I'm back! It's been a busy few weeks since I last wrote, between an onslaught of strep throat infections at work and the election, I'm utterly exhausted! Even though the election was decided fairly early on Tuesday evening, I was up too late because I was too stirred up to go to sleep. I was so excited but also apprehensive about our future as a country. Anyway, I'll stop talking about the election, since I have no new and/or amazing insight to add to all the discussion, except that I am very proud of the people of the United States.

On a completely different note, I had a patient this week that reminded me of Stuart from MadTV. For those of you who don't know what I'm talking about, here it is:

http://www.youtube.com/watch?v=U02xbYhhjxQ

My patient was a little younger, fortunately, and I was not thrown out of the window, only because we don't have windows in our exam rooms. But his mother just stood there and watched, then reinforced his behavior by comforting him. She then proceeded to threaten him with a shot if he wasn't good, asking me to back her up on that!! The boy had already dismantled the exam room and managed to pull down almost all the stickers off of our sticker boxes...all this within the first few minutes before I even walked in. The first thing he did, actually, when he arrived at my office, was set off the fire alarm in the patient bathroom. As soon as the alarm went off, I knew he had arrived - it's one of his favorite things to do!

This boy can be well-behaved, I've seen it. When he comes in with his grandmother, he's fine. We've come to an agreement with the physical exam: he holds the stethoscope for me on his chest, I hold it when I listen to his lungs; he holds the otoscope with my hand on his, same goes for the ophthalmoscope. So, needless to say, when I see how he behaves with his mother, it frustrates me. When I ask her about it, she explains to me that his feelings get hurt when she disciplines him, so she's given up. I offered her a session with our social worker to help her understand how she can be her son's friend but also his mother...she was interested, now we just have to see if she shows up; until then, I can only hope that he comes with his grandmother!

We all have our Stuarts, be they children or adults. Sometimes we can work with them, sometimes we can't. They can be difficult to examine, and I always worry about missing something, a murmur for example, when I have one of these wild screaming ones. But, when I'm ready to pull my hair out, I just think about Stuart, and I start to laugh, and think, in his voice, "I can do it...."

ADHD and Nature Walks

I was perusing the NY Times today when I came across an article on Tara Parker-Pope's blog on wellness about a small study conducted at the University of Illinois at Urbana-Champaign about nature walks for children with ADHD.

Here is a quote from her blog which can be found at http://tinyurl.com/5lqqhm

"A small study conducted at the University of Illinois at Urbana-Champaign
looked at how the environment influenced a child’s concentration skills. The
researchers evaluated 17 children with attention deficit hyperactivity disorder,
who all took part in three 20-minute walks in a park, a residential neighborhood
and a downtown area.

After each walk, the children were given a standard
test called Digit Span Backwards, in which a series of numbers are said aloud
and the child recites them backwards. The test is a useful measure of attention
and concentration because practice doesn’t improve the score. The order of the
walks varied for all the children, and the tester wasn’t aware of which walk the
child had just taken.

The study, published online in the August The
Journal of Attention Disorders, found that children were able to focus better
after the “green” walks compared to walks in other settings."

I did not find this discovery to be at all surprising. This was a suggestion given to me when I was diagnosed with ADHD, and it's one I always recommend to parents. Whether a child is on medication or not, I recommend twenty to thirty minutes of outside play immediately after school before homework. Unfortunately, not all parents seem to believe me that it works. I am happy to have a study, be it small, to quote, rather than only my own experience.

For myself, I have learned that I am able to focus much better when I get home when I have gone for a run, once I recover a little...To help motivate myself, I like to sign up for races, it gives me something to work towards; if I don't, then I can come up with one hundred excuses not to exercise on any given day! I cherish my runs outdoors, breathing in the fresh air, having quiet time without interruption, and working my muscles. I also get a mental boost from the sense of accomplishment.

On a different note, I worry about "kids these days," to sound like an old lady. Most of them have such busy schedules, going from school, to soccer, to music, home or out for dinner, then homework. Does anyone play kickball on the street anymore after school? Does this over-scheduling have something to do with the increase in the diagnosis of AHD? I also wonder what happens to some of these kids when they get to college, and suddenly they are in charge of their time after classes. Do they know how to allocate their time wisely? I don't know, but I'd love to hear from some readers!

last debate

Two nights ago, I watched the last debate, more out of curiosity than a notion that I might hear something new; I wanted to see how Sen. McCain behaved in light of his declining popularity. Sure enough, neither candidate said anything particularly new and exciting, and each one responded to the other in much the same way they had in the previous debates, one with an awkward chuckle, the other with utter calm and poise.

However, I, along with Orac, a fellow blogger (see http://tinyurl.com/4a695j), was puzzled by McCain's discussion of autism. Orac, along with others, felt that this was pandering to the "autism-vaccine" people, as well as an attempt to make up for previous incorrect statements about vaccines. I suspect that this is true. But what I found particularly strange was this focus on Gov. Palin's understanding of autism...because she has a child with Trisomy 21? Or does McCain get the two diagnoses confused? They couldn't be more different! I realize that children with autism and with Trisomy 21 both are considered to have special needs but to assume that a parent of one is an expert on the other just doesn't make sense. Maybe he didn't realize that this discussion which he inserted into a statement about reform (and again, how is this related???) would cause a negative stir.

Both as a pediatrician and as a former early interventionist, I am extremely interested in education, including early childhood, special education, and regular education (if you can call it that!). I have been listening carefully to what the candidates have been saying about this. Wednesday night, Sen. McCain proved again to me that he doesn't know much about the topic and that he doesn't really care much about it. Although Sen. Obama hasn't spoken a lot about special education, I am thrilled with his interest/belief in early childhood education. Sadly, with a rotting economy and the "war on terror" to pay for, I don't know how much can truly be done about it, but I think it is a wise investment, even in this economic state. I like Sen. Obama's idea of getting parents more involved, although I don't really know how he can enforce that. But, how can we continue to be a world leader if our educational system is in a similar state to our economy? Certainly, a spending freeze would do nothing for the state of education, it might even diminish Gov. Palin's ability to get early intervention services for her son....Now I'm rambling, so I'll stop. We all know that our future president has an enormous task in front of him (or her, heaven forbid) and will likely not be able to accomplish all his goals, I just hope that the vision of a brighter future will motivate people to go out and VOTE!!!!!

I thought this video from The Onion was quite amusing, helps lower the blood pressure after listening to these debates!!



Latest Poll Reveals 430 New Demographics That Will Decide Election

drug samples in pediatric offices

This morning, as I was catching up on the news in between patients, an article in the NY Times caught my eye: http://tinyurl.com/42ttru. Upon seeing the title, I immediately thought the article would address the issue that drug samples do not come in child-proof containers; however, it actually addresses another serious issue with drug samples which is drug safety.

The pharmaceutical industry gives samples to physicians generally of the latest, "greatest," most expensive drugs. These often have not been tested on pediatric populations yet. This is quite concerning when one considers some of the black box warnings which end up coming out, as happened with Elidel, among others. It is attractive, however, for physicians to use the samples they are given, but difficult for the family if the drug works and they then have large co-pays to cover. I have to admit that, working at a community health center, I don't see much in the way of pharmaceutical representatives, except for those representing immunizations. The majority of my patients have medicaid, so I stick with those formularies as much as possible.

I would like to bring up the point I made earlier, though, and that is patient safety of sample packages. Our pharmacy encourages us to put all samples in child-resistant containers, print out a label like with a regular prescription, which has exact dosing on it, and to print out the drug information to hand the family with the sample. Now, if that sounds like a lot of work, it is, especially when I am the pharmacist dispensing the sample while seeing a full load of patients. Yet, I think it's worth the time to prevent an accidental ingestion. For example, one of the few samples I have is chewable Singulair. This comes in a foil push-out packet (I don't know the official term for this type of packaging). If a child gets a hold of one of these packets, it would be very easy to play with it and pop out one of the yummy pills...chomp chomp. Fortunately, this is not a terrible dangerous drug, but nonetheless... Do most offices dispense samples using this tedious process? Or is there a simpler way of doing it? I am open to suggestions. It just strikes me as odd in this litigious world we live in and especially as safety-conscious pediatricians, we allow this to continue. Perhaps we need to start bugging our friendly pharmaceutical reps! Any takers?

Investing in a turbulent stock market

These are rough, interesting days on the stock market. Up until fairly recently, I was only vaguely aware of what was going on the market but didn't really think it affected me directly. I learned about the history of NYSE when I went to see it in action when I was still in elementary school, and it was still a very busy floor with men in suits running around like chickens with their heads cut off. I hear it's a bit different now with modernized computer systems! Then, as a senior in high school, we "traded" stocks for two weeks in my government class, buying stocks and following them in the newspaper. It was a fun game, or so I thought, again with no real consequences. I also remember Black Monday in 1987, talking about it in government class and seeing adults walking around with furrowed eyebrows. But I was a teenager who was more concerned about college applications and crushes on boys...

Come college, I happily took a variety of classes - there were so many interesting topics to choose from! I took language classes, geography classes, history classes, I even tried music theory, which I absolutely despised. I started off pre-med, so I also enrolled in chemistry and biology classes. I eventually became a French major, having tired of science classes. Did I ever take an economics class? No way. Sounded too boring. Perhaps if the department could have come up with some sexy titles to the courses, I might have, but I'm not even sure then because that was a section of classes in the course guide that I pretty much skipped over.

As you can guess, I eventually ended up in medical school. I attended a school with a very innovative curriculum which included a block at the end of our fourth year with classes relevant to residency, such as medical Spanish, yoga (to help us relax through those grueling intern years), and I honestly don't remember what else. We did have a lecture on paying off our loans which basically gave us the message to pay them off as rapidly as possible, to keep living like a resident after residency in order to make large payments on our loans. Certainly that was sage advice, but that was it for our financial education.

Needless to say, residency was about the same. Our daily noon conferences was excellent medical lectures. Each year we were given a talk on choosing a job which included learning about different types of malpractice, head hunters, and helping involve one's spouse in the decision. Very helpful, but again, not much about how to handle the money we were about to start making. Can you see a theme here?

So, I eventually landed in my first job. I signed on the dotted line to put the maximum amount of money I could into a retirement account because my parents had taught me that saving was a good thing. I chose the default funds to put my money into. For whatever reason, I didn't consult my husband on this choice, I think perhaps because I was overwhelmed by all the paperwork I had to fill out on my first day of work, and I figured that I was being guided in my investment decision by someone who knew more than me. And, as you can gather, I didn't know a whole lot. And my husband would have been an excellent resource.

Happily, the first few years, the economy was still relatively strong, although to an astute observer, there were signs of the current problems. As I started hearing about the stock market losing losing losing, I decided to take a look at my portfolio. Yikes. I had the feeling that this was going to be baptism by fire! The glorious 90s were over. Ignorance was bliss. Since then, I have made the effort to educate myself on the art of investing. I say art, because unless you are completely invested in index funds, there is an art to it. I just finished an informative book my father-in-law sent us called, "The Little Book of Common Sense Investing," by John Bogle, the founder of Vanguard. Although I prefer to read novels in bed after a long day of work, I read this book cover to cover. It was actually pretty interesting and well-written, without too much jargon for a lay person like me. Mr. Bogle focuses on the index fund, his own creation, which has gained many supporters in the financial fields. Basically, this is a fund that owns the entire stock market, thereby minimizing risk, and also, by owning a little bit of everything and not actively buying and selling stocks trying to guess who to invest in, there are low costs associated with it. This is investing for both the non-investor who doesn't have the time and/or skill and/or luck to buy and sell stocks daily, as well as financial wizards like Warren Buffett and John Bogle himself. It is a beautifully simple plan. And the book, although focusing on this particular type of fund, also teaches the reader about other types of investing. I highly recommend it. I obviously still have a long way to go, but I am an active learner now. Honestly, I would still rather read about neurofibromatosis than finances, but I also realize that I would eventually like to retire, preferably before the age of ninety...

The moral of this story is that perhaps some basic classes on investing could be incorporated somewhere into our education. The challenge is that there is just an amazing fount of knowledge we already have to acquire in medical school and residency. Where would this fit in? Maybe we could have quarterly lectures on it during residency or medical school. Many of us become physicians "to do good," not just to make money, and frankly, these days, there are other fields to go into to make money; but there is no reason we shouldn't have the resources to be wise with what we do take home. We work hard for our money, and it should work hard for us.

not too much

Just a quick note from Colorado! I'm at my District VIII meeting, being awed by the work that pediatricians all over my district are doing. It's both inspiring and motivating to be surrounded by leaders in the field. It's also comforting to hear about the struggles they face that I too face, I am not alone!! I'll have lots to report when I get back, new resources, new websites, new ideas. For those of you who may not know what District VIII means, it is a district of the American Academy of Pediatrics, and it includes Alaska, Hawaii, British Columbia, Alberta, Washington, Oregon, Montana, Idaho, Utah, Wyoming, Nevada, Colorado, Arizona, New Mexico, and Uniformed Services West. It's the largest district geographically and obviously quite diverse.

Sorry this is short, but I have limited time!

primary care shortage

All the buzz in the media and on doctor blogs in the past day or two has been the announcement that, according to a survey published in the Journal of American Medical Association, only 2 percent of graduating medical students are going into primary care, primarily due to poor salaries and increased workloads. TWO PERCENT!!!!!! That is just frightening to think about, especially from the viewpoint of an already busy rural pediatrician. We, as primary care physicians, are already pushed to see as many patients as possible by our reimbursement schedules. I know that I am getting busier every season than I was the last. This year, my "slow" period consisted of approximately two weeks of slower days, then we picked right back, last year, my "slow" period lasted closer to one month; this year, I'm already seeing winter time numbers with school having been in session only for a few weeks....I'm afraid things will only get worse.

How about talking about solutions to this problem?! Neither candidate is addressing this specific problems. Then again, nobody is really asking them to. I have a proposal: mandatory one to two year service in primary care medicine prior to specialization. In other countries such as New Zealand, they have general practitioners (GPs) who tend to the primary care needs of their citizens. Perhaps we could do something like that here in the US. I have just recently completed my service time for the National Health Service Corps and although that system is severely flawed, it could be used a loose guide. I am now free to do a fellowship, if I so desire. I've learned a lot from practicing this kind of remote primary care medicine, and I think this type of background would serve me well were I to do further training.

This is by no means a perfect solution, and I'm sure I'm not the first to suggest it, but perhaps it could get people talking if it were put out on the table. I know that we, as physicians, already go through many years of training, and some would groan at an additional two years, but how else will we take care of an increasing population of baby boomers?? We cannot simply rely on foreign medical grads. We cannot rely on the whims of medical students. And, at least at this point, we cannot rely on improved salaries to draw medical students to primary care.