is being advocated now in other parts of the country.  For those who may have missed it, Florida has passed a law that says that a pediatrician is not allowed to ask a parent if there are guns in the home.  This bill was a joint effort by the National Rifle Association and the Florida Medical Association.  Proponents of the bill apparently fear that the questions that physicians ask in the setting of a confidential medical visit will be used against them by the U.S. government at some point in the future.  Let me preface the rest of this discussion by saying that I support the second amendment and the right of Americans to bear arms.  My objection to the Florida law is its interference in the patient-doctor relationship.

Former Georgia congressman Bob Barr has written a blog post criticizing pediatricians for asking the question and proposes that pediatricians should concern themselves only with recognizing and treating illness, rather than preventing illness.  As a practicing pediatrician who politically falls on the spectrum between libertarian and conservative, I believe that the government should interfere with citizens' personal lives as little as possible.  I believe that law and order, the common defense, and the provision of public necessities, such as the highway system, should be the primary focus of our government.  I believe the Constitution, with its amendments, is one of the greatest achievements in human history.  I believe the Constitution should be respected by our congress and by our courts and that alterations to our constitution should only be made by the prescribed constitutional process and not through activist judges.

Bob Barr claims to be a libertarian, yet his support for this misguided Florida law reveals him to be a libertarian in name only.  A true libertarian would not advocate for the protection of one constitutional right (the Second Amendment) by unconstitutionally limiting another (the First Amendment).  A true libertarian would not support governmental interference in the doctor-patient relationship, but would recognize the importance of confidentiality in that relationship.  A true libertarian would say that what a physician discusses with his or her patients is none of the government's business.

Bob Barr makes a number of ridiculous statements in his blog on this issue, such as the assertion that you will see your pediatrician for an illness and be asked if you have a gun.  He also suggests that pediatricians ask children to snitch on their parents with regard to the presence of guns in the home.  If he had been to a pediatrician's office in the last 20 years, he would be aware that pediatricians are so busy making sure they cover all the things they are supposed to cover that they really aren't going to waste their time interrogating parents and their children about guns. Pediatricians may counsel about gun safety verbally or, more likely, in written format, because prevention of injury is part of what we do. We will also warn about the dangers of certain sleep positions, we will advise the use of helmets when biking or skating, and we will counsel about water safety. Apparently though, Barr also objects to any discussion of safety since he doesn't want pediatricians talking about pools either. For his blog on the topic, go here: http://blogs.ajc.com/bob-barr-blog/2011/05/02/“say-‘ahhh-’-does-daddy-have-a-gun

Barr further asserts that all pediatricians believe that no one should own a gun. He states "Apparently, the Hippocratic Oath taken by these pediatricians includes a footnote to ignore the Second Amendment guaranteeing Americans the right to own a firearm." Mr. Barr neglects to acknowledge that this legislation is an infringement to the First Amendment's guarantee of freedom of speech and also fails to recognize that pediatricians are not agents of the federal government (although I would love to be able to take advantage of the federal holiday schedule).

Leaving the fact that Barr's position on this issue reveals him to be just another politician who will say whatever he thinks will bring him popular support, let's move on to the question of whether a pediatrician should only be concerned with treating disease and not preventing it, as Barr asserts in his blog.  This logic, if applied to medicine in general, would be catastrophic.  Vaccines, probably the single greatest medical achievement in history, would not exist.  Countless multitudes of people would have already died or been permanently disabled just since the advent of the modern vaccine era in the last century if vaccines had not come to be.  Countless more would never have been born to begin with, since one or more of their parents would not have been able to conceive them.  You and I might not be around to even have this discussion.

According to the CDC: Before polio vaccine was available, 13,000 to 20,000 cases of paralytic polio were reported each year in the United States. Before measles immunization was available, nearly everyone in the U.S. got measles. An average of 450 measles-associated deaths were reported each year between 1953 and 1963. If vaccinations were stopped, each year about 2.7 million measles deaths worldwide could be expected. Before Hib vaccine, Hib meningitis once killed 600 children each year and left many survivors with deafness, seizures, or mental retardation. Since the introduction of conjugate Hib vaccine in December 1987, the incidence of Hib has declined by 98 percent. Prior to the licensing of the chickenpox vaccine in 1995, almost all persons in the United States had suffered from chickenpox by adulthood. Each year, the virus caused an estimated 4 million cases of chickenpox, 11,000 hospitalizations, and 100-150 deaths.

Besides the overwhelming success of vaccines, there are numerous other successes achieved by practicing preventive medicine and providing anticipatory guidance (anticipatory guidance is the practice of providing advice to parents to help avoid injury, illness, and other negative events that may compromise the health of children).  Since pediatricians began to recommend putting babies to sleep on their backs, cases of Sudden Infant Death Syndrome have declined by 60%-75%.  Since removal of lead from paint and gasoline, cases of true lead toxicity in the U.S. have decreased dramatically, except in certain limited geographical areas.

Preventive medicine is the cornerstone of pediatrics, particularly in the United States of America. It is far better to prevent illness and injury than to treat it once the damage has been done. Perhaps I should frame this in a way that a politician can understand: Is it better to do damage control once your extramarital affair has been discovered or never have the affair to begin with? Is it better to defend yourself before a grand jury regarding the funds that you misappropriated or is it better not to misappropriate the funds to begin with?

If you would rather that your state and federal governments not interfere with what you can say to your doctor and what your doctor can say to you, please let your representatives and senators know that this kind of intrusive legislation is not acceptable.  Our politicians need to know without a doubt that passing laws such as these will be detrimental to their careers.