With the federal health reform bill inching closer to becoming a true law, it’s still up for debate whether it will even begin to put a dent in turning around our very confusing, disjointed, expensive and chaotic health care system.

The issue, of course, is that health insurance is not even the tip of the iceberg. Without reforming the innards of the health care system and giving people a system that they can understand and use more easily, it matters very little whether people have insurance coverage.

At the same time, true reform is less about any system and more about how people address their own lives and health habits. Even in a broken system, there are many things we can all do to improve our overall health and minimize our need to see doctors, be on prescription and nonprescription medications, and need medical procedures.

If we all applied ourselves to spending more time on the areas that improve our health for the better — such as exercising more, losing weight, addressing health problems that put us on medications — we’d all be better off, and our health care system would actually start to be unloaded and cost less, even in its current form.

This doesn’t just apply to adults but kids, too. Kids deserve to enter their adult lives as healthy as possible, so be honest with them about their health issues — whatever they may be. Help kids overcome health issues today so they can be more healthy tomorrow. Believe me, if your kids are overweight or dealing with some other medical issue, they know it and want help addressing it.

With the new year upon us, this is the perfect time to examine the habits we have that maximize good health and be realistic about the habits we have that put our good health at risk. For example, ask yourselves:

- What do I do for exercise?

- What do I eat and drink drink each day? (Keeping a log for a week can be very eye-opening!)

- How many packs of cigarettes do I smoke per week — or day? (If “none,” congratulations!)

- Do I have health problems I need to address?

- Am I on medications I’d like to be off of?

- When was the last time I went to the doctor for a general physical?

Sit down as a family and answer these questions together. Then work together on the issues that you all have in common and help each other with the issues unique to each person. By the end of 2010, you’ll all be more fit and will have kicked some habits you’ve needed to for a long time.

You deserve to live a healthy life, and that type of reform can’t be found in any health care law but starts with you and the changes you make in your life.

In fact, those are the only health care reform changes that really matter in the long run to you and your family, so start reforming today.

(Initially published January 2010)

A few years ago, I treated an adorable 6 month old infant girl in the ER for a cold.  The EMR (electronic medical record) highlighted that the family had recently been to the ER for a variety of other common complaints: diaper rashes, colic, sleep and breastfeeding problems – all issues that could have been handled in any pediatric office.

As this visit concluded, I mentioned that their pediatrician could help them with further issues.  The baby’s mother looked perplexed.  “We have an appointment tomorrow with her pediatrician but that’s for shots and measurements,” she mentioned.  That was my light-bulb moment with this family – they truly did not understand the full role of their pediatrician in their daughter’s life.  And, they are not alone.

People trek to emergency rooms for a variety of reasons:

• They are having a true emergencies or need urgent care after hours
• They are visiting the area and require medical care
• They falsely believe they will be seen quicker than calling their own doctor
• They don’t truly understand all the services their doctor’s office offers

Emergency rooms do treat all comers but the sickest get seen first and there is always a wait, in fact 4-6 hour on average.   Visiting the ER for simple matters instead of your primary care physician is like calling a repairman if your TV remote stops working. For a child, there are a few disadvantages to ER visits. The wait time can be very difficult for kids and lack of familiarity with the setting and staff disarming.  Luckily, most ERs are much more child-friendly than in the past but it is still a more intense experience for a child than visiting their own pediatrician.

Pediatricians are trained in the complete child – sickness and health. Knowing what your pediatrician is trained to offer you can help considerably in knowing what to do after-hours and in feeling comfortable with an ER visit should it be needed. Here’s an A to Z guide of the myriad of areas your pediatrician can help with for your kids:

a.     Anticipatory Guidance (informing you and your child of what’s to come next)

b.     Bullying (and cyberbullying): helping the bully and the victim

c.     Cell Phones and Computers: The Internet, Facebook, cyberbullying, sexting and everything else our kids and teens are doing with online and mobile technologies.

d.     Drugs and Alcohol Abuse: finding help and support.

e.     Eating and feeding issue – including eating disorders

f.      Fever and sick symptoms – sore throats, headaches, vomiting, diarrhea, rashes, ear aches, cough, and runny nose – and just about every sick symptom you can think of!

g.     Growth and development

h.     Hearing issues, Headaches

i.      Immunizations (shots)

j.      Journal articles and web sites to help you learn more about your child’s condition

k.     Kid-specific issues for all ages

l.      Laceration repair and suture removal

m.    Monitoring medical problems – new and chronic

n.     Negotiating the world of specialists – including the ER

o.     Orthopedic issues including injury treatment and sports participation

p.     Potty-Training and Puberty

q.     Queries about anything worrying you about your child

r.      Rashes

s.      School issues; Sexuality

t.      Travel advice

u.     Use of new technologies

v.     Vision issues

w.    Weight issues – too little, too much and eating disorders

x.     X-ray ordering (including acute injuries!)

y.     Your concerns about your child

z.     Zeroing in on what’s really important – our kids!

I bolded the new additions to the list since I first created it in 2006:  bullying and technology. Our world keeps evolving and as it does, so, too, does the role of the pediatrician in your kids’ lives. Anything your kids do that involves their growth and health, in either a positive or negative way, your pediatrician is there to help you with. And, as the person trained in the total child, is your best guide should an issue arise that puts your child’s health at risk.

So, if any issue arises with your child, think “call the pediatrician”. You’ll never go wrong by starting there, even if technology is concerned.

(Originally posted August 2006; Updated August 2011)

Family Works: When to call the doctor: MyFoxBOSTON.com

Thankfully most children are healthy and many will never need the care of a specialist. But should you find yourself in a situation that requires input beyond your pediatrician, there are some important issues to consider. Here’s a true story that will shed some light on the issues to consider.

A writing colleague’s two year old son developed a snoring problem so severe it interfered with his sleep, his family’s sleep, and his mood during the day. After exhausting all simple outpatient remedies, their pediatrician referred them to a local Ear-Nose-Throat (ENT) doctor who advised a tonsillectomy. Is this the end of the story, or should they dig a bit deeper?

At the heart of this issue is whether the advice we are given is what we should do. An equally important consideration is why we want the extra input. Is it because we are uncomfortable with the advice? Is it because we don’t like what we are hearing? Having a solid relationship with your pediatrician is what will help you find your answer. In fact, your pediatrician should be the person in the center of the entire consultant maze to help keep the focus on your child and to make sure you don’t end up in a black hole of referrals.

By knowing you well, your pediatrician  can help you find the answers you need in a way that works for your family; and  knowing your pediatrician will help you feel comfortable with following a course of action that you may not want to pursue emotionally but know you have to for your child.

Many times your pediatrician can get you more information by consulting a specialist by phone for you.  If that alone is not enough or you are facing a situation that requires an intervention, surgery or specialized care for a problem, then you may need to take your child to a specialist. Here are some questions to consider when contemplating obtaining a second opinion:

1. Are you comfortable with the initial advice? If you are not comfortable, why? Is it a hospital issue? A credentials issue? A bed-side manner issue? If at all uncomfortable, talk to another specialist.

2. Does the advice seem too conservative, or too aggressive, for the problem?  If so, a second opinion would be very valuable as a comparison.

3. Does it matter to you if the person helping your child is a pediatric sub-specialist? In many areas of the country, including the Boston-area, community physicians, particularly ENT specialists, have very large pediatric practices, particularly if they practice a distance from a major city. Moreover, the training of community physicians does include pediatrics.  So, unless your child is facing an unusual situation or something very pediatric-specific (a congenital problem, for example) either type of doctor would serve your child well.

4. What are the pediatric services of the specialist’s hospital?   The only difference between a full children’s hospital and a community hospital with elaborate pediatric services is the amount of the hospital dedicated to children.

5. How many similar cases has this specialist treated? This is particularly important if surgery is being considered.  The considerations are the same here as for #3 above.

6. Does the hospital have 24 hour coverage with residents or hospitalists? Having 24 hour in-house pediatric coverage often improves the level of care because there are always pediatric doctors in the hospital and available.

7. If your child is being treated at a community hospital, how close is the nearest children’s hospital should a higher level of care be needed?

8. What’s your pediatrician’s opinion on the specialist’s input?

9. How comfortable are you with not having a pediatric specialist treat your child?

10. What does your gut tell you?  Tell your pediatrician if you have any concerns or are uncomfortable with the advice.

Back to our story. The family did seek a second opinion from a pediatric ENT who happened to be on staff at a large community hospital with a huge in-house pediatric service.  The pediatric ENT doctor confirmed what the first ENT doctor had advised, that a tonsillectomy was needed to help their son’s snoring and breathing during sleep which would in turn allow him to get more restful sleep.

Now they had two similar opinions from doctors with slightly different training who practiced at two very different types of hospitals. For this family, the decision boiled down to the level of pediatric services at the hospital so they opted for the pediatric ENT. Another family faced with this exact scenario may have chosen the first doctor and had the exact same outcome for their child.

Their toddler’s snoring is now gone and the entire family is finally getting a good night’s sleep.  Happy ending for all.

(Originally posted September 2006; Updated December 2009)

Have you ever consulted a doctor for an opinion about your health but found yourself unsure whether to follow the advice given? Even as a physician, I’ve been in that position and it isn’t at all comfortable.

In my case, I suddenly found my self with achy joints, not an uncommon situation for adults as they “get older”. The problem is I’m not that old! I was soon diagnosed with a form of arthritis after consulting a rheumatologist at one of the top hospitals in Boston, which wasn’t too surprising given my family history.

The medication regimen proved a bit intense and my husband and I were not thrilled with the recommendation for the next step of treatment. We found this group very focused on treatment first, life impact second and decided to seek alternate opinions to see if there was a way to treat the joints while have some sort of quality of life considerations.

The next rheumatologist had a better handle on the life impact issues but had a different major flaw: he opted to ignore key diagnostic tests done with the first group and attempt to shake up the entire diagnosis without adding any insight into treatment.

So, we’re pushing for another opinion. That’s right, a third opinion.

It’s important that I have a doctor that looks at me as a person, not a diagnosis. It’s important that my doctor consider treatment options for me that take into account my life, as a mom, wife and physician, and not just focus on marching through a protocol. It’s important that I find someone who listens and doesn’t discount what my body is telling me even if it doesn’t fit nicely into some diagnostic box. Human bodies don’t tend to work that way. As I learned early in medical school, human bodies don’t read medical books and why we have to practice the art of medicine with a solid clinical background.

The art of medicine is what I want my doctor to practice…not some lab focused, protocol oriented medicine, which seems to be a bit more common these days. Whether for me, my husband or my children, this is the type of medicine I feel is a must to get the care needed for any problem, large or small.

Good care is still possible in a dysfunctional system and don’t let any health care provider tell you otherwise. You always have the power to change and should use that power to find the provider who meets your health and wellness needs, or those of a family member if you are acting as an advocate.

By the way, notice I never mentioned health insurance once. The core of what we need from our health and wellness system isn’t about health insurance reform, it’s about health and medical reform and finding providers who still believe in the value of providing good care in a run down system.

While our government leaders are busy debate “health reform”, I often get the sense they forget that most of us have medical needs now that need to get addressed in today’s very broken system. Our medical needs and those of our kids are actually blind and deaf to their discussions because they just wanted to get addressed – today.

While today’s system is far from perfect, there is still a lot we can do to get the care we need. Instead of blindly accepting the system as is, we can become more empowered and partner with our physicians as advocates of our own health care, and those of our loved ones such as our kids. This means speaking up when we have questions and becoming more health literate. This also means working with our physicians to be sure the treatment we receive works for our lives. To accomplish this, we may have to seek more than one opinion on a health matter, and that’s not only ok to do but possible even in today’s chaotic health climate.

All too often I see people settle for treatment plans they are not comfortable with instead of pushing their current doctor for alternatives or seeking an alternative opinion. After going through my own health hurdles the last two years, some medical and one surgical, I can attest to the value of asking questions, seeking additional opinions and even switching primary care doctors if needed.

The goal isn’t to find someone to give you the answer you seek but to find someone who will take the time to listen and help you find the answer to what’s going on in a way that makes you feel comfortable with the result, whatever it is. Sometimes accomplishing that requires more than one opinion and it’s our right as patients to obtain that input.

Seeking a second opinion can help you in the following situations:

1. Confirming a major diagnosis.

2. Obtaining another opinion about treatment for a medical condition.

3. Obtaining another opinion about treatment for a surgical condition.

4. Helping clarify an unclear medical or surgical situation.

5. If you are unhappy with the care given by a previous provider and want additional input.

6. If the advice given seems different from what you’ve read or been told by your physician.  (Always confirm online sources with your primary care physician before worrying too much and be sure you basing your opinion off of true medical sources such as WebMd or a medical association website).

Try to see the top consultant in your area. Sometimes this will be at a community hospital and sometimes at a big medical center. Your primary care physician can help guide you to who would be best given your situation.

So, if you are struggling with a medical situation and are feeling unsure about the path you are on, talk to your primary care physician about your concerns. It’s your health – so ask for what you need. Even a broken system can give you that.

The last decade has produced some amazing changes in child health. Recently, I consulted some of the top pediatricians in the country to figure out where we’ve come from and where we are going next.  Some of these changes may surprise you, so hold on to your seat!

1. IMMUNIZATIONS HAVE REDUCED DISEASE AND CHANGED PEDIATRIC CARE

Hands down, immunizations have been our number one advancement in child health. As Carden Johnston, MD, FAAP, past American Academy of Pediatrics President, put it:

“Immunizations… (have) changed the way we practice medicine” by dramatically reducing the amount of incurable and devastating diseases.

2. GENERAL HEALTH CARE OF INFANTS IS BETTER

Dr. Johnston also pointed out that simple interventions have dramatically improved infant health:  “How about folic acid (for pregnant moms) and its impact on neural tube defects. The back to sleep campaign has had a tremendous change in [infant mortality rates]. “

3. PARENTING IMAGE AND CONFIDENCE IS SHAKY

American Academy of Pediatrics Member and Seattle pediatrics Don Shifrin, MD, FAAP, noted that parents are not portrayed very positively by Hollywood compared to years past:

“On the screen most parents are portrayed as absent, ineffective, clueless, or just plain mean. No more Cosby shows, Growing Pains, or that ilk. Just check the Disney Channel for examples daily.”

This erosion of a strong parental image may be what is behind the shaky parental confidence so many of us are observing in our offices and the dramatic rise in emergency room visits for relatively simple issues. Elizabeth Murray, MD, FAAP, Fellow, Pediatrics Emergency Medicine notes:   “During my training, I have lived and worked in 4 different parts of the country (and) one thing that seems to be on the decline is tolerance of a sick child.I think families are busier (with) moms often on their own.  They do not have an experienced grandparent to show them the ropes.”

4. YOUTH SPORTS INJURIES ARE ON THE RISE

Kids are simply playing sports too young and too hard with injuries occurring at younger ages such as Tommy John surgery that simply shouldn’t be occurring. Don’t count on your town’s league to do the right thing by your young athlete.  You must get more informed and be your child’s best advocate!

5. OUR KIDS ARE OVERSCHEDULED…AND DON’T NEED TO BE!

Dr. David Elkind wrote his famous book “The Hurried Child” in 1981. Today, in 2008, 27 years later, the situation is markedly worse than his famous book predicted.  The impact on our kids is increased stress with poor self-esteem. Studies are crystal clear on two fronts that our kids need more free time and more play.

Dr. Alvin Rosenfeld calls what we are doing “hyper-parenting” and suggests we all need to schedule our kids less so we can be as a family more.  The National Family Night movement came from his call to action that we’re truly pushing our kids in teh wrong direction and over parenting.

6. DR. GOOGLE

Many parents often turn to the web for information instead of calling their child’s pediatrician. This is a dangerous practice, as pointed out by Mark Rosenberg, MD, FAAP, a pediatrician from Chicago, Illinois:

“As recently as two generations ago, when a parent needed advice on the care and raising of their child, the trusted source of information was a grandparent or other close relative.  Now the ‘trusted’ source of information is the internet and the various information services available on line. While we owe a great deal to the information revolution online, there is much to be wary of.  Information may be posted by literally anyone, who then becomes an instant expert. “

7. BODY IMAGE

Visiting the McCord Museum at McGill University recently, I stumbled upon a fashion exhibit,  Reveal or Conceal?, that looked at trends in woman’s fashion from the 1900s to now. Click here to see the slide show of the exhibit.

Clearly, we show more skin and our clothes have much less material than even a decade ago.

Kids are looking too much like young adults and too many adults are trying to look like older kids. And, way too much skin is being shown on all ages.

Fashion can still be trendy with a bit more modesty and it is up to us to help our kids understand that and to lead by example.

8. THE FUTURE: TECHNOLOGY

According to Dr. Carden, “ Providers (in the next 10 years) will do more “eyes on hands off” care (where) monitors for the chronically ill will be connected to the physicians office so then they can use their cell phones (and computers) to look at each other, saving trips to the office and  (avoiding) many trips to emergency departments during evening hours.”

9. …AND GENETICS

Utilizing our new and growing understanding of the genetics of illness, it won’t be long before we see new and very high tech treatments of disease that utilize this knowledge and go after the imperfections in the genetic code that are resulting in disease.  This won’t be a comfortable situation for everyone initially but in many ways no different than the shock many people felt when vaccines were introduced. That was considered revolutionary way back when.  Dr.Johnston agrees.  “…the ethics, technology, science and entrepreneurism of genetics will confuse parents and providers alike”, he told me. “By 10 years we should be working through those issues…Challenges facing parents and providers will be almost as big as they were in the 40s and 50s with polio.”

10. A LOOKING GLASS INTO THE FUTURE

In a snap shot, what we are doing is not working out so well.  We must reclaim those values from the past that worked do well for kids and families and learn to move forward with social and scientific progress without losing them…again.

(Originally posted October 2008; updated December 2009)

Q)
Dr. Gwenn:

I have an 11month old son who weighs 20lbs. How much Tylenol or Motrin can I give him?

Thanks!

AC, Massachusetts

A)

Dear AC:

Great question.  Figuring out over the counter medications dosing can be confusing, especially since kid’s weights are constantly changing and dosing is based on weight. You’ll notice that dosing guidelines on the medication packaging include ranges by weight and age.  These are ok in a pinch but are not very accurate because they cover a wide range of weights and are not precise for your child.

In addition to talking to your health care provider or pharmacist, you can do a simple calculation yourself to determine your child’s more accurate dose by just knowing your child’s weight, in either pounds or kilograms.

Here are the formulas we use for both Tylenol(acemaminophen) and Motrin/Advil(ibuprofen):

Tylenol: 15mg/kg/dose or 7mg/pound/dose every 4 hours.

Dose = 15xweight(kg) or 7xweight(lb)

Motrin: 10mg/kg/dose or 4.5mg/pound/dose every 6hours.

Dose = 10xweighg(kg) or 4.5xweight(lb)

So, based on your son’s current weight of 20lbs,  here’s how’d you’d figure out his current dose:

Tylenol:   20 x 7 = 140mg of tylenol. Tylenol comes in 80mg droppers or 160mg teaspoon. So, to not over dose him, you’d give him the closest reasonable dose which is about 120mg or 1 1/2 droppers of infant Tylenol or 3/4 Teaspoon of Children’s Tylenol.  When in doubt, go a bit less than a bit more if you are between doses.

Motrin: 20 x 4.5 – 90mg. Motrin comes 50 mg in the Infant dropper or 100 mg per teaspoon in the Children’s elixir. So, just shy of 1 teaspoon or just about 2 droppers of the 50mg line would be your son’s dose of Motrin.

When children are infants and toddlers, their weights change rapidly so you’ll want to be sure you have an idea of your child’s current weight every month or so until your child is age 3.  After that, the weight gain slows down and you can get a weight every 6 months without much concern.

In a pinch, you can figure out your infant’s weight on any home scale by weighing yourself holding your infant and subtracting your weight. Home scales are very inaccurate for very teeny weights, such as 20ish pounds and less.

Finally, be sure you really need to give either medication before you give it. Your pediatrician can guide you best on that front if you are all uncertain.

Cheers,
Dr. Gwenn

We’re all connected by our family tree. It’s uncanny how traits in families get passed on. Passions for cooking, sports, fashion, music all show up in varying degrees in different family members through the generations.

On the outside, we all have some understanding of these similarities and accept them. We even joke and talk about them in family gatherings. “She has my knack for clumsiness.” “Look at his cooking talents – he’s a chip off the old block.”

Did you know that on the inside we are just as alike, and even more so? The very core of our insides – our cells and organs themselves share similarities which is why so many illnesses and conditions “run in families.”

Our genes are really our body’s computer programs for how we work and function on the inside and out. The genes that get “passed” on are not a sure thing, however. They get turned on by a complicated cascade of switches that are really triggered by our experiences. This is where the phrase “nature or nurture” has come from. We are all born with tendencies for “things” on the inside and out due to our genes – our heredity. The environment of those genes – meaning, the experiences of the body those genes live in, is what determines whether those genes stay off or turn on. So, you could carry around the gene for your dad’s high blood pressure and never get it.

The question we need to ask is how we can learn about this tendency. How in the world can we begin to discover what our family members experience as they get older? The answer to this questions is already at the dinner table! It’s as simple as sharing your, and other family member’s, medical histories.

Now, keep in mind this knowledge does by no means mean your kids or grandkids will develop any of these conditions.  If they learn that every person on your side was over weight by the time they were 20, you may help your kids and grandkids eat and move differently. Same with high blood pressure trends or even cancers. This is where their doctor comes in. By discussing their family medical history with a doctor and your grandchild’s pediatrician can come up with a medical screening plan that makes sense– if one is needed at all. This is called a “risk assessment.”

My family tends to be chatty but my grandparents didn’t discuss their health histories much, until after they were hospitalized! Many relatives in my family have migraines, including me. Recently we learned that my own grandmother had horrible migraines. That was news to many of us and the relative that new never thought it was important to let us know (“You already have headaches, how would it have helped?”) Well, given our strong family history back to my grandmother made it possible to diagnose my own daughter at a much younger age and get her treatment than it would have been possible otherwise. So, family history is important and these trends do help. But, they can only help if people talk about them.

But, you don’t have to talk. We live in a modern age, you can email, blog or IM!  The key is sharing medical histories. Here is a list to get you going:

• Blood pressure: high and low
• Migraines and headaches
• Menstrual issues
• Stress, anxiety and depression
• Cancers
• Allergies and Asthma (including food allergies and drug allergies)
• Diabetes
• Obesity
• Stress Fractures
• Heart Problems, including heart attacks
• High Cholesterol and Triglycerides
• Eye problems of any and all kinds
• ADHD and learning issues
• Stomach Issues
• Urinary Issues

Basically, if you are going to a doctor and receiving treatment, that is what you have to communicate to each other!

Go as far back as you can recall then hand to your family for their next doctor’s appointment. This information may be FYI for now but could come in handy for someone down the line. If nothing else, learning about your family is always worthwhile and you may find you learn something interesting about each other all at once (“I didn’t know Great Uncle Herman had 6 toes!”)

(Originally posted October 2007; Updated December 2009)

When I worked in the ER, wait times were always an issue. Some days we had “only” a 2-3 hour wait, but many days the wait could be up to 4+ hours. The longer the wait time, the bigger the “LWBS” pile…which translates to “left without being seen”. Long wait times are sure to eventually weed out the people who came in but likely could have waited to see their own doctor.

Even for truly sick people, however, waiting in ERs is hard to avoid and this is where triage comes into play. The nurses have to pull in the sickest of the sick first and everyone else gets seen after. It’s not a first come, first serve system at all. In addition, there are other variables to consider that can increase the waiting room time:

• Volume of people waiting to be seen – the more people, the longer the wait.
• Acuity of people already being seen – the more sick a person or more complicated a case, the longer it takes to clear the room so another person can be seen. And, the more sick people will get seen first – always.
• A huge emergency taking all of our attention. This happens – and often…even with kids. One true emergency can sometimes siphon an entire ERs resources depending on how intensive the situation is.
• ER staffing. We need people to see sick people. Some ERs are short staffed on either the nursing or doctor side…or both.

So, this Reuters story was not a shocker to me.

My advice to families in the practice I work in has been the same for years: “If you think your child is sick enough to need an ER, call us 24/7!”

By the way, true emergencies don’t hide. You’ll know those and will be calling 911 without even thinking. Those tend to respiratory things – like asthma attacks or a child with an illness who is having trouble breathing. Or, an accident at home of any number of kinds.

For the other issues that you may have gone to the emergency room for in the past, your doctor’s office can likely handle it in the morning. The means always has to justify the end. If you are going to wait with your child 2+ hours in an emergency room, make sure it’s something that is truly worth waiting to be seen for. Your doctor’s office can help you sort that out! Call 24/7…that’s what they are there for.