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Tuesday, December 30, 2014

Concerta, Methylphenidate ER formulations, Shortages and Formularies

The popular ADHD medicine, Concerta, has been subject of a lot of debate in the past couple of years, and that is continuing into 2015.

This is from a Canadian blogger, but I love the picture showing the difference inside.


Problem #1: Generics vs Concerta

It started when companies started making generic formulations that had a different delivery system.  (If you haven't heard of the issue, you need to read this before reading further for it to make any sense.)

The FDA said that the non-OROS formulations are not acceptable substitutions in November 2014.

Even the same active ingredient in a different delivery system could cause a problem with a child who is doing well on one type of delivery system who gets a different type the following month. The drug releases into the body at a different rate, so the drug is distributed differently throughout the day. This can be insignificant for some people, but can cause significant issues in others. I have heard that some children's medicine wears off much earlier (before the end of the school day) and much faster (leading to emotional and behavioral problems) with different delivery systems.

It is important that whatever delivery system a child does well on continues to be used. They are not interchangeable. Talk with your pharmacist every time you fill the prescription to be sure it is the same manufacturer, or in the case of Concerta, one of the manufacturers that makes the name brand or authorized generic.

Problem #2: Shortages

Since pharmacists can no longer use two of the three brands of generics to fill Concerta prescriptions, there is now a nationwide shortage of Concerta and the one generic that uses the OROS technology. The shortages are expected to last through the second quarter of 2015.

Problem #3: Formularies

To top it off, many insurance companies dropped Concerta and the authorized generic from their 2015 formularies. This means that if you buy the OROS methylphenidate medicine, it is not covered at all by insurance. You must pay cash and it does not count toward your deductible. This makes it out of reach for many most families. I am happy to see that some companies are adding it back to their formularies already -- I suspect there have been a lot of complaints. If it is not on your formulary and it is the medicine that works best for your family member, start complaining.

You will most likely need to try another medicine - or several other medicines - to make a good argument. If a formulary medicine also works, simply use it instead. Save yourself the trouble of going through the hoops to get the OROS methylphenidate. It is only if there is not a well tolerated and effective other option that you should fight for the OROS methylphenidate.

How do you fight the fight? Talk to your HR representative who deals with the insurance company. Call your insurance company directly. Send them e-mails and snail mail. Ask your physician to write a letter on your behalf. State why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates and why the amphetamine class of medication failed. People were able to get the FDA to look into the issue and they agreed that there are significant differences, so insurance companies cannot pretend that it is an equal substitution.

Finding the right medicine


Due to the formulary changes and the shortage of OROS methylphenidate, I have heard that pharmacists are telling patients that they cannot fill a prescription because it cannot say "Concerta" and that they doctor must re-write the prescription as "methylphenidate ER" for them to be able to fill it. This means that they will fill it with the non-authorized generic formulation. If your child has done well on a non-OROS medicine in the past, great! If not, you must find out if it is a formulary issue or if the pharmacy is out of stock of one of the brands, since the remedy is different for different issues.

You will need to check on your formulary, usually available on your insurance company website, for the amount in milligrams that is allowable. It might be that another generic formulation of methylphenidate, not one for Concerta, is on formulary. Concerta comes in very odd sizes (18mg, 27mg, 36 mg, 54mg) and most others come in multiples of 5s or 10s. So if your formulary has only methylphenidates in multiples of 5s or 10s, you know that your child will not be getting the OROS formulation. It is more tricky if the odd sizes are available on the formulary, because unless the prescription says "Concerta", the pharmacist can pick which one to use.  All the pills with the OROS technology say "ALZA" on the pill. Look at the pills before finalizing the purchase and keep your child's medicine the same from month to month unless there are problems on it.

If a prescription is written "methylphenidate ER __ mg" instead of "Concerta __ mg" a pharmacist can fill with any of the long acting methylphenidate medicines that are the same strength, regardless of it is is OROS technology or another form of long acting medicine. The problem is that the same strength of the same active ingredient does not become usable at the same rate due to the delivery system of the pill, so try to keep your child on the same brand if he does well on it. If he doesn't do well on it, it might be better to simply try a different brand with a different delivery system, if allowable by your insurance and available at the pharmacy.

Since the prescription can no longer say "Concerta" if you want to try the other formulation, it might take a few trips between the doctor's office and the pharmacy to find a prescription to match the medicine available at the pharmacy that is covered on your formulary. Each might require a prior authorization before being able to finalize the purchase, so anticipate a few days to weeks before you will be able to take home the medicine.

It will be difficult to deal with drug shortages once the formulary issue is resolved. If your insurance allows 90 day prescriptions, this might be a good option once the dose is optimized. (This is not a good option for the first few months of a new medicine because dose changes might be needed.) Be sure to fill a new prescription as soon as possible to give time for the pharmacy to order in the drug if needed and to have any required prior authorizations completed by your doctor.

Take a deep breath. Slowly exhale. This will all pass in time, but it will be a rocky road for a bit.

Sunday, December 21, 2014

Going to a new place for convenience

My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there's always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.

Image source: Wikipedia


But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home. Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well... convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent. While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks. The food wasn't the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn't of any use helping me decide if what we ate was good for us or not. Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there. Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it's usual for Convenience Cooks to bill added fees.

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but don't offer slow-cooked BBQ, so they refer customers to BBQ-R-Us. But BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation. When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask if you should have gotten the burnt ends or the ribs. Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee.

Most people can see just how crazy it is for a restaurant to "fix" the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or after we refer to a specialist. The scenarios above are based on real phone calls about medical care.

Convenience Cooks = Urgent Cares

I'm sure I'm not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn't fixed at an urgent care. I am glad that patient families feel so comfortable with my office that you will call to ask for help, but if I am not a part of the evaluation, I can't help.

Many problems seen at urgent cares can wait. I know it's easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it's strep throat and they start an antibiotic at 8pm, they can't go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night. The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

If your child was having an issue that did need to be seen ASAP after our office hours, we would have referred you to an urgent care that has quality pediatric providers we trust and sends us a written report of what happened. Even with that, sometimes we need to see a patient on follow up to ascertain if a treatment plan is working or if it needs to be changed.

If you call us because your child is having an allergic reaction to a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that "they're not open yet" or "they don't do phone calls, they want us to come back." Sorry. We will want to see your child before we treat him for this issue.

BBQ-R-Us = Subspecialist Referrals

As for specialist referrals, I know it's hard for people to wait for appointments, but I really can't get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. But usually it isn't really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I'm not saying that's a good thing, it's simply reality. Please don't beg me to call them to get you in sooner. I cannot invent time and I can't alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I've done this frustrating scenario many times-- often when I really want the child seen sooner than scheduled. Unfortunately, it usually doesn't significantly alter the appointment time.

After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it is usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don't like to "step on toes" if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road.

Expect higher fees any time you use a hospital based facility, whether it's for an office visit, a lab, or a procedure. They not only have charges for the physician's time, but they have facility fees to cover the costs of running the hospital. Of course the primary care physician cannot affect the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do... I can't even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that. It is hard to anticipate costs, and that is a problem with our healthcare system. I know that, but it is not in my control to fix that. We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn't help plan before the visit. I understand how that's frustrating, but I can only help with what is in my control. I cannot control how our billing and insurance system works and another office's charges are in no way under my control.

Friday, December 12, 2014

Dry Skin Tips

With the cold temperatures we've already seen this season, our skin is really taking a hit. Dry skin is often called eczema or atopic dermatitis. Whatever you call it, it's itchy and annoying!



It is really important to keep skin well hydrated or it tends to snowball. The dry skin is broken skin, which allows water to escape, which further dries it, which leads to more evaporation.... Broken skin is more likely to become secondarily infected, which leads to more problems....

Itching dry skin also contributes to its worsening by further damaging the skin and allowing more water to evaporate, so try to keep fingers from scratching! (I know this is easier said than done.)

Eczema is not simply dry skin. It can cause significant distress to infants and children. It can impair sleep. It can distract from learning at school. Children with eczema have higher rates of anxiety and depression.

Eczema doesn't simply go away with good treatment: it can come and go even with the best treatment. It can therefore be a serious problem for families.

Your goal with dry skin is to hydrate it as much as possible to repair the skin barrier. We don't always think about skin as an organ (like the heart and liver), but it is. Its functions are to help keep us at a normal temperature, to keep stuff (such as bones, blood, and nerves) inside our bodies, and it helps to keep some things (such as germs) out of our bodies. When skin is excessively dry, there is inflammation and cracking. This keeps the skin from doing its job. We must try to get it back to normal so it can help keep the rest of our body healthy.

Eczema can be from many factors.


  • There is a genetic component, so if a parent or sibling has eczema, it is common for other family members to have it. 
  • It is often worsened by environment, both cold dry air and excessive heat. 
  • Clothing can irritate some skin, depending on the fabric and the detergent left in the fibers. 
  • Any scented lotions or soaps can also irritate skin. (Don't be fooled that "baby" soaps and lotions are better for baby. I usually say to avoid any of the baby products because they are often scented. They make them to sell them, not to be better for baby's skin!)
  • Allergies can exacerbate eczema.
  • Saliva is very harsh on the skin. Drooling can cause problems around the mouth, chin, and chest. Thumb or finger suckers often have red, thick scaly areas on the preferred finger from the drying effects of saliva.


New eczema guidelines recently released downplay the need to alter foods to treat the skin. There are some kids who have true food allergies that manifest as atopic dermatitis (dry skin), but the large majority of kids do not. Restricting their diet can lead to nutritional deficiencies without any benefit. Talk to you doctor (and be sure they have read the newest on the topic) if you think a food might be exacerbating your child's dry skin.

My best tips for treating dry skin:

  • Avoid exposures to soaps because they further damage skin. Non-soap cleansers that are fragrance free are much more mild on the skin.
  • Soaking in bath water or in the shower can help hydrate the skin. After bathing the skin should be only briefly dried (remove large water droplets, but allow the skin to still be moist with water) and moisturizers (with or without steroids) must be applied immediately afterwards to prevent water from evaporating out of skin.
  • Moisturizers should be hypoallergenic, fragrance free, and dye free. A good place to review if a product is good is on the National Eczema Association website. I really like the moisturizers with ceramide. This has been shown to help heal the skin barrier without steroids. Use moisturizers at least twice per day, more often as needed on the really dry spots.
  • After the moisturizer soaks into the skin, cover extremely dry spots with petrolatum jelly. 
  • Steroids can be used for flares. Steroids are available in 7 different strength categories. The stronger the steroid, the less often it should be used. Over the counter hydrocortisone is a very mild steroid and can be used twice a day with mild flares. Stronger (prescription) steroids should be discussed with your doctor if the eczema is more severe, but they can be safe and effective when used appropriately.
  • Bleach baths have been shown to help in moderate to severe eczema. Add 2 ounces of bleach to the bath water and soak the body (not the face) for 20 minutes a few times a week.
  • Oral antihistamines, such as zyrtec, allegra, or claritin (or any of their generics) can help control the itch. I recommend the long acting antihistamines over the short acting ones, especially overnight, to avoid gaps in dosing leading to the itch/scratch cycle. Avoid topical antihistamines due to variable absorption from disrupted skin.
  • Add water to the air during the dry months. If your air conditioner is running you shouldn't need (or want) to add humidity. If your heat is on, you might have an attached humidifier, which is great. You can also buy a room humidifier or vaporizer to add water to the air. When there's more water in the air, the skin will have less evaporation.
  • Use wet water cloths on dry patches. This can help get a child through an itchy time with a cool compress. It also helps hydrate the skin. Since it might remove the moisturizer, re-apply moisturizer when the wet cloth is removed. Some kids benefit from wet wraps (see link). This is time intensive, but very effective, so worth trying for more severe eczema patches. 
  • If your child just can't stop itching, be sure nails are clipped to help avoid scratching. Sleeping with socks or mittens helps the inadvertent scratching during sleep. Many kids remove these, so sewing an old pair of socks onto the arms of long sleeve PJs can help. (Don't forget to put moisturizer on first!)
  • If your child drools or sucks a finger, wipe the saliva off regularly and protect the skin with petrolatum jelly.
At times prescription medicines are needed. These can include steroids, immune modulators, and antibiotics. If your doctor recommends them, don't be afraid to use them. Many parents under utilize medical treatments out of fear of side effects. Yes, there are risks to all medicines, but there are also risks to having eczema untreated. Discuss fears with your doctor to come up with a good plan that you both agree with. Don't just not use the prescriptions.

Get control of your child's eczema. If you can't seem to do it alone, schedule an appointment with your pediatrician to see what else can be done.

For more information, see the American Academy of Pediatrics clinical report on eczema management and the American Academy of Dermatology's Guidelines.



Tuesday, November 18, 2014

Do Your Vaccines Contain Mercury?

We are often asked if our vaccines contain mercury. Some parents even want to see the package insert to check. Note: even if they do contain mercury, it usually doesn't say "mercury", so I suspect some of these parents wouldn't notice. Why wouldn't they notice? Because they learn one tag word that they should avoid, but they really don't understand what it is and why they need to avoid it. It's hard to talk to some parents who are adamant that they don't want vaccines for their children, but they don't know why... they just "heard they aren't safe." Really? You're not going to give your child something that has been shown time and time again to not only be safe, but that also saves lives? Just because you heard something you don't even remember details to you'll skip something that could save your child's life?

Short answer to the above question: No standard vaccine for children has had thimerosol since 2001. Some flu vaccine for older children and adults continues to have thimerosol, but most that we order for our office does not. If we offer a type with thimerosol, we will notify you before you choose to vaccinate. Not that we think it matters, but we know parents worry and want to know.

Most years I get the FluMist, but I think the year pictured it was in short supply.

Parents worry about thimerosol despite not really understanding when or why it's used. It's really sad when they ask if we have the "new" MMR without thimerosol. The MMR has never had thimerosol in it. Not ever. Yet many people share the mis-information online that it was/is the cause of autism. And people believe it. That's how much their online research has taught them.

If you hear that vaccines aren't safe from someone but don't ask for and understand the details, including looking at research papers and written articles that address the issue (along with evaluating the reliability of each research report and article) then you really shouldn't take the advice blindly. They might know as little as you on the subject and are just passing along bad information. Or the article you read might just be filling you with incorrect information. It's easy to do when a writer has a motivating factor, such as when the CDC Whistleblower "reanalyzed" data.

Mercury comes in many forms. Thimerosol (one form) is felt by scientists to be safe for use in vaccines at the very low levels required for its effect in vaccines. It has been removed from most vaccines given to children though due to a very vocal group of anti-vaxers getting some congressmen on their side. Not scientists or doctors, but law makers. This has increased the cost but not the safety, in my opinion. We use single dose vaccines except for staff flu shots, for whom we use the cheaper multi-dose vial. The multi dose must have preservatives, such as thimerosol, to keep it from getting contaminated with multiple uses. We usually have a few doses left out of that to give to patients so it's not wasted. When this type is given to patients, their parents are always told it is a multi dose type. There were only limited doses left over this season and they were gone long ago. Many parents were just happy to be able to get a flu shot for their child when they were in short supply early in the vaccine season and they trusted that it was safe.

So... would I give a vaccine with thimerosol to my kids? Yes. (And my oldest is a teen who did get the standard back when he was a baby, which was vaccines with thimerosol.)

Do we give them now? Not usually.

I think that many smart people still get blindsighted by well written but technically not correct information. They simply can't read all the studies, know how to understand the statistical significance of each study, and all the science behind everything. I have a degree in medicine and still rely on experts to do reviews and summarize the vast amount of information. I read some of the studies, but don't have enough information to make truly educated decisions based on what I have access to. Too many studies are behind pay walls and I don't want to pay to read them, nor do I have the time to read every study. 


But I trust expert panels that do.

Here are some links to pages that list the studies if you want to read them for yourself:

http://www.vaccinesafety.edu/cc-thim.htm
http://www.immunize.org/journalarticles/conc_thim.asp
http://www.immunizationinfo.org/science/mercury-vaccines

Sunday, November 9, 2014

What if the flu vaccine doesn't cover the right strains?

Recent news reported that the FluMist nasal spray might not cover the Influenza A H1N1 strain as well as the injectable might. I know this may cause concern for parents whose children have already gotten the FluMist vaccine this season.



Don't panic! (Gee, I've said that a lot this year with the delayed shipments of flu vaccine...)

Why not panic? 

First, this is a theoretical concern. It is based on the findings that the FluMist didn't cover the H1N1 well last season and it is the same vaccine this year.

Second, the main strains of influenza that are starting to circulate this year are NOT that H1N1 strain anyway.

I thought FluMist was preferred this year...

The CDC continues to state that the preferred vaccine for 2-8 year olds is the FluMist because it seems to be more effective than the injectable form against the other strains contained in the vaccines. (This is of course only if the child doesn't have contraindications to the FluMist and the FluMist is available. No one should delay vaccination if one form is available to wait for another form.)

Should we wait to get the shot? I know there are shipping delays...

Both the CDC and the AAP state to give whatever vaccine is available as appropriate and to not delay giving the vaccine to wait for another type. This makes sense. If you can be vaccinated with only one type due to the shipping delays, why risk being completely unprotected when you can get a vaccine that will most likely protect. No vaccine is 100% effective. With influenza we have the additional difficulty that the flu virus changes each year, but there is some protection across types when the flu vaccine is given.

Why doesn't the strain match?

Flu strains change every year and scientists predict what strains will be circulating. The vaccine companies all make vaccine against the predicted strains. This year the main strains that have been identified in people sick with the flu are Influenza A H3N2 and Influenza B. It is still early in the season, so findings might change, but so far both the FluMist and injectable vaccines seem to be effective against those strains. The FluMist appears to offer better protection than the injectable if the strains are not quite matched.

In short: 

Any age-appropriate influenza vaccine should be used as soon as possible to protect as many people as possible against the flu.

Do kids who got the FluMist need to be given a shot this year?

No. It is not recommended to do a second vaccination unless it is the first flu vaccine and a child needs a booster dose this season. It is appropriate to use either form of the vaccine for eligible children over 2 years, and mixing and matching is okay, but there is no recommendation specifically to do that.

The good news: 

We are starting to see shipments of flu vaccine! Hopefully we'll soon be able to vaccinate your children!

Sunday, November 2, 2014

Menthol for Sore Throat, Colds and Coughs... Should we use it?

I am often asked about the use of Vick's Vapo Rub (or other menthol products and refer to all brands in this post).



We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops 


Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. The menthol is basically a local anesthetic which can temporarily numbs the nerves in the throat that are irritated by the cold symptoms and provide some relief. (Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm...)

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking. Since science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines, I use the "if it seems to help, use it" rule for children not at risk of choking. Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air


When it is put into a vaporized solution, menthol can decrease the feeling of need to cough. It should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress. Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We've all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me, and the link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with spirometry tests (but people stated they could breathe better) in this interesting study. (So people felt better, but there really was no objective improvement.) Putting menthol rubs directly under the nose, as opposed to rubbing it on the chest, may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick's BabyRub that does not contain menthol. Its ingredients have not been proven to be effective and some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

If a child ingests camphor (another ingredient along with menthol in the rubs) it can be deadly. It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations. Menthol rubs sold in the US contain camphor in a concentration that is felt to be safe if applied to intact skin in those over 2 years of age. Mucus membranes absorb medicines more readily than intact skin, so do not apply to nostrils, lips, or broken skin. Do not allow children to handle these rubs. Apply only below their necks to intact skin. 

Many people using the menthol rubs experience skin irritation. Discontinue use if this happens.


Tuesday, October 28, 2014

Talk About Bullying With Your Kids

Bullying. Fist fights. Cyberbullying. Mean girls. Playground scuffles.

There are many labels and many variations on the same theme. Kids aren't always nice. Even nice kids get caught up in mean behaviors. We all remember being young and getting picked on. Or maybe we were the instigator of trouble. Chances are we've been on both sides of the line. Whatever roll we had, we know that this is not new behavior. But that doesn't make it any easier for parents to watch their kids suffer at the words and actions of other kids.

photo source: Shutterstock


We all need to talk with our kids often about their lives: what they are doing, how they feel about things, what they are looking forward to, dislikes, and more. Many kids clam up when it's time to open up, and sometimes the best thing for a parent to say is simply, "I'm here if you want to talk later."

Sometimes a general talk about bullying behaviors is a good idea, whether you suspect some bullying is going on or not. As with most things, a little prevention is worth a pound of cure.

If you see your own child saying or doing something that could be interpreted as mean, pull them aside and point it out as soon as possible so the memory is fresh in their mind. Children and young teens often don't even realize what they've said or done can be taken in a negative way. Don't punish or yell at them for the words. Don't belittle them. Making them angry will only block their mind to seeing another point of view. Use this time as a teaching moment to point out what was said. They might not get it right away, but later you can role play and see if they can understand better in a different situation.

I've put together things to use as talking points. Don't try to tackle this all in one sitting. Talk about one subtopic at a time, but talk often.

What else would you add?


  • A small comment that seems to not be so bad to you can make someone else feel awful, even if you didn't intend for it to be. Those comments often come out of the blue and you don't give it a second thought, but the other person can dwell on its negativity for a long time. Even worse are the comments that are repeated over time. 
  • You cannot change what others do or say, but you can change how you respond to what they do and say. 
  • If you did or said something hurtful, it can't be taken back, but you can ask for forgiveness.
  • If you know you're tired or in a bad mood, try to be extra careful before you say anything. 
  • Don't send texts when you're angry, sad, or tired. 
  • Don't reply to a text that makes you angry, scared, or sad. Show an adult if it is a threatening text or if it really upsets you.
  • If you have negative thoughts, keep them to yourself. This might mean that you think someone got something they didn't deserve, someone's a teacher's pet, or their hair is awful. Whatever. Nothing good comes from sharing a negative opinion. In the end, people will see that you are negative and won't want to be around you as much if you share those thoughts. 
  • If in doubt about saying or sending something, save the thought overnight and see if you still think it needs to be said. Think about the wording to make it constructive and not destructive if it does need to be said. Talk to an adult if you're not sure.
  • If you wouldn't say something to someone's face, don't say it at all.
  • If you hear someone saying something negative, tell them to stop. Let them know you don't like hearing negative comments. This might teach them what they are saying is hurtful, because sometimes people don't realize what they are saying. They can learn to be a nicer person- what a great friend you can be to help them in this way! If they don't change their behaviors over a few days or weeks after being told what they are doing (depending on how severely or intentionally they are being hurtful) then you need to tell an adult. Doing nothing or agreeing with them puts you down to the level of being a bully, even if you didn't start it. If you don't feel comfortable telling them to stop, leave. If you stay, you’re part of the cruelty. Leaving means you refuse to be part. If they don't have an audience they won't continue.
  • If you realize that something you said was hurtful to someone, talk to them about it. If you have a hard time talking face to face, a nice note can work. Have a trusted adult help you wordsmith what you will say so the words don't get twisted. You must be careful to not put blame back on the person or put them down again when you apologize. It can be tricky to find the right words, but it is possible. 
  • Texting is a dangerous way to communicate emotional or sensitive issues. It is great for simple questions and answers, but short phrases in texts can easily be misunderstood or incomplete. If you are disagreeing with someone, do not use texts to talk it out. Remember that anything shared electronically is public and permanent. Even if you think you are sending it to just one person, there are many ways for it to be seen by others. These words and pictures can be very hurtful. Never send anything you wouldn't want to put on a sign on your front door for all to see.
  • Kids are often afraid to tell adults things for many reasons. It is okay to tell an adult if you are trying to help someone or yourself, but not if you are trying to get someone in trouble. Think about it. There's a difference. 

Positives drown out the negatives...

  • Every day write down (or discuss as a family) one thing that you really appreciate or are grateful for. It can be anything, but think of things that really mean something to you. It can be as simple as a person said something really nice when you were feeling down, or you did well on a test you studied hard for. It doesn't have to be a huge thing like winning the lottery, but it should be something that you really feel thankful or happy about. Focusing on the good things really helps keep life in a healthy perspective. It can help protect you from the negative effects of other people's behavior.
  • Smiling really can make you feel better, so try it.  
  • If you see a friend struggling because negative things have been said, say kind words to him or her. Be extra nice to him or her so they know they aren't alone.
  • Praise people when they say nice things. Recognize the kindness. Make it contagious!
  • Try to do something nice or say something nice to at least one person each day. Notice the response over time in yourself as well as others.

Everyone needs a circle of respect. You don't have to like everyone, but you need to treat everyone with respect.
  • Respect yourself enough to do what is right. Eat right. Exercise. Get 9-10 hours of sleep each night. Don't take unnecessary risks, such as smoking or drinking alcohol. 
  • Respect others. Say kind words and keep negative thoughts to yourself. Don't make anyone else do something they aren't comfortable doing. Don't make fun of people. 
  • Be sure people respect you. If someone says or does something that you feel is disrespectful, let them know. If they don't change their behaviors, avoid them and find other people to have fun with. Get away from people who make you uncomfortable or scared immediately. Find new friends if your friends repeatedly disrespect you. Get help from an adult when needed.

Tuesday, October 14, 2014

Teal Pumpkins for Non-Food Items at Halloween

Teal pumpkins have a new meaning this Halloween. Displaying one means that your home has non-food items available for the little goblins and superheroes as they come looking for treats.



Some might wonder why this is important.

Because what child likes to be left out of the fun of Trick or Treating?

And what happens if that child has severe food allergies, diabetes, or another condition that limits the types of foods the child can eat? Or what about all the parents who worry about the excessive intake of sugar this time of year?

Show parents that you are giving kids the option of a safe treat by displaying a teal pumpkin. There are many non-food treats that kids would love ~ stickers, pencils, glow sticks, bubbles, plastic jewelry, vampire teeth, pencil toppers, hair pieces, magic trick cards, and many more. Be sure you have some that are safe for toddlers.

Non-food items are better than nut-free, because kids have allergies to all kinds of things, and it is impossible to know in advance what all those allergies are. And for kids who must limit their overall sugar intake, non-food treats rule.

We put together some reusable teal pumpkins at the office. My initial plan was to spray paint some plastic pumpkins, but decided to use Duct tape to cover plastic pumpkins instead. Less smell, no time waiting for them to dry, and if we ever want to use them outside, they will be fairly weather-proof.

Pretty cute, huh?

And yes, plenty of people have asked if they are to celebrate our KC Royals. Not exactly. But hey, we can double their duty during Blue October!

Share this idea with your neighbors and friends. Use social media. Put a note in your neighborhood bulletin. Share with your school nurse. Ask stores to display a flyer.

Get the word out!

For more information and a free printable flyer (like the one pictured in our office above), see the original post where I learned about this great idea: The Teal Pumpkin Project

Tuesday, October 7, 2014

Why We Should Cherish the Gift of ADHD

Ok, so I know most parents of children with ADHD will read this title and think I'm crazy. Kids with ADHD wreck havoc on family life. Spouses with ADHD can do the same. How in the world can we cherish ADHD? It involves impairments in executive functioning... how can anything causing a broken executive functioning system be cherished?

photo source: Shutterstock


First, we must realize that everyone has gifts. ADHD has many variables in the way it shows up, so people with it also have many variations in gifts. But they do have gifts. I want parents, spouses, siblings, grandparents, aunts, uncle, neighbors, teachers, and more to understand the value of these gifts and help children (and adults) recognize the benefits that people with ADHD can have. I'm not saying life for them is easy. It's not. They struggle with many things other people can easily manage. But they still have gifts. I want kids to grow up building their confidence by using their gifts, not by measuring their failures when they don't conform to norms.

People with ADHD tend to think outside the box. They have lots of energy. They are often very creative. We all think of their inattention and poor focus, but they also hyper focus on things they love. If they become passionate about something, they can sustain attention and work on it for long periods of time. If they use this hyper focus wisely (with setting time limits so they can do other daily activities) they can become an expert in that area. For young children the hyper focus tends to be on "kid" things, like trains or video games, but as they get older, allowing kids to experience activities that interest them will give the opportunity to find a life passion that could turn into a fantastic career.
"ADD people are high-energy and incredibly good brainstormers. They will often happily work 12 to 15 hours by choice. The business community should not fear ADD. Instead, they should see that they have a potential gold mine here.” - Dr. Kathleen Nadeau, psychologist
With all that good, we are more quick to see the negatives. Kids can lose their drive and ambition if they are not supported along the way. School is not favorable to kids with ADHD. Kids must follow rules. They need to color in the lines. They need to do all the steps in the order the teacher wants. Doing things someone else's way is not easy for kids with ADHD.

For example, kids need to learn the steps to solve a mathematical problem. They need to solve the math problem the way the teacher did it and show their work. They lose points if they get to the right answer but didn't show their work or if they get there a different way. The teacher might assume they cheated to get the answer, but some kids just skip steps. To me that might just show brilliance. They can skip steps. Their brain just "gets" to the right answer. I never could figure math out without being told how to do it, but there are kids out there who can. What a gift! Unfortunately they feel dumb if they can't show the steps just like the teacher taught. And it would be quite typical for a child with ADHD to have a brain that thinks this way if math is that child's gift. What a shame that our schools tend to make these kids feel inferior because in the end they might resist working on math and will never reach their potential.

For a fun look at ADHD that will continue to show you the better side of the diagnosis, check out this short documentary, A.D.D & Loving It. I promise it will have you laughing, but you will get a lot of great information from respected ADHD experts.

If your child struggles with the diagnosis, consider reading about real people who have done well despite (or due to) ADHD (link with many articles about successful people with ADHD and other learning disorders). Have them read Percy Jackson (link to a book review). He's a fictional character with ADHD and dyslexia that kids can look up to.

Throughout history many successful people have had ADHD. Your child with ADHD can also become a leader, an inventor, an artist, or an otherwise excellent contributor to society. We just need to help them find their gifts and work on their challenges so that they can flourish. Support them so they do not lose self confidence. Celebrate what they do right more than harping on what they do wrong. Encourage them to develop their talents. Help them find ways to accommodate for their struggles and to learn tools to help with some of the executive functioning problems they have. Cherish them!

Tuesday, September 30, 2014

Heart Screenings for Athletes - Are they worth it?

In recent years I've been getting more and more reports of athletic heart screenings. The schools and sports clubs locally are offering for athletes to get a heart work up for a relatively small fee.



Why are they offering this? Because sudden cardiac death in athletes has been in the news a lot over the years, and we all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk. Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator. (Side note: if you've not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow "A B C" so it is very different. CPR is recommended for all teens and adults.)

Is the cost of a heart screen worth it?

A new report, Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology, is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation and is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD). Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue 
It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: To do an ECG screening on all athletes is not inheritantly unwarranted nor discouraged, but it isn't recommended either.

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is available below.

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive.
If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time, so one normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so. The evidence does not support mass required screenings.

If however, your child has identified risks based on the questionnaire, a more thorough testing should be done.




These 14 points are listed in Table 1 of the above linked statement:

The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history* 
  Personal history
    1. Chest pain/discomfort/tightness/pressure related to exertion
    2. Unexplained syncope/near-syncope†
    3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
    4. Prior recognition of a heart murmur
    5. Elevated systemic blood pressure
    6. Prior restriction from participation in sports
    7. Prior testing for the heart, ordered by a physician

 Family history
    8. Premature death (sudden and unexpected, or otherwise) before 50 y

of age attributable to heart disease in 1 relative
    9. Disability from heart disease in close relative <50 y of age

    10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination
    11. Heart murmur‡
    12. Femoral pulses to exclude aortic coarctation 

    13. Physical stigmata of Marfan syndrome
    14. Brachial artery blood pressure (sitting position)§

AHA indicates American Heart Association.
*Parental verification is recommended for high school and middle school athletes.
†Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
§Preferably taken in both arms.
Modified with permission from Maron et al.3 Copyright © 2007, American Heart Association, Inc. 

Tuesday, September 9, 2014

How long will a cough or cold last?

How long will a cough or cold last?

I get this question all the time. Most people want it gone now. Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.

Unfortunately our area has been hit with Enterovirus D68, which seems to cause prolonged symptoms compared to many respiratory viruses.

I don't hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I've been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can't make them better faster.

cough, cold, sore throat, fever, earache, bronchitis


We have our standard instructions:

  • Fluids (water)
  • Rest
  • Saline washes to the nose
  • Blow the mucus out. If a child's too young to blow his nose well, parents can suck the snot right out.
  • Honey for children over 12 months of age
  • Prop the head up during sleep
  • Prevent spread
But then we still have the original question: How long will a cough or cold last?

One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960's, but since we don't have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.


Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren't going down fast at that point, they both seem to linger. 

A more recent review of medical studies showed that the many symptoms of illness linger for much longer than parents want to accept. From this study:
* Earache range 7-8 days, Sore throat 2-7 days

Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away. That is an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis. It isn't the color of the mucus (really!) We don't want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.

So if you're struggling with cough and cold symptoms in your house, follow these instructions. To help determine when your child needs to be seen:
Urgently or emergently: If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children. 
Routine office visits: If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.


More reading:



Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature

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Tuesday, September 2, 2014

Swollen Eyelids: Causes, Treatments, and When to Worry

There are many causes of swollen eyelids in kids (and adults). The good news is that the most common ones are usually not serious. Some swellings herald warning though and should be properly evaluated and treated by a doctor. Warning signs include vision changes, pain, protrusion of the eye, fever, difficulty breathing, abnormal eye movements (or loss of movement), foreign body that cannot be removed, or signs of anaphylaxis (swollen tongue or throat, difficulty breathing, hives). Any warning signs deserve prompt medical attention.

swollen eyelids, eyes, bug bites, cellulitis



Allergies can make the eyelids puffy due to the histamine reaction. This is usually accompanied by itching, red eyes that are watery. Treatment involves either oral allergy medicines, topical allergy medicine (eye drops) or a combination of both. Washing the face, hair, and eyes after exposure to allergen can also be an important part of treatment.

Anaphylaxis is a more serious allergic reaction. It involves swelling of the eyelids, throat, and airways. This is a medical emergency. If epinephrine is available, use it. Call 911.

Blepharitis is an inflammation of the eyelids that can cause swollen lids, often with flaky eyelid skin and loss of the lashes. This chronic condition should be managed by an eye care specialist.

Bug bites are the most common cause of swollen eyelids we see in our office. Usually there is a known exposure to insects and there may be other bug bites on the body. Bug bites on the eyelid tend to itch rather than hurt despite the significant swelling they produce. There should be no fever or other signs of illness. The eyeball should move freely in the socket. (See "orbital cellulitis" below.) Treatment of bug bites involves cool compresses and oral antihistamines. Occasionally oral steroids are required for significant swelling, but they require a prescription. If the swelling is concerning to you or your child, bring him in to be seen.

Conjunctivitis, also known as pink eye, causes inflammation of the surface of the eye ball and sometimes a puffy appearance to the eye lids. It can be from bacteria, virus, or allergies. Bacterial conjunctivitis causes the whites of the eyes to look red and includes a yellow discharge from the eye. Viral conjunctivitis causes the white of the eye to look red, but there is no yellow discharge. Allergic conjunctivitis is described above under "allergies." If unsure which type your child has, or if it is probably bacterial, see your doctor.

Contact lenses can contribute to swollen eyes if they are dirty or damaged. See your eye doctor in this case.

Crying can cause the eye lids to become puffy. The lacrimal glands produce an overflow of tears, so the fine tissues around the eyes absorb the fluid, causing them to appear swollen. This is compounded by the autonomic nervous system increasing blood flow to the face during times of strong emotion and rubbing the eyes to wipe away the tears. This cause of swelling is short lived. Cool compresses and avoidance of rubbing can help decrease the swelling.

Graves' disease can cause swelling of the eyelids and protruding eyes. Sometimes a drooping eyelid or double vision occurs. It is caused by thyroid problems, which also can cause problems with appetite, fatigue, heat intolerance, and more. These symptoms should be evaluated by a doctor.

Kidney problems can lead to fluid retention. If the eyes are puffy along with puffiness of the ankles or swelling of the abdomen, kidney problems should be considered. Children can develop this suddenly from infections, like certain diarrheal illnesses or Strep throat. The urine may look tea colored or like it has blood in it. This is a medical emergency and you should seek care immediately.

Sinus infections can cause puffy eyelids. Congestion, runny nose, headache, postnasal drip, and cough are typical symptoms. See your doctor if you suspect sinusitis.

Styes look like a swelling at the edge of the eyelid, often red or pink with a small white central area. It is caused by a blockage in one of the small glands in the eyelid. Another swelling from blockage of oil glands of the eyelid is a chalazion. Both a stye and a chalazion can start as painful bumps, but after a few days they no longer hurt. They can cause the whole eyelid to swell. Applying warm packs to the area several times per day often helps treat styes. Chalazions more often need to see an ophthalmologist for treatment. If a stye persists beyond a few months or the lid swells to cover the pupil, see your doctor.

Trauma of the eye or nose, like any trauma, can cause swelling. A broken nose can cause swelling and bruising to the eyelids. Any significant trauma to the eye or nose should be seen by a doctor. Symptoms may include vision changes, chemical exposure, foreign body in the eye, blood in the eye, severe pain, or nausea or vomiting after injury.

Ocular herpes is an infection of the eye by the herpes virus. (Not all herpes infections are sexually transmitted!) It can appear initially like a blister or cluster of blisters near the eye. It can lead to permanent damage to the eye, so prompt care by an ophthalmologist is important.

Orbital cellulitis is a potentially serious infection of the eyelids. The infection can extend behind the eyes, causing meningitis. It is suspected when there is painful swelling of the upper and lower eyelids, fever, bulging eyes, vision problems, and pain with eye movement (or inability to move the eyes). This is a medical emergency and if suspected, prompt medical attention is warranted. Treatment involves iv antibiotics. To assess the extent of swelling or to differentiate between pre-septal cellulitis (which is not into the deep tissues) and orbital cellulitis, imaging is often done.

Ptosis, or drooping of the eyelid, can look like a swollen lid. There are many causes and this should be evaluated by a doctor.

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Wednesday, August 27, 2014

Medical Billing and a Restaurant

Medical insurance and billing is a mess. That is one thing I think most people would agree upon. The difficult thing is to find a solution that most people agree upon.

photo source: Shutterstock


Since our office has started a new financial policy that includes sending credit card information for secure storage to be used for payment of money owed, we have been encouraged by many people. They realize that businesses must have a means to collect payments owed. Many businesses use a credit card storage system. For instance, when someone books a hotel room they must have a credit card on file with the hotel. That protects the hotel in case people never show up (so the hotel can collect per their cancellation policy), if they damage the room, or otherwise build charges for which the hotel needs to collect payment. Because the hotel industry has been doing this for so long, most people don't question the practice when booking a room. There have been a few (but vocal) people who are upset by our new financial policy. I am hopeful that they can begin to see from our perspective just why this is a much needed policy.

We see most collection issues with high deductible plans but can't pick and choose which patients need to give a credit card. It must be the same policy for everyone. If you never owe money, we will never charge your card. If you owe money, you owe money. Your insurance company lets you know how much after they make their adjustments on the Explanation of Benefits (EOB). That amount is not up to us. It is per your contract with your insurance company. We will save you time in processing the bill by submitting it to your credit card if it's under the amount stated in our policy. If it's a higher amount owed, out of courtesy we will contact you to alert you to the charge. If you need to work out a payment plan, we're happy to work with you. But you still owe the money for services already rendered. It's that simple.

Where else does someone make a purchase, but only find out how much it will cost them weeks later? That is exactly what happens when someone goes to the doctor or has a lab or procedure done. You don't know the cost to you (and neither does the office) because it depends on how your insurance adjusts the bill and what portion they pay versus what they state is expected from you. It is not my system nor my office's system. It is the insurance system.

Our office does have a "menu" of codes representing common procedures, vaccines, and more with the associated charges, but it doesn't really tell people how much they will owe. This menu is in every patient room and can be given to parents if requested. The charges listed are our charges, but the amount any family will owe depends on how their insurance company adjusts and pays for things. I think it would be ideal for people to have access to a standard set of codes on their insurance company website, with a clear depiction of how much their portion will be for each code. But this would be difficult since there are so many plans, people who owe a percentage that varies based on if their deductible is met or not, etc. It varies even to the point that your employer has a different contract with your insurance company than the next employer has with the same company.

When we get the adjustment report from the insurance company and there is a portion left to be paid by the patient, it is typically already weeks after the service was provided. We then are responsible for collecting that money from the family. Many practices (including my own) are starting to hold credit card information to help with collecting payments. We simply can't afford to track down the high volume of patients that owe money. It is often small amounts, sometimes so small that it would cost more to send the bill than the amount owed. But to simply not collect small amounts from hundreds of people adds up to a business in the red.

Think of it like this: "Pay Later Restaurant" doesn't have people pay immediately after dinner. They send the bill to one of the people who enjoyed the meal. About 2 - 4 weeks later, the restaurant receives a payment, but the customer first adjusted the bill down 80% because they have a contract that states they can. But even that payment of 80% of the bill doesn't all come. Since the payment will come from multiple people at the table, only a portion of that discounted price is paid. The remaining portion of the discounted price is owed by someone else at the table. That person wants to see the bill and have it explained to them. They still take a few weeks to pay because they didn't know they were going to pay for their portion of the bill. They thought it would be covered by their dining partner. During all these weeks of trying to decide if the diner really does owe the restaurant, the restaurant still has to pay their rent, pay salaries to their employees, buy new food to sell, and otherwise pay business expenses. How can they continue to stay in business if they don't collect? Businesses in the red close. This is exactly how medical offices must operate.

We want to keep seeing patients, so we need to collect money owed us to be able to pay our bills.

In my perfect world the insurance company would pay the office the full contracted amount owed, and if the patient had a responsibility for part of that fee, the insurance company would charge the family. This keeps it clear that the money is due per the insurance contract because the bill would be to the insurance company, not the doctor's office. This helps the doctor-patient relationship continue to be about medical care, not payments. The insurance company also would have the benefit of withholding coverage if patients don't pay their bills. That encourages people to stay current on payment of their fees. When patients owe the doctor, the doctor has little to do to collect payment other than send the patient to collections and discharge them from the practice - which is really hard for physicians who want to care for people, not worry about paying bills. But we need to think of the business bottom line. If we don't collect payments, we cannot pay our bills. Then we close (or sell to large hospital systems, as many offices have done) and we can't take care of patients the way we want.

My friend, Suzanne Berman, MD, FAAP, of Plateau Pediatrics in Crossville, Tennessee, has written this list of similarities between a restaurant and medical care. It might just help clear up some of the issues we have with competition of walk in clinics, office scheduling, billing, and collecting.


1)      A meal at Hardee’s is different than a meal at the Palm, in many ways (including costs).
2)      Sometimes it’s just cheaper to eat at home.
3)      Most restaurants are a la carte.   The more you order, even if you don’t eat it all, the more you pay. 
4)      Yes, some restaurants are all-you-can-eat for one price, but drinks are still extra.
5)      Just because you had to wait for a table doesn’t entitle you to a free meal.
6)      Some places bring you chips for free.  Other places charge for chips.
7)      Plate sharing and corkage fees have legitimate reasons behind them, even if you don’t like the idea of them.
8)      Just because there are no prices posted on the menu does not mean that the chateaubriand is free.
9)      Your total does not include tax.
10)   Your total does not include tip.
11)   Liquor is always a very expensive add-on relative to the wholesale price of spirits. 
12)   Even if you don’t like how the shrimp makes your pasta taste, you’re still obliged to pay.
13)   Do you treat your own house like you treat our establishment?
14)   If you want a soufflĂ©, you need to declare that BEFORE you order your meal.  Adding on an “oh by the way” does not work with soufflĂ©s.
15)   We can help you split the bill and decide which party owes how much, but before you leave the restaurant, the bill must be paid in full by SOMEONE.

Monday, August 18, 2014

Flu Vaccine 2014-15 Season

Every year it's something.

Flu vaccine causes distress every year for physician offices around the country.

I wrote about some of the issues last year here and here.

This year's flu vaccine is identical to the trivalent and quadrivalent vaccines of last season, so it should be easier.

But as always, there's a hitch.

This year there is a delay in shipping but no one really knows why. I've heard pharmacies are starting to advertise they have flu vaccine. From a business standpoint, we start to worry when we hear people say "I'll just do it at the pharmacy." We've already ordered more doses than last year and don't want to get stuck with supplies we can't use. Bad for business...

How flu vaccine makers choose their shipping times to various offices around the country is unknown to me. We order nearly a year in advance so they can make the requested number of doses. We must project how many infant vs child injectable doses of vaccine we will need and how many nasal spray doses we will need. Some years we can add to our order, but other years there are shortages. There are several makers of various brands, but in pediatrics we are limited to what types we order based on the ages for which it can be used.

As soon as we start getting the vaccine we will begin to offer them in the office. Typically we start getting a few doses at a time, so we can't advertise with those first small shipments. It will simply be patients who are in the office and eligible for the type we have will be offered flu vaccine. When we get enough to hold a flu vaccine clinic, we will send out e-newsletters to patients who are registered, as well as post on our website and Facebook page. Our flu clinics run smoothly because parents sign up on line. We will send paperwork ahead of time for you to fill out at home. Bringing that really helps. You will need to have signed our financial policy before the flu vaccine. To keep things running smoothly, we encourage you to do that ahead of time if you have not already done so. We also ask that your child is current on well visits in order to use our flu clinic. If your child needs a well visit, simply schedule one and he can get the vaccine at that visit. We will always give flu vaccine to patients and their siblings who are in the office for a visit (but without significant illness, such as fever) as long as supply lasts.

Who needs a flu vaccine and when should it be given?

It is recommended that everyone over 6 months of age get a flu vaccine each year. As soon as the vaccine is available, it can be given. Ideally the vaccine is given before the influenza season starts. Flu season usually peaks in January, but influenza can occur at any time of the year. I must put a plug in for getting the vaccine in your medical home if at all possible. This keeps vaccine records all in one place and helps support your doctor's office.

Which vaccine should my child get?

Children 6 months to 2 years should get the injectable vaccine. They are not eligible for the nasal spray (FluMist).

Starting in 2014-2015, the CDC recommends use of the nasal spray vaccine (FluMist) in healthy children 2 - 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine.

Contraindications to the FluMist are:
  • Children younger than 2 years
  • Adults 50 years and older
  • People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
  • Young children with asthma
  • Children or adolescents on long-term aspirin treatment
  • Children and adults who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
  • Children and adults who have immunosuppression (including immunosuppression caused by medications or by HIV)
  • Pregnant women
  • Live virus vaccine (such as MMR or Varicella/chickenpox) within the past 4 weeks. The vaccines can be given together on the same day, but if not on the same day they must be given 28 days apart from one another.
  • Most people with the above contraindications can still be vaccinated with the injectable vaccine - ask your doctor

Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine.

How many doses does my child need?

In young children who have never received a flu vaccine, two doses of the same strain should be given. If they've had two doses of the same strain previously, they only need one dose. In children over 9 years of age, regardless of previous vaccines, only one dose is needed. This is because it is presumed that by 9 years of age a child has been exposed to the influenza virus previously. Think of it as the first vaccine is the initial body's exposure to the virus in young children, then everyone needs a booster dose for the season, including the first season if a child has never had one before.

The CDC has put together a flow chart of how many doses are needed:


Can a person still get the flu even after getting the vaccine?

Each year experts pick the most likely strains of influenza virus that are expected. Some years they do a great job, other years it is not as accurate. There is some cross-reactivity among strains, so even in years that the wrong strains are in the vaccine, there is some protection against severe flu illness. So yes, it is possible to still get influenza, but usually the illness is mild.

Can a person get the flu from the vaccine?

No. I have heard many people say they get the flu from the vaccine, but this is not possible. People who get the nasal vaccine can get mild congestion (cold like symptoms), but they do not get the flu from the vaccine. It is possible that they were exposed to the actual flu virus and get sick before the vaccine has a chance to provide protection. Or they have a viral illness that isn't the flu. People with influenza often say they feel like they were run over by a train. They are sick. It is not just a cold.

Can I get the flu vaccine even though I have an egg allergy?

The following recommendations come from the Advisory Committee on Immunization Practices (ACIP):

People with a history of egg allergy who have experienced only hives after exposure to egg should receive the injectable influenza vaccine. Because there is limited data in the use of live attenuated influenza vaccine (FluMist) in egg allergic people, inactivated influenza vaccines (shots) either the IIV or trivalent recombinant influenza vaccine (RIV3) should be used.

Where can I get more information? 

Each year the CDC provides summary information about the current influenza vaccine season. You can read about the 2014-15 season, information on flu vaccine myths and misconceptions, and you can even see where the flu has hit.