Screen time: Do you have a love - hate relationship with it?

Screen time. Parents often have a love - hate relationship with it. We've all heard the warnings that it is bad for our kids, but we've experienced the benefits of it keeping our kids occupied while we get things done. And some programs and games have an educational component -- do we group those in the same category as purely entertaining ones?

Most parents by now have heard the recommendations that kids under 2 years should have no screen time. At all. And older kids should have no more than 10 hours / week total.

Most parents are also fully aware that their kids exceed those guidelines. Some by a little. Others by a  lot. There are all kinds of reasons parents have for allowing this. Some are good reasons, others are not.

To be honest, there is still a lot we don't know about screen time. Research continues. When I was a child, television and movies were just passive watching. Thankfully there wasn't much offered, and with a limited number of channels, we usually stuck to watching tv only on Saturday mornings. Other times we played outside. Shows were not as action packed and overstimulating as those of today. Compare Mr. Rogers to pretty much any show designed for kids today with quick scene changes, music in the background and motion everywhere. Now there are interactive games, many of which are educational, or at least they seem to be teaching letters, counting, or other skills. There's even Wii and Kinect that use whole body movements to get kids off the couch. One can get a good workout with some of the games, but Wii bowling is nothing compared to real bowling.

So how do you count educational and active game time? Should it be included in that 10 hours/ week, or should you allow extra time for it? Are e-readers a form of screen? They often allow interaction like a computer and many can show videos and offer games.

Short answer about counting total screen time: We don't know.  Experts can give thoughtful opinions, but really at this point it's all educated guesses.

Some studies show that kids learn better when things are presented on a computer or video format. Maybe it keeps their attention better than a paper workbook. I love the ability to hold my finger on a word in an electronic e-reader and have the pronunciation and definition pop up. How many times as a young reader did I simply skip over words I didn't know? My daughter likes to increase the font size so only a sentence or two are on the screen. She feels like she reads faster because she "turns the page" more often. Does this build her confidence reading? Does it actually slow her down? I don't know. But she's happier to read and it seems to work for her. (This does drive me nuts if I pick up the Kindle after she's changed the settings... but I can change it back to my preferences easily.) Are kids losing the ability to find things in alphabetical order, such as using an encyclopedia to look something up, since they just hit "search" and find the answers? Does it matter?

Parents must really pay attention to what kids are watching and playing as well as how much time they are spending on a screen. For every minute they are on a screen they aren't interacting with people to work on social skills, they aren't outside playing games and getting exercise. If the games they are playing help develop thinking skills, strategy, math, reading, and more, then some screen time every day can benefit. If the content has violence or other age inappropriate material, it can be very detrimental. If they are online playing against other people, dangers multiply. While I can see kids who hate to read actually not notice how much they must read to play a game on a computer or tablet, are there better ways to get them pumped into reading a book?

There's a time and place for everything. The dinner table and bedroom are never a good place for online/screen time. Watch and play with your kids. They will love the time with you and you can better supervise what they're exposure is and modify it as needed.

More information:
Media Resolutions Every Family Should Make in 2014 has some tips to help monitor and limit screen time.
For information on internet safety, check out YourSphere for Parents.
American Academy of Pediatrics Media page.

Shorted at the pharmacy

Has this ever happened to you? Your baby has an ear infection, so you pick up the antibiotic and diligently give it as directed on the bottle. Every day you remember it because you want the infection to go away. But as the days pass, you notice there isn't enough in the bottle to give the full 10 days of medicine.

We get frequent calls from worried parents that they run out of medicine before the full course is completed.

Since pharmacists give exactly the amount calculated for the dose to be dispensed, it is understandable that it doesn't quite last that long.

Why?

A little medicine will stick to the insides of the bottle. A few drops can be lost on a syringe. If you're using a dosing cup, it can be over or under filled by a few milliliters (or more if you look at an angle) each time you use it. Add a few milliliters with each dose, often twice a day for 10 days, it is easy to see how you can be off by a couple teaspoons by the end of the 10 day course.

photo source: Shutterstock

When I was in training, I was taught to increase the dispense volume by 10- 20%. This means if a child would take 5ml twice a day for 10 days I would give 110 - 120 mls.

5ml x 2 x 10 days = 100 ml

10% x 100 ml = 10 ml "extra" or 20% x 100 ml = 20ml "extra" 

100ml + 10ml = 110 ml or  100ml + 20ml = 120 ml

Pharmacists no longer will give extra volume. If the dose is 5 ml twice a day for 10 days, they will only give 100ml. That means there is no wiggle room. Small drops of "waste" all add up by the end of the bottle and you will come up short.

What you can do to help:

Can you tell from the poor photo quality that this was taken by me with old dosing devices I found at home?

• Only use a medicine dispensing container, such as a syringe, dosing spoon, or dosing cup. A cereal spoon varies in size and is not reliable.
• Shake the bottle before dispensing liquid medicines.
• Tighten the lid after use to decrease the risk of spills.
• Store the medicine away from kids. 
• Refrigerate medicines if needed - the label should state this.
• Measure carefully. 
• If the dosing device is labeled with a different measurement type (such as tsp vs ml) be sure you know the conversion-- if not, ask the pharmacist before you make the purchase.
• Syringe: Use the smallest syringe that will fit the entire dose. For instance, if your child needs 0.6 ml, but you use a 10ml syringe, it will not be accurate. Be sure to hold the syringe straight up and down, not at an angle, or one part of the liquid will be higher than the other. Also be sure the syringe is marked for the dose you need to give-- don't guess where 3.75 is between 3 and 4. 
• Medicine cup: I find it helps to put the medicine cup on the counter to level it out, then I get my eyes at the level of the cup to measure. Again, be sure it is marked for the volume you need.
• Medicine spoon: Hold it at eye level straight up and down to align the medicine with the appropriate line.
• If you use a syringe, see if the pharmacist has a syringe adapter for the bottle (as pictured above) to be able to hold the bottle upside down to avoid sticking the syringe into the bottle and losing medicine on the outside of the syringe.
• Don't share medications. 
• Don't save "leftover" medicines for another time. Liquid medicines tend to expire pretty quickly and no prescription medicine should be used without a professional evaluating the need for it.

Despite your best efforts, it is possible that you will run out of medicine before the full number of doses you were supposed to give. 

• If it is an antibiotic: There is research supporting shorter courses of antibiotic work as well as the traditional 7-10 days for some infections, so you might just need to have your doctor check to be sure the infection cleared before filling another prescription. 
• If it is a long term medicine that needs to be taken daily: Talk to your doctor to see if they can help get a little more medicine per bottle if you routinely are short at the end of the month.

Developing healthcare responsibility in your children

I am writing this fully knowing I am at risk of upsetting some parents. But this is the time of year we see more school aged kids for their annual physicals, so it is the time of year I think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent.

source: Shutterstock

I read an article recently (The Overprotected Kid) that really hit home with me about how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life. Although the article is based on allowing kids to roam and play with things that haven't been engineered to keep them safe, it did touch on the fact that parents hang around to answer for kids and speak up for them.

I find that parents often try to help their children during visits to my office by answering questions about their health, sometimes even what they are feeling. I'm sure they want to be sure I know their (parent) perspective. Maybe they are just trying to speed up the visit so they can leave and do the other things on their to do list. But it usually ends up taking longer, because I then spend more time trying to talk to the child.

When a question is directed at the child, let the child answer. If I need parental clarification, I'll ask for it. Obviously a pre-schooler needs more help than a high schooler, but if the teen has never had the opportunity to answer for himself, he might not have the skills and confidence to do it.

Sometimes a parent will start asking their child questions or tell them to tell me about .... I'm sure they are thinking that it is helping me, but it doesn't. (I'm not talking about the parent reminding the child to tell me something they previously discussed, I'm talking about the parent who in response to something I've asked tries to draw the child into conversation-- that's my job.) I have a set amount of time to assess a child's physical exam as well as other factors, and I have a process of evaluating all the points I must consider.

When I ask a child a question, I'm not only looking for the answer they are giving, but I'm also gaining valuable information about the child. Can they speak clearly? Do they understand a question that is age appropriate? Do they make eye contact? Are they developmentally mature for their age? Do they understand how their habits effect their health?

So often well intentioned parents pipe up and answer questions directed at the child. It doesn't matter if I'm looking directly at the child, the parent answers. Even if the child starts to answer. I will often redirect to the child for clarification and the parent still answers. Some of the kids roll their eyes. Others take it in stride without much of an expression at all, as if they're used to their parent taking care of everything. Some simply turn back to their hand held game and play, ignoring the grown ups in the room. Ugh! How does that help me get to know the kid?

Sometimes I wonder how the parent makes it through the day when the child is at school since they can't be there to speak up for the child all day there. It can be that bad.

I really worry about the older school aged kids, especially those in high school, who have parents answer for them. How will they be able to assume their healthcare responsibilties once they turn 18? If they don't know about their past medical history, allergies, and family medical history how can they eventually establish healthcare with a new physician without a parent? If they can't give a clear and concise summary of what their symptoms are for an illness, what will they do when you're not there?

And yes, I see parents piping up for their high schoolers.

I guess it's a learned behavior for all. Parents get used to answering the questions for pre-verbal kids, and they keep doing it.

Please stop.

Let kids in elementary school be prepared to order off the menu when the waitress comes to the table -- after discussing their choice before she gets there if they need help deciding on a healthy item. Have older elementary kids speak up at the store to ask for help when they need a dressing room or if they need a price check. Let them talk to their teachers first if they question a grade or need help learning a concept. Let them give their own health summaries at the doctor's office. You can be there for support along the way, but offer less and less as they get older and more experienced.

If your child has true inabilities to do these things there might be an underlying problem, such as anxiety or developmental delay. Those should be addressed. But by far and away most school aged kids can do these things. Let them.

They need to do these things to be able to one day live independently. Trust me, they will appreciate it some day! Too many college kids call home for parents to "fix" things that the young adult should be able to handle. But they can't jump into the deep end of the pool without learning to swim along the way.

Hair loss in children

Spring is a time I often hear complaints of hair loss. It only took a couple seasons to notice the pattern, both in the office and with my own hairbrush. I have long suspected that it is similar to our pets shedding unneeded hair this time of year, but have never been able to find supporting evidence, at least on a reputable site.

Notice the hair loss pattern.
Photo source: Shutterstock

What I do see reproduced on many sites (mostly hair clinic sites, nothing I would rely on for information) is that both Fall and Spring are a time of normal hair thinning. Studies link hair growth to sun exposure and melatonin levels. I am definitely not a hair expert, but wanted you to know some warning signs of abnormal hair loss and when it is safe to wait it out.

Most of us lose 50-100 head hairs a day. Long hair is obviously more noticeable when lost, since it plugs shower drains, accumulates on brushes, and is seen on our clothing. Simply seeing hair being lost is not a concern.

Hair loss causes

Some causes of hair loss are easily identified. Others are harder to identify because associated symptoms are vague and not always noted to be associated with hair loss. If you are concerned, make an appointment to discuss it with your child's doctor. Since this can be a chronic issue, it is not ideally handled at an urgent care or walk in clinic. If indicated by the findings of their exam, your child's doctor may refer to a dermatologist, endocrinologist, or other specialist, but many of these can be managed by the pediatrician.

• Traction: Braids or other hair styles that pull the hair shafts (as in picture above) can cause hair loss in a pattern easily identified by the hair style. Treatment is simple: stop styling the hair with traction. If continued, damage to the hair follicles might make regrowth impossible.
• Babies often have hair breakage from friction on the back of their head. It usually develops the first few months of life. When they start sitting up most of the day and sleeping on their tummies it regrows. (Note: Do NOT put your baby to sleep on his tummy to prevent this. Tummy sleeping is associated with SIDS.)
• Trichotillomania (or hair pulling disorder) is the compulsive urge to pull out (even sometimes eat) hair. It can be seen in infants and toddlers, but peaks in young school aged kids. Treatment can be difficult and involves behavioral therapy. There is some encouraging research into N-acetylcysteine (NAC) treating trichotillomania and other behaviors. 
• Ringworm of the scalp is a fungal infection that can cause hair to break, leaving the base of the hair in the scalp. The skin can appear red and/or scaly. It can be secondarily infected with bacteria, causing swelling, pain, and drainage. After the diagnosis is confirmed, an oral medication is needed. 
• Malnutrition can cause thinning of the hair, growth problems, behavior problems, muscle wasting, and abdominal swelling. Too little iron and/or protein in the diet can lead to hair loss. Biotin, zinc, and B12 deficiency are specific associations. In this country malnutrition is very uncommon. Treatment involves improving nutrition and addressing any underlying condition causing the malnutrition.
• Too much Vitamin A has been linked to hair loss. If your child takes supplements, be sure to let your doctor know when you are discussing hair loss.
• Hypothyroidism (low thyroid levels) has many symptoms, including thinning of hair. Not all need to be present, and some symptoms can be there without hypothyroidism because they are vague and common issues. Hair may become brittle and break off more easily. Hypothyroidism can cause kids to feel tired and not have much energy. Constipation is a frequent complaint. Heartbeats might slow and kids may feel cold when others are comfortable. Skin is often dry. Kids can slow their growth and may become overweight. Blood tests can help identify hypothyroidism and thyroid hormone replacement can treat it.
• Uncontrolled diabetes can affect hair growth and loss. Working with an endocrine specialist is important to get diabetes under control.
• Polycystic ovarian syndrome (PCOS) can affect hair thickness. Girls with PCOS can have excessive hair growth on their body but male pattern hair loss on the head, acne, obesity, diabetes, heart disease, high blood pressure, and abnormal menstrual cycles. Blood tests along with a history and physical can help identify PCOS. 
• Medications can cause hair loss. The most commonly known type are chemotherapy drugs, but also some acne medicines, anabolic steroids and lithium can cause hair loss. If hair loss is a concern, be sure your doctor knows all the medicines and supplements you give your child.
• Alopecia areata causes patches of hair loss. It is an autoimmune disease --the body's immune system attacks the hair follicles. The patches can be small or cover the entire head (or even body). Skin in the area is normal. See the link above for more information.
• Hair treatments: chemical treatments, such as coloring, straightening, bleaching and curling can lead to hair loss. Heat from a hair dryer, curler, or flat iron can break hairs. Even combing wet hair leads to more breakage because wet hair is more elastic. Limiting these treatments can allow hair to re-grow.
• Severe stress, including that from infection or surgery, can lead to sudden hair loss. Because hair grows slowly, this is seen many weeks to months after the event. It will re-grow, usually within 6 -12 months.

Screen time for under 2 years might be okay? What!!!???

I was initially confused by recent headlines such as this reporting that Dr. Dimitri Christakis now says some interactive time on tablets or computers might be okay at young ages. He is one of the authors of the 2011 American Academy of Pediatrics Guidelines that recommended no screen time under 2 years of age, so this seemed at first contradictory. He has previously been on record affirming that television for children under 3 years is very detrimental for their attention span, stating that it permanently damaged their brains. So naturally my first impression was the news must have the angle wrong.

photo source: Shutterstock

Then I was reminded that when those guidelines were written, the scope of screen time availability was much different. The guidelines relied on research done well before iPads or other tablets were readily available. It was a time of flip phones, not smart phones. We have little information on what interactive screen time does for development since it is such a new concept.

Toddlers in my office are often on their parent's smart phone or other device. They scroll through family pictures. They try to match puzzle pieces. They find the letter or count the objects. They watch a movie. Each of these is very different in what the child is exposed to and what they can potentially gain. There are lists of educational games for 2-4 year olds to teach various skills. I suspect if the under 2 year crowd playing e-games is sanctioned officially by the AAP, lists for that age group will develop too.

We really are in infancy stages of learning what kids of all ages can learn from these devices or all the negatives that could be attributed to them. Of course the types of interactions make a big difference in addition to the total amount of time spent on these activities. As Dr. Christakis explains in this TED talk, some screen time is too action packed and fast moving for healthy brain development, encouraging short attention spans and hyperactivity. Children under 3 years have an especially rapidly developing brain, so they are more sensitive to the interactions they have in real life or on a screen. (He starts talking about television at about 5 minutes into the video but I encourage watching all of it, it is that good.) It is still unclear if television actually causes increased risk of ADHD or if children with ADHD are simply more drawn to action-packed television. Interestingly, educational television programs aren't linked to increased risk of ADHD but action packed and violent shows are. In short, any experience we have during our developmental years changes us, we just don't know exactly how influential television and video games are.

Toddlers who interact with a screen are learning hand-eye coordination and cause and effect. Yes, that can be learned the old fashioned way with exploring their world around them, and I encourage that most of it should be learned from playing with real objects. They need human interaction to learn social skills. Screen time can over-stimulate them if the action is too fast-paced, too loud, done in excess, or done at the wrong time (such as bedtime). Most of us know how addictive screen time can be. We can lose track of time as adults and so can toddlers and kids. If kids get frustrated playing (or refuse to turn it off when asked) they might be getting inappropriate or too much screen time. If this happens, stop all screen time for awhile and slowly re-introduce it after screening the games/ shows to evaluate if they are appropriate for your child's stage of development. Just because an older sibling or friend enjoys a show or game doesn't mean your child is developmentally ready for it.

For most families children using screen time is a given, it's not something parents avoid until at least 2 years of age. Regardless of recommendations to have no screen time under 2 years and only up to 10 hours per week for older children, most kids have much more screen time than that. Parents know that screen time is a great behavior motivator. Parents use screen time as a token to get chores done or to behave well. It can afford a parent time to get a few things done while kids are not running around the house. It is an easy way to keep kids occupied when they must sit quietly for a long period.

We still should use screen time wisely and responsibly. It should be age appropriate. Especially for younger children, it should have a learning goal and should not be too fast paced. A great video from CommonSenseMedia.org, Not All Screens Are Created Equal, discusses quality as well as quantity of screen time. I regularly use that site to pre-screen media my children want to watch or play to be sure it is appropriate for my child. I encourage you to do the same.

Playing learning games on a computer or tablet has the potential to be beneficial for children, as long as it is balanced with active play to allow for plenty of exercise. Remember as parents we must put down our devices too! Kids need our attention. If we are hiding behind our smart phone or tablet, we are not focusing on them like we need to. Set aside time just for family and turn off all the electronics. Model the behaviors you want your kids to do. Help toddlers and kids use screen time wisely and appropriately.

Allergy testing: When to Use It and When to Not

As food allergies have gotten more common, more parents than ever want testing. There are definitely reasons to test, but testing can be expensive, and not all tests are equal. There are also differences between food allergies and food insensitivities. A true allergy occurs when the immune system reacts to something that really is not a threat, but causes measurable symptoms.

Created at http://www.wordle.net

Food allergies are reaction to food proteins because the body's immune system is reacting to something that really shouldn't be a threat. They are different from food insensitivities or intolerances, such as diarrhea and gas from lactose intolerance or red cheeks after eating tomato sauce.

There are three main types of food allergies: immunoglobulin E (IgE)–mediated (immediate) reactions, non–IgE-mediated (delayed) hypersensitivity reactions, and mixed reactions. IgE-mediated reactions are the type we often think about when we hear about a food allergy-- hives, itchy skin, wheezing, vomiting, throat swelling, and anaphylaxis. These reactions can occur immediately following exposure. Non-IgE-mediated allergic reactions can cause localized or generalized reactions, such as a skin rash or stomach upset, or even Celiac disease. Some allergic disorders have components of both IgE and non-IgE mediated types, such as eczema.

Determining if there is a food allergy requires both a history of symptoms with exposure and confirmation testing. In general, there are two different types of allergy testing. Children and adults can be tested by either method, depending on symptoms and other considerations. Both types of testing can lead to false positive results, meaning there is a reaction that makes a person look allergic to that trigger, but they really aren't. That means we have to look at symptoms along with the tests. No one should undergo testing "just to know" if there really aren't specific symptoms to evaluate. This can lead to overestimation of allergies, which can result in patients being on a severely restricted diet and lead to nutritional deficiencies. It also uses healthcare resources inappropriately and drives up healthcare costs.

Available testing:

• The first step is a careful history of exposures and symptoms. This may include a food elimination diet to help diagnose allergies.  
• Skin testing involves scratching a small amount of suspected allergens onto the skin or injecting a small amount of allergen into the skin. It is typically done in an allergist office, though some primary care doctors will offer it. (If you do this type, be sure the doctor has adequate training and does it routinely-- it requires a lot of expertise!) Results are generally known within minutes, based on local reactions to the various allergen areas. It can be uncomfortable for children, but many tolerate it just fine. This type of testing is often less expensive than blood panels. Patients must be off of their allergy medicines for this type of testing, which can be difficult for some severely allergic people. It can also be difficult in people with extensive eczema or other skin conditions. 
• Blood testing involves drawing a sample of blood and running many tests on a single sample. This may be preferred in children who cannot tolerate being off their allergy medicines (they can stay on medicines before testing blood) or in those who will not tolerate multiple skin scratches for the skin testing. It is generally more expensive than the skin testing and results can take a week or so to learn results. Blood tests that are recommended for allergy testing involve testing IgE, one of our immunoglobins that triggers allergy symptoms. There are health care providers who recommend IgG testing for food allergies. These are NOT proven to be of benefit. More on that below.   
• Oral challenges (giving the suspected food to the person and watching for a reaction) is often the best test for food allergies, but obviously can be very risky and should only be done in an experienced doctor's office.

Our website has information on the testing we offer from our office on the Allergy Test Results page. I don't want to duplicate all of that information here.

The driving force to write this post is the number of patients who come to me requesting that I order tests that were recommended by another healthcare provider. I always refuse to order tests that I do not think are indicated or worth while. It is difficult in the space of an office visit to go into all the details of why we don't want to order the labs, but a simple "they aren't recommended" doesn't sit well with families when they have their hopes set on finding answers. Insurance rarely covers non-proven tests, so if you're warned that insurance might not cover testing, that is a red flag that you should investigate further.

What are some of the tests that are not recommended?

There are medical providers who will order IgG panels for food allergies. This is simply not an appropriate test. Both allergic and non-allergic people will have IgG antibodies. They are the normal antibodies used to fight off infections and it is thought that when a food is eaten, the body makes IgG antibodies as a normal response. When food allergic people have been in clinical trials to desensitize their food allergies with immunotherapy, the IgG levels actually go up, despite lessening of clinical symptoms. IgG antibodies show exposure to foods—not allergy. For this reason most people who are tested react to MANY foods and are erroneously told they are allergic to those foods. This severely restricts the foods they are told are safe to eat. I worry that kids will suffer from nutritional deficiencies with such restricted diets. Of course, many of the providers who offer this testing also sell nutritional supplements, so they make money from the "allergies"... Think about it awhile. Do they really care if the test is valid or not? They know the numbers look convincing. They also know the more a person reacts to, the more money is to be made. Maybe they really believe in the tests and their procedures. Maybe they feel it helps. I don't agree and neither do the studies.

Hair analysis is another test that some people will recommend to look for allergies. It simply isn't helpful. At all.

I've had a few patients who have been tested by holding the food while the "specialist" measures arm strength. Supposedly if they are weakened by holding the food they are allergic to it. This is called applied kinesiology and has not been shown to help at all in identifying allergies.

People will take your money. They are usually good sales people. They will claim that labs can't lie and it is based on science. Ask to see the research. Learn to evaluate research first, because sometimes they will show fancy graphs that don't really support anything. But they look impressive. Beware! For some information on how to help learn to be a good judge of whether information is scientifically valid or not, see some of the links below.

Want to learn more? There is a lot of information available!

• More about how blood tests work and why they have false positives: Foodallergy.org 
• More on how skin prick testing works and why they have false positives: Foodallergy.org
• More on IgE testing: ScienceBasedMedicine.org
• More on other unproven diagnostic tests: FoodAllergy.org
• Guidelines for the Diagnosis and Management of Food Allergy in the United States is a comprehensive summary for patients and parents of the guidelines outlining testing for as well as management of allergies. It is important to note that it was published in 2011. (I can't find an update.) The recommendations for influenza vaccine for those with egg allergy has changed since then. It is now recommended to give the influenza vaccine despite an egg allergy. For more information on egg allergy and influenza vaccine, see this update.
• Want to know if what you're reading on the internet is reliable? Take this quick tutorial from the National Library of Medicine. It's free and only takes about 15 minutes!
• Still want to learn more about how to evaluate science? Take a look a the many resources on www.ScienceOrNot.net.

Are you following your doctor's instructions?

Every day doctors assess and treat patients. Most doctors follow standard guideline practices or have good reason to not follow them for any individual patient. Insurance companies are taking it upon themselves to "help" doctors follow these guidelines. They review their records for certain diagnoses to see if proper testing and treatments are used by those patients.

While this can be helpful to nudge doctors who might not follow standard guidelines, it is annoying for those of us who try to. 

It is not uncommon for me to get a letter from an insurance company telling me that my patient is not being cared for properly. Usually it is because a child with a diagnosis of obesity has not had a lipid panel (cholesterol) drawn despite my ordering it months ago (or even multiple times with many reminders). Or a patient with asthma is not on a controller medicine or hasn't had an asthma check in 6 months.

The letter includes something like this (sorry for the poor focus):

picture from actual letter

These letters frustrate me because what am I supposed to do with them? I note it in the chart to discuss at the next visit and often have a nurse call for a parent to schedule a visit or go to the lab or pharmacy to get the tests or medications previously ordered, but typically it doesn't make a difference. Parents still do not follow through with recommendations.

Doctors are graded by insurance companies. We are supposed to follow guidelines to provide appropriate care in a cost -saving manner to the clients of the insurance company. Insurance companies can use the information they have about patient compliance (through coding and billing submitted by the doctor, the lab, the radiology facility, and the pharmacy) with standard guidelines to pay physicians various amounts (i.e. higher payments for "top notch" docs and lower payments for those who don't meet compliance standards) or they might simply stop allowing a doctor to be one of their providers. Remember it doesn't matter if a doctor orders a test or medication, only if those orders are completed. The insurance company only knows about the order if the code is submitted at the time the test is done or the medication is filled. They have no idea if the patient got samples in the office (therefore doesn't need to fill a script) or if the doctor gave a prescription, but the patient can't afford to pick it up or doesn't fill it for any number of other reasons.

Unless you were under a rock or never watch the news, you probably heard about the thousands of doctors recently removed from certain insurance panels. Some of this is probably unrelated to following the guidelines, but it is very possible that your favorite doctor might not be invited to participate in an insurance plan because enough of their patients do not get the recommended tests and treatments. Whether this is due to the physician not following guidelines or patients not following the doctor's recommendations does not matter. If a prescription is unfilled, the insurance company never knows it was written. If you fail complete the autism screen, do the lung function test, or go to the lab to have the labs drawn, the insurance company does not know they were recommended and ordered. If you do not follow up as requested by your doctor, the doctor gets dinged by the insurance company.

Part of the new healthcare laws includes that physicians must show follow up of referrals, completion of labs, and in general follow up on all orders.

Insurance is in a general state of uncertainty at this time. Pediatricians and other physicians around the country are nervous with all of the recent and upcoming changes. No one is certain how we will be paid. I know everyone thinks doctors are rich, but that is often not true and another discussion entirely. The truth is that any business needs an influx of cash to survive.

New high deductible plans mean that we will need to collect payment from patient families instead of the insurance company, which will likely decrease collections and increase the time to collect. This affects the bottom line. In October, a new coding and billing system is due to be implemented. Many experts expect that payments will be delayed by insurance companies for 3-6 months. What business can survive without any income for 3-6 months? New healthcare laws make it possible for patients to appear that they have active insurance, but if they haven't' paid their premium, the insurance company can refuse to pay. If insurance companies grade us on a "lower" quality scale or cut us from their panels, an office will bring in less income. All of these variables will make it more difficult for physician's offices to pay their bills (rent, insurance, staff salaries, purchase supplies, etc). Many private physicians are already selling out to big hospital or other medical systems. With this they lose control over their practice and become employees. I do not want to go that route.

What can you do to help insure that your favorite doctor's office stays in business?

• Schedule and keep appointments as recommended. This includes all routine well visits, follow up visits for chronic illnesses, and rechecks of acute illnesses as recommended. If you don't intend to do the recommended follow up, talk to your doctor about why.
• Know your insurance plan to estimate your medical costs. I know this is very difficult because there is little transparency in medical billing. What a doctor charges, what an insurance company has the doctor's office write off, what insurance pays, and what insurance requires the patient to pay is usually not clear. Believe me, I wish the system was different too, but we must work within the system until it changes. Take the time to ask the doctor's office about charges and call your insurance company ahead of time if there is question about your percentage of that charge.
• Pay bills on time. If you question a bill, call your doctor's billing office for an explanation. If you are unable to pay the full amount, call the billing office to set up a payment plan. Don't simply ignore a bill! It won't go away if you don't address it.
• If you disagree with a recommended lab, test, prescription, referral, or follow up: tell the doctor at that visit! Either we can change the recommendation and document in the chart why we are changing it, or we can discuss with you further why it is important. 
• If you cannot pay for the recommended lab, X-ray, or prescription, tell your doctor. We might have ideas of how to get help.