Saturday, July 21, 2012

Health Insurance Woes

Insurance is an expensive benefit for employers and families, but the coverage is so variable it's difficult to navigate the whole healthcare thing. I am a pretty well informed consumer, given that I hear patient concerns often about how much things cost and if something will even be covered or not. I often change prescriptions due to insurance formularies or have a nurse call a script to change to a cheaper pharmacy. I know these things happen, but even informed consumers can get caught off guard.

My family's health insurance changed April 1st, and I dutifully put the new card in my wallet but didn't read anything about the new plan. The new plan was chosen by my husband's company as the best deal they could get. We both work for small companies, so insurance deals are not great. I didn't make the time to read about the formulary or what pharmacies are preferred. Or even if they offer or require mail order pharmacies. (Typical consumer mistake.)

I had dropped off 2 prescriptions that members of my family have been on for quite awhile on Saturday, March 31st, but didn't have time to pick them up that day. I returned Sunday to pick them up and realized that my new insurance had kicked in that day, so gave my new card. 

Drug A had been $4 previously and was now $10.
Drug B had been $10 previously and was now $75. 
Both are generic!

The next month I forgot to look into pharmacies. A little busy, you know.  So my old cost of $14 was now $85 monthly. A difference of $852/year. I made a mental note that I really had to make the time to look into things. 

Finally in June I looked up preferred pharmacies on the insurance plan's website.  The pharmacy I have used is not on the list, but another close to home is, so I changed our prescriptions to the "preferred" pharmacy.

Drug A is now $15.
Drug B is still $75.
The preferred pharmacy is actually MORE money!

How can consumers win?

My next step could be to look closely at the formulary to see if they have another medicine in the same category that is less expensive, but it is already a generic, so I am doubtful. And I know that this medicine has been working well for about a year. If we change to another medicine it might not work as well and there is a history of a bad reaction to another medicine in this category for my family member, so changes are concerning.

So I will probably suck it up and pay $75 for one generic medicine. And I will go to the non-preferred pharmacy so the other generic is less expensive. I am thankful I can afford these because I know many go without needed prescriptions. 

I might call around to other pharmacies to see how much they cost, but that can be time consuming and may or may not be fruitful.  I hate to waste precious time. But $75 a month for a generic is crazy to me. Does anyone agree that this should not be so difficult?

Thanks for letting me rant. 

Tuesday, July 10, 2012

Cut the cord... Give them the World!

We were recently having lunch at the office and the conversation turned to sending kids off to college. One person shared the story of a friend's very smart, straight A, "jammed on the ACT" child who flunked out of college because he never went to class and played video games all day.  The point being made was that person was going to keep closer tabs on their children when they went to college to avoid letting them fail.

Dr Mellick and I both chimed in at that point, each with very similar points of view.

By college a child is no longer a child, and is treated by the law and banks as an adult.  They should have learned self control and self management long ago.  If they fail to learn along the way under the supervision of parents life's lessons, they will fail in many ways.  I had two college friends (now parents themselves) who had parents that still tried to run their schedules and keep close tabs on them.  Mom or Dad would call every night to be sure the student was in the dorm by a certain hour.  This takes the responsibility away from the college student and puts it on the parents. The students then looked for ways to outsmart the parents, rather than ways to manage their lives. They knew they had to be home by a certain time, but then they left to party or stay at a friend's apartment after they hung up.  They hadn't learned self control or time management.  They had learned to manipulate the parents and the system.  Not what I want for my kids! Not what a potential boss wants from an employee. Not what makes for a caring and supportive spouse or parent.

Kids need to learn so many things before they move out of the house to become well rounded adults who can hold down a job, lead a family, and contribute to society.  This is a process ~ not something they learn the summer before college, and hopefully not something they learn after falling on their face in life.  A recent article in the New Yorker, Spoiled Rotten Why do kids rule the roost?  highlights why American children are so spoiled they become adultescents (adults who have yet to grow up). Worth the read!

Life skills to learn:

  • how to eat nutritious foods in proper portions
  • to spend, save, and give wisely
  • when to recognize they are tired and to get enough sleep
  • time management: work, school, social/fun, rest, chores, projects, exercise, etc
  • self control
  • study habits
  • how to clean the home 
  • simple repairs around the house
  • cooking
  • laundry
  • how to pay bills on time
  • exercise daily
  • following routine dental and medical care
  • how to stay within a budget
  • caring for others
  • respect for self and others
None of these things are learned by someone telling kids how to do them.  They are best learned over time by doing each of them.  Skills build upon previous skills, so first learning basic daily needs (dressing, brushing teeth, washing body, picking up after self) and then learning to do each more independently and finally being able to organize their own schedule to get it all done.  Many of these are learned by sometimes failing, and that is okay.  For more information specifically on chores, see my past post Chores for kids become chores for parents.

Even young children can be taught to help with daily chores.  Starting with preschoolers, the "chores" can be self-skills, such as picking out weather - appropriate clothes and getting dressed, brushing teeth, and other daily activities.  It is much faster for a parent to dress a child (usually) than having a young child do it themselves, but at some point they need to learn, and the earlier, the better!  If they choose weather- inappropriate clothes after discussion of the anticipated forecast, you can help with suggestions.  Sometimes the best way for them to learn is to wear something inappropriate and seeing what it feels like to be too hot or too cold.  This is within reason, of course-- a parent needs to be sure kids are safe: the younger the child, the more supervision needed.  When they were young, I would make them carry another layer if they were underdressed, but I feel no guilt in allowing my middle schoolers to choose shorts in the winter-- their choice!

We follow this process of increasing expectations in our office. Have you noticed as your kids get older  I ask more history from them, not the parent? When Mom or Dad chimes in with the answer, I try to redirect to the child to let them answer what the symptoms are, how long they've been there, what treatments have been tried and if they worked or not. Please let your kids answer ~ they know this stuff! Eventually we offer if the kids want the parents out of the room for privacy. This allows tweens and teens to start accepting responsibility for their healthcare. 

Kids will fail, and that is okay. All part of the learning process. Allow them to learn from failure when the risks are lower as young kids, not when the risk is higher as a teen or young adult.  Kids tend to just get mad if parents always point out the failure but then "save" them by not enforcing consequences.  Examples would be yelling at a child who didn't finish chores and continuing to remind them that they didn't do the chore and you had to do it for them, yet allowing the activities they want to do. Their chore has now become your problem.  They don't own it, so they don't care.  They will continue to allow you to own that chore.  They simply have to listen to you complain about it, which doesn't build strong family bonds, but doesn't require any work on their part.  

Often parents "own" the child's work: the parents keep harping on the child to do his homework, but the child is not motivated. I have previously written about the Homework Battle Plan, and I suggest reading it if your child struggles.  Too often parents "help" by doing much of the work for the child, who complains every step of the way. There are many parents who bring in the forgotten homework because the child forgets it routinely and the parent doesn't want the grades to suffer.  Are you going to drive the homework to the college professor too?  Let young kids suffer the consequence of a bad grade to hopefully learn.  If you keep "helping" them through elementary, middle, and high school, they have never learned what is really important: being responsible for your own work. 

Each stage of growing up has a new set of skills kids can learn to help with.  As kids grow and want to be away from home more, begin by training them how a decision is made, how to spend appropriately, how to make healthy choices.
A family calendar is a great way to let them help with time management.  I love the Google Calendar for this.  Everyone who is invited to the calendar can view it (and add to it if permission is given) so potential conflicts can be identified before they even ask if something is okay to do.  
Start going through questions that are pertinent to the situation so they can learn to think about it themselves:  Is all work done before doing an activity? How will you get there and back safely?  What time do you plan to be home and what time do you have to get up in the morning-- is that enough sleep? How much does this activity cost, and do you have the money to do it? Who will be there and who will be supervising? You still make the final decision, but you might also see the light click when they realize they have other priorities that need to be done first.
Talk about money management without worrying kids about family finances. If kids want a new game, don't get it for them, have them save. Talk about how much they need to save each week to have enough money by a deadline. How will they earn the money? When kids beg to eat out, talk about how much it costs for the family to eat at XYZ restaurant and how much it would cost buy similar food at the grocery store to eat at home. (One that comes up often at my house is going out for ice cream.  How much it costs to go out for ice cream vs buy one container for home is easy to calculate and makes a great point.)  Allow teens to get a job and help them balance money spending and saving. Require that they pay for certain needs or desires.
Have young kids help with simple chores around the house, then increase responsibilities as they get older. My kids loved putting clothes on hangers as preschoolers. I admit that now my kids choose to keep their clean laundry in a pile rather than putting it away, but I suspect they will learn that it is easier to find clothes when put away in their place eventually. Kids can learn to vacuum, dust, and even clean toilets in elementary school. Initially supervising and teaching takes more time than doing it yourself, but when kids learn the skills, that time spent pays off! 
If  kids learn the complex process parents go through to make sure kids will be safe and the activity doesn't conflict with other things, they will start to learn to think through all those things too.  Model good behaviors with time and money management.  Spend quality fun family time together to build strong bonds so they will ask for help when needed ~ but don't give answers, just direction!  Over the years you will watch them grow and mature and they have the world in their hands!

Wednesday, July 4, 2012

Vaccine timing... is it too late?

It is common in the summer months for parents to worry about their child's vaccines being delayed by summer travel or simply scheduling conflicts.

The typical question I am asked is along the lines of, "He is due for his 4 month shots on July 5th, but we are on vacation. Is it okay to wait until the end of July?"


"Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?"

The answer to both questions: yes.

Vaccines are recommended with minimal intervals (you can't give them too soon) but if there is a delay for whatever reason (missed appointments, scheduling conflicts, immune compromise-such as cancer in a child or their caregiver) it is recommended to catch up as soon as possible.  Doses do not need to be repeated if the interval has been longer than recommended.

Conversely, it is not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in Kansas.  Some states have a leeway for giving doses early, but Kansas does not. This is an issue with some children moving to our state from a more lenient state. Maybe they get their MMR a couple days before their first birthday. Does this protect them against measles, mumps, and rubella? Probably. Does the school count it? No. They need to repeat it.

Another scenario is children traveling outside the US. It is recommended for international travelers over 6 months to get an MMR early due to worldwide outbreaks. This dose does not count toward the 2 doses typically given because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Another common scenario involves Hepatitis A and B vaccines due to the ages given and the intervals required.
The dosing interval for Hepatitis A is a minimum of 6 months. We typically give it at 12 months and 18 months, but if these appointments are scheduled with less than 6 months between, we typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine. This delay is okay. 
Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.  If a newborn does not get the first Hepatitis B vaccine on the date of birth for whatever reason (too ill, parental preference, prematurity) and the one month well check is less than 28 days from the first dose, we delay the 2nd Hepatitis B vaccine until a future visit. This will push the 3rd dose back in most cases.
Each year the CDC updates the recommended vaccine schedule. We know it is confusing to parents, but we will help keep your kids on track!

Sunday, July 1, 2012

Decisions Parents Make: Use all the facts

Parents struggle with decisions

I was recently asked to clarify a comment I made on facebook, and the comment deserves more than a quick facebook blurb.

The original post:

If you ever plan on having kids, PLEASE make sure you educate yourself about this!
My reply:
This is one way to use "studies" to distort facts. This article has so many inaccuracies I don't know where to start. 

One of the great things about our country is we have freedom of speech.  I highly support everyone being able to state their opinion, including those who disagree with my opinion.  But I also think we all need to look at opinions as opinions, not as hard fact.  Read articles critically and form your own opinion. Read articles from both sides of the line before you draw your conclusion.  When authors have an agenda (which is why most writers write, including myself here) you must be able to see when they are able to share both sides of a story and when they are simply stating the facts that support their cause.  I am not saying that it is wrong to just state your opinion, just that readers must know how to filter the information. I personally dislike/hate when an argument is actually based on emotion and fears, but comes off as science.  Too many parents are made to feel guilty because they have made a choice for their child that differs from a friend or relative. They read something that differs from what they did and they feel like they made the wrong choice. Regret is a dangerous thing, and is often misplaced.

The intent of my facebook comment above is not to support or discourage circumcision, but rather to warn that when authors have a strong agenda, the methods of persuasion often cause doubt and guilt in readers. I do not find this to be helpful in any way. Data and statistics can be used to distort reality, especially when studies are hand picked to only discuss the ones that support your cause and the ones supporting the contrary are omitted. This includes not only circumcision, but also breastfeeding, vaccines, home schooling, discipline, religion, government, and many, many other topics. 

The first clue that this is an article with a cause is the title and subtitle: “Myths about Circumcision You Likely Believe  CIrcumcision does great harm to babies”.  Simply reading this title alerts the reader that the author is going to persuade you that circumcision is a bad thing.  Their argument is one side of the circumcision debate, but you need to read the counter point from someone who supports circumcision before you make a decision.  

As a disclaimer and credentials for why I feel I can give an educated opinion:  I am a pediatrician who has performed many circumcisions during my 13+ years of private practice. I let parents make the decision to do or not do the circumcision and do not try to sway their decision in any way. I invite parents to watch every time, and nearly half of boys have one or both parents present. Typically parents are impressed by the overall brief procedure. Many have commented that it wasn’t as bad as they thought it would be. I have never had anyone comment how bad it was and have never had anyone (parents, nurses, medical students, or nursing students) become physically ill from watching. I admit that it could be awkward for a parent to express negative comments, so they could simply keep their thoughts to themselves, but experience tells me that when people are upset about things, they tend to complain.  So the many positive comments without any negative comments supports that parents have a generally good feeling about their decision even after watching the procedure.  Note: parents are self selecting here. The parents who don’t want a circumcision in the first place don’t agree to the procedure, and the parents who don’t want to watch are not able to comment on the actual procedure.
Starting with myth 1.  The foreskin is the distal skin of the penis and is removed during the circumcision. It is true that it is adhered to the glans of the penis in a newborn, and there are several means to break these adhesions. This is the most painful part of the circumcision in my opinion (but with adequate pain relief, this pain is diminished/eliminated-- see #3).  As for the surface area of the foreskin in an adult male, I do not see how that accounts for anything about a newborn’s circumcision. A newborn does not have 15 square inches removed. Adult males have wide variation in penile size, and therefore foreskin size.  What has been documented is the more foreskin surface area, the more likely a male will suffer from sexually transmitted diseases:

Myth #2.  Procedures hurt, but that doesn’t mean pain isn’t managed. I agree that anesthesia helps, and this has been shown by several studies. The small study by Lander the author mentions shows that the best form of pain control is with the ring block, which injects lidocaine around the base of the penis. However the only form of anesthetic mentioned in the Myth article is the dorsal block, stating that it is the most common. In reading the article by Narvaez, it is stated that one patient in Lander's study suffered a seizure. Reading Lander’s summary, it appears the baby had apnea and loss of tone in the limbs. While this could represent a seizure, it could also be a choking episode, which is common with newborns feeding or crying. I have seen these in many newborns not associated with any procedure. It is difficult to presume it was a seizure from this documentation, and the conclusion of a direct cause/effect from the procedure cannot  be certain. The small sample size of the study limits the validity and generalizability of any findings, including problems encountered. I personally use sucrose pacification (sugar water on a parent or nurse finger or a pacifier) plus a ring block. Neither of these were mentioned by the author. Sucrose pacification has been shown to help with painful procedures the first 4 months of life. I use it to decrease the pain associated with the injection of lidocaine for the ring block and throughout the procedure. I find that babies tolerate the procedure very well the large majority of the time. What also wasn’t mentioned is that there are many types of circumcisions. Training of the physician typically dictates method used, but they each have their own risks and benefits and pain scores.
Myth #3.  See also #2. I do not know where the 45% of doctors using anesthesia number comes from. In my geographic area at the 4 hospitals in which I take care of newborns, anesthesia of some sort is used by all physicians doing circumcisions to my knowledge. In my area it is typically the pediatrician who performs the circumcision, and few obstetricians do it, not OBs.  As for it taking 30 minutes to achieve anesthesia, I have no idea where that number came from.  Local anesthetics have rapid onset once injected. Lidocaine takes 0.5-1 minute, prilocaine 1-2 minutes.  Topical preparations do take longer and should be placed at least 30 minutes prior to the procedure, and they are much less effective in general than injectable anesthetics.  
Myth #4. I cannot understand how this can be reliably tested. The process of birth itself is traumatic. The large majority of boys in the United States are circumcised, but I do not need to treat the majority of boys for Post Traumatic Stress Disorder. The choice of pain relief by Taddio in his studies (referenced in the Myth article) was a topical anesthetic, which is not as effective as other forms of anesthesia. This highlights that you can formulate the methods of your study to get the answer you are looking for, not necessarily the whole truth of the matter. If Taddio really wanted to prove that anesthesia made a difference, the choice of anesthesia should have either included several types ~ or at least the most efficacious, not the least.  Linking long term effects to a single newborn experience would be impossible in my humble opinion because there are too many confounding factors and it is impossible to isolate a single cause/effect relationship.  This is simply a ploy to get parents to regret a choice they have made for their children. This is horrendous in my opinion. We have many opportunities to feel guilt, please do not try to make parents feel guilty about a choice they have made that can impact the health of their son.
Myth #5. Yes, some babies sleep comfortably during the procedure. I have many parents that can agree with this statement after watching their sons undergo the circumcision.  Their babies did not cry themselves to sleep or go into a shock state. They were just sleepy babies. Most do not sleep ~ after all we are stimulating them by moving them around, washing the area, and otherwise touching them.
Myth #6. There are risks to all procedures. A physician should discuss the risks and benefits prior to the procedure. Parents have the right and responsibility to make choices for their children.  Of the complications listed, these are not unique to circumcised males. 

  • Meatal stenosis is a narrowing of the urethra that both boys and girls can have, not necessarily after circumcision.  It can be a complication of circumcision from irritation, but is rare.
  • Adhesions are NORMAL.  I mentioned above (Myth 1) that they must be broken to remove the foreskin. Without a circumcision they tend to release by 6 years of age. Some circumcised boys re-attach the foreskin without any need to do anything since they typically release on their own by 6 years of age. This is especially common if the pubic fat pad pushes the skin of the penis up and buries the penis (see next item).  While some physicians recommend breaking these adhesions, I have found that it is not required to break these attachments in most cases. This has been validated by Ponsky et al at Penile adhesions after neonatal circumcision. Rarely boys develop bridging adhesions which are different, and these do need to be repaired. 
  • Buried penis is common when infants have a thick fat pad at the base of the penis. This happens in both circumcised and uncircumcised boys. It has nothing to do with the amount of foreskin removed. The worst I ever saw was in an uncircumcised toddler. He suffered complications to the point where he needed a circumcision as a preschooler to resolve the problems. This required general anesthesia which involved greater risk than neonatal circumcision.
  • Infections are possible any time the skin is broken, yet I have never seen an infected circumcision. It is a risk that should be discussed prior to the procedure so parents know how to identify it early and seek help.  Poor sterile technique has been associated with infection and has made the news earlier this year. If done in a hospital setting with proper technique this risk is minimized. Those having a bris should find a qualified mohel with a good record for safety and proper hygiene.
  • Death is very rare. Risk factors, such as family history of bleeding disorders should be discussed prior to the procedure. Vitamin K should be given prior to procedures to decrease risk of bleeding. After the circumcision the site should be routinely checked by trained persons to assess for bleeding. See also infection risk above.
Of course no mention of benefits was made by the author. This unbalanced view does not allow a full disclosure of both sides. 

  • A significant decrease in sexually transmitted diseases has been shown among circumcised men. 
  • Urinary tract infection risk can be decreased in infants. 
  • Phimosis and balanoposthitis are infections caused by improper cleaning of the uncircumcised foreskin. I have seen phimosis once when working as a nurse assistant in a nursing home. It was painful and a horrible consequence of care takers not knowing how to care for the uncircumcised penis. Can this be prevented? Yes. But in our country where most men are circumcised, it is not common knowledge. 
  • Improved hygiene in general is easier in circumcised males. I have instructed many families on how to care for the penis, but find that many boys don’t care for themselves properly as they become independent in the shower. Parents need to discuss this with their uncircumcised sons often!
  • A decrease in penile cancer risk after circumcision.  

My intent on writing this is not to support or condemn circumcision, it is to simply show how only looking at one side of any conflict can lead to confusion and misinformation.  Learn to look at both sides of an argument to make a better informed decision that is right for you! Don't judge others for their decisions, and don't feel regret for decisions you made based on the information you had!