Paying for labs

Last month, we received news at my clinic from "the bosses" that we were to use only one particular lab company for all our labs except for a few types of private insurance. This news came as a surprise, and the medical providers had not been asked for any input on choosing the company. I was very disappointed, as the one that was chosen just happened to be one of the slowest in processing times. When I questioned the administration about the decision, I was told that they offered our organization the best prices for our uninsured patients. End of discussion. Since there was nothing I could do to change the decision, I tried to improve the speed of processing through our customer service representative. Needless to say, nothing has changed on that front either.

So, I went about my business, grateful each time when I had a patient who had the kind of insurance which allowed us to use a different company. But, then, last week, bammm!!! out of the blue, another dictum. This lab company who had contracted to take on the organization's uninsured patients decided that they were losing too much money on us; understandably, they cannot do thousands of labs for free. And our organization decided that we cannot keep losing money by writing off the bad debt. Keep in mind that we are a group of federally-funded community health centers (CHCs), so we provide healthcare for any and all, regardless of insurance status. The policy on labs now has changed, and our patients who don't have health insurance have to pay cash up front for labs. As a provider, I do have the ability to say that a particular lab must be done, regardless of the ability of the patient to pay. However, someone from my staff has to inform the family of the cost of the lab, ask if they can afford to pay, then let me know if they can or can't, and then I need to note in several different places whether the lab is critical or not. I already try not to do unneccesary labs on my patients since for most kids a blood draw is very frightening, so when I order a test, it is generally very important! I suppose I am disappointed because I chose to work for a CHC so that I could provide care to all. I already have to choose medications by whether they are covered or not by each particular Medicaid program, I often have to get prior authorizations for medications and radiologic procedures!

I am very bothered and saddened by this new policy. Many of the families in this community are already struggling to make ends meet. My worry is that they will stop coming in when word gets out about this policy. Fortunately, most of the children I see are covered by Medicaid, but there is a fairly large population of adults who can't afford health insurance. I also understand that our organization cannot continue to provide essentially free care indefinitely. The patients know that we do not send out bill collectors, and some of them have large unpaid bills. However, if they can come in for preventive healthcare, which sometimes includes labs like lipid panels, we end up saving money on them in the long term. I really don't know what the solution is, except that we need to address the healthcare crisis immediately.

Along those lines, I happened to come across the blog of the country doc, Dr. Cohen, discussing President-Elect Obama's choice of Tom Daschle for head of the Department of Health and Human Services, which seemed quite relevant to me, as I continue to struggle with this new policy. I admire Mr. Daschle, but like Dr. Cohen, I am concerned that he may not truly understand what is going on the ground level of healthcare. Both Mr. Daschle and his wife have ties to healthcare firms. Now, I know that healthcare firms are not inherently evil, but they are businesses which want to make money. I'm also not against making money, but I think that sacrifices will have to be made on everyone's part. I am simply hoping that Mr. Daschle will seek input from all participants in our broken healthcare system, including families, primary care physicians, specialists, pharmaceutical companies, and health insurance companies. We need a comprehensive team approach if reform is going to succeed. As a country, we have a lot on our plate right now, and I frankly don't envy Mr. Obama's position one tiny bit!

Brain Power

When I was eleven years old, one of my cousins had an aneurysm which left him a quadriplegic. He had been in medical school, was an avid mountain climber, and an outstanding violist. He had had some non-specific neck pain for a couple of days, and one night, it was bad enough that his mother took him to the hospital. The short story is that he went to the operating room with the hopes that the aneurysm could be repaired but woke up paralyzed, on a ventilator. This really impressed me, as he could speak, but he had to use a computer to write, using his tongue to move a cursor. Ever since then, I have been afraid of a similar thing happening to me, especially after learning about multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) a few years later. Of course, when I was a first year medical student, I had every disease we learned about, including MS and ALS! Fortunately, I survived intact.

For those of you who may not know what ALS is, it is a rapidly progressive and always fatal disease which attacks the nerve cells that control voluntary motor function. Eventually, the upper motor neurons (those in the brain) and the lower motor neurons (those in the spinal cord) stop working, so messages do not get transmitted to muscles, and the muscles eventually shrink and waste away. Oddly enough, most patients retain control of bladder and bowel function, eye muscles, and the senses of smell, taste, hearing, and touch. Usually patients die within three to five years from the onset of the diagnosis, although approximately ten percent live for ten or more years. For more information, I found the website from the National Institute of Neurological Disorders and Stroke to be very informative.

These memories of worrying about various illnesses came back to me last week when I watched the CBS news show, Sixty Minutes. There was a segment called, "Behind the Scenes: Brain Power" (http://www.cbsnews.com/stories/2008/11/04/60minutes/main4570731.shtml) which just blew me away. It focused on a neuroscientist by the name of Scott Mackler from the University of Pennsylvania. He was diagnosed with ALS, and the disease has progressed to where he is ventilator-dependent and unable to speak. However, he is now able to communicate using Brain Computer Interface Technology, which basically allows a person's brain to be connected to a computer using EEG electrodes attached to a cap which is placed on his skull. So, in order to write a letter or to speak, Dr. Mackler looks at a computer screen with flashing letters, and the computer writes the letter that he is thinking of. Absolutely amazing!! The neuroscientist who was "locked in" by his disease now can write journal articles and goes to work in his lab where he conducts research. The story also talks about a woman, Cathy, who suffered a brain stem stroke which left her only able to move her eyes and with some facial expression. She volunteered to participate in a clinical trial where the Braingate system was implanted directly into the motor cortex of her brain. Cathy is able to move a cursor on a computer screen by thinking about how she would move her hand; she is able to turn off lights, for example, using this technology.

Advances in the science like this are always so exciting to me. Yes, I'm a nerd, I know. But the potential for this Braingate technology is limitless, and there are so many people who could benefit from this. Obviously, it would be even better if we could find the causes of neurodegenerative diseases so that we could prevent them, but even if we did, it could be used for stroke victims, accident victims, and many others. I am concerned that with our healthcare system in shambles, along with our economy, that funding for research will be cut, but I hope that our amazing, creative, dedicated science community can continue to thrive somehow.

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.