Monday, June 27, 2016

CMS + MIPS/APM = Death of the Private Practice Physician.




Small, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care.  The old-fashioned practice my father and I have built is a dying entity.  Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter.  I am fighting for the survival of primary care practices.  MACRA proposed reimbursement will decimate rural care as we know it.  

Seven days ago, I attended an “informational listening session” for rural physicians, sponsored by the Center for Medicare and Medicaid Services (CMS) to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.)  This plan will penalize 7 out of 10 small 1-2 physician practices in this country.  Why? Because we will be overwhelmed complying with statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients. 

I inquired as to how CMS proposes to ease our burden of data reporting.  “I am not sure, but leave a website comment and someone might consider your needs.”  Not likely.  A family practice physician described how technical mistakes at the claims clearinghouse froze her Medicare payments for 8 months.  “Thank God my father died and left me a small inheritance,” she said.  Otherwise her solo practice would have gone bankrupt.  Is this the future of medical care in this country?  Over 50% of her patients are on Medicare.  If we allow this MACRA atrocity to go into effect, who will be left to care for the sick, disabled, and elderly?

MIPS will base reimbursement on four categories:  Quality, Resource use, Clinical practice improvement, and meaningful technology use; the details of which have not yet been finalized.  The four meeting facilitators answered 9 out of the 10 questions (including mine) with the following statement:  “I don’t know.  I can email you.”  Can someone please hire me to do their job?  Or maybe hire a group of monkeys from the zoo?  Healthcare would be on stronger footing either way.

We should pay physicians for time spent engaging patients in conversation, instead of rewarding them for checking boxes on a computer screen.  Unfortunately, reimbursement for “valuable” dialogue is difficult to quantify within the physician-patient framework.  Physicians were trained to care and comfort people, not chase blood pressure numbers and pain scale scores.  Changes masquerading as meaningful have only increased physician workload.  We are widgets in the ever expanding assembly line.  Do you think the MIPS will give us more time to practice medicine?  If you believe it will, then I have a bridge to sell you.    



CMS coordinators are traveling around the country armed with useless knowledge, assembling groups of health care providers under the guise of providing “information”, and selling them snake oil.  It is ridiculous CMS will determine what constitutes provision of high quality care; they could not recognize value if it were right under their nose.  

I get it.  You do not want to pay me for work saving lives.  You want to pay me for crunching numbers that hypothetically constitute the illusion of high quality health care.  Which numbers exactly?  The CMS coordinator responded, “I don’t know, but here is my card for us to communicate further”.  This might come as a surprise, but I want to communicate with my patients more, not a coordinator hired by CMS who peddles false hope. 

Why have physicians given CMS dominion over medical care delivery in this country?  They are essentially in charge of a relationship they are incapable of comprehending.   The system is incentivizing incorrectly.  Remember what EMR’s have done for the quality of care? Not much, but physicians sure know what it did to our workload.  Where are the anticipated benefits of technology for patient care, physician work-life balance, and improved efficiency?   These benefits have not materialized.

CMS believes they are just not compiling the correct statistics; practicing physicians know technology requirements have only served to further undermine the physician-patient relationship.  Investment in the physician-patient relationship and direct physician to physician communication are two methods that could pay huge health dividends for future generations.  However, the return on investment is not glitzy enough for those controlling the health care machine. 

Neither my father nor I have admitted a single patient to the hospital for asthma or dehydration in more than 15 years, we see sick patients the same day, and our families are rarely seen in the ER except for true emergencies.  Before you think we cherry pick patients, understand 45-50% of ours are on Medicaid.  I know these families just as well as any who walk through our door. 

If I am paid for my time spent talking to patients, teaching them how to use their inhaler regularly, and helping avoid hospital admission, it is far cheaper than cost of a 3 day hospital stay.  But CMS misses the forest for the trees.  They believe saving on the office visit altogether is better overall.  Do you honestly believe value-based payments will benefit physicians and patients?   I can still sell you that bridge...

Undoubtedly, value-based care will result in lower reimbursement to physicians and death to private practices in rural towns where access is already less than optimal.  MIPS will do little to enhance patients’ lives or physicians’ livelihoods.  I can guarantee it will boost the bottom line for capitalists in control.

There are 826,000 physicians in this country.  We must refuse to tolerate a reimbursement scheme until its parameters help us provide better quality health care to the human beings we serve.  Our collective future wellness is at stake.  Is the statistical framework and useless data collection necessary in high quality health care or are thriving patients and contented physicians more essential?  Do not settle for more robots and fewer humans.  We will all be patients someday. 

























Thursday, June 23, 2016

Dehydration and the Need for Oral Rehydration Solution




Parents who bring in their children to my office with vomiting or severe diarrhea for the very first time often tell me their child is drinking a lot of “water” to stay hydrated.  Children lose electrolytes through vomiting and diarrhea, such as sodium, potassium, chloride and bicarbonate.  Water alone cannot replace these losses, but Oral Rehydration Solution (ORS) can.   I always recommend lots of ORS until signs a child is on their way to recovery. 



Some parents persist with the “water plan” however and inevitably, their child ends up back in my office 2 days later.  They look and feel worse, appear more tired and weak, and usually have started throwing up again.  Their little bodies cannot recover until electrolytes and fluid volume losses have been adequately replaced. 



A recent, ground breaking article in the Journal of Pediatrics studied aggressive management for children with Ebola less than 5 years of age.  Mortality (death) rate in previous outbreaks was estimated at 75-80%.  With this new protocol, during an outbreak in Sierra Leone, they were able to reduce mortality to 31%.  That is a HUGE achievement.  One part of the protocol involves recommendations for Oral Rehydration Solution. The results are applicable to non-nursing children over 1 year of age with vomiting, diarrhea, and dehydration caused by other viral illnesses.  Since reading this study, I have started more aggressive rehydration in children with influenza and they too are recovering more quickly. 



Paraphrased Oral Rehydration Recommendations: 

1.    All children are encouraged to drink Oral Rehydration Solution throughout their illness. It is best to start your child on 1-2 teaspoons (5-10ml) of an ORS every 10-15 minutes.  You may advance slowly from there with no maximum amount they should drink.  It should be guided by thirst and parents should provide positive reinforcement for drinking enough.

2.    The exact amount of ORS needed is dependent on the degree to which a child is dehydrated and how much vomiting or diarrhea is continuing to occur. 

3.    Children with severe diarrhea may be expected to drink up to 20ml/kg of ORS per hour when initially dehydrated if not given IV fluids.  If your child is 20 pounds, their goal for fluid intake would be approximately 6oz. per hour; if they are 40 pounds, 12 oz. is a reasonable hourly goal. 

4.  NO Sports drinks or sugary drinks such as fruit-flavored and carbonated commercial drinks should be given to children as they can worsen diarrhea.

5.   Please do NOT rehydrate your children with water.  It takes longer for them to recover and could actually be harmful in the long run.  (This is my own added recommendation.)



Disclaimer:  The caveat is if your child refuses ORS then you could mix in a melted Popsicle or juice for palatability.  If you are breastfeeding, this article is not applicable and hydration recommendations would be completely different.



IF something as simple as Oral Rehydration Solution can save the lives of so many children age 5 and under from Ebola, then think of what it can do for garden variety vomiting, diarrhea and dehydration in children?



Now here the MAGIC part where I say something new you might not read anywhere else.  The best method for administration of Oral Rehydration Solution is to use a syringe.   It sounds crazy, but is worth a try. I have looked like the “baby whisperer” before because children are more than willing to take liquids from me by syringe as if it were medicine without a fight. 



My own children have been trained from toddlerhood that with Pedialyte they will soon feel better.  They grab a bottle of their favorite flavor, a 10ml syringe, and go to work practically rehydrating themselves.   They love the grape and strawberry flavors best; blue raspberry is my personal preference to drink. Try a few different ones to see which your family prefers.  It tastes better cold and you can mix 1 part juice to 2 parts ORS to help with tolerability.



The take home message with vomiting and diarrheal illness is hydrate, hydrate, hydrate.  But do NOT hydrate with plain water; Oral Electrolyte containing solution truly decreases their time to recovery and returns them to the healthy energetic kids we want them to be. 


Tuesday, June 21, 2016

The Promise of a Rainbow



This story has been on my mind for many years but each time I sat down to write it, the words would not fall into place.  The other day, a family mentioned the concept of having a “rainbow baby” referring to a child born after tragedy.  Rainbows symbolize to me that even after the roughest storm, things can get better.  To see a rainbow there must be falling rain in the presence of sunshine.   Beauty and light will always return.  I have hoped for almost two decades a certain family found peace and was granted a rainbow baby themselves. 

During my final rotation in the Neonatal Intensive Care Unit during training, I attended a C-section with a supervising Neonatal Nurse Practitioner.  She said the newborn had severe congenital defects not compatible with life and would only live a few short hours.  Babies with this particular condition do not look different from healthy infants on ultrasound until they are in the final trimester, when it is often discovered and diagnosed.  These parents had made the difficult decision not to hold their child after birth. 

The newborn was handed off to me and seemed fragile as I placed him on the isolette table.  The family requested definitive genetic testing to determine the chances of having another baby with this abnormality in the future.   Back in those days, it required 12 teaspoons of blood (translation:  ALOT), collection of which seemed to take an eternity. 

He was not active and vigorous like other healthy infants.  He was taking small and shallow breaths.  My supervisor said to wrap him up and take him down to the morgue.  I was crestfallen at the thought of this tiny human being taking his last breaths on a metal table all alone.  I respectfully refused.  No one should die alone.  Another senior resident felt the same and the two of us brought this fragile newborn back to the NICU with us. 

My co-worker agreed to round on my patients while I held the baby in the rocking chair and then after an hour or so, we would trade places and I would pick up where she left off.  It went on like this for about 4 hours.  In my arms, he still had color in his cheeks just as his breathing rate began to slow and his father walked in explaining he wanted to hold his child.  Relief washed over me knowing this beautiful infant would be held by one of his parents before his untimely death.  We left the father with his baby to spend precious time, grieve, and say goodbye.   At some point, he emerged from the room and handed the newborn back to me.  After six hours, this tiny human being took his final breaths and his heart stopped. 

Over the years, I have thought most often about this experience while pregnant and nearing time of my delivery.   My birth plan has could always be summed up in one sentence:  do your best to get the baby out alive and place them on me to hold as soon as possible.  I had strong feelings about what should happen in case I ever had to say goodbye; I wanted my son or daughter to hear loving words from the voice they knew well.  

As physicians, we do not realize how much our life experiences can shape our perspective.  It is a side of medicine we rarely talk about.  Some of us become jaded, anxious, or fearful based on the patient cases in which we were involved.  Throughout our careers, we are privileged to share in the overwhelming joy of others, yet bear witness to much human suffering that leaves scars on our souls. 

I wish these parents knew how deeply their son touched us all in the NICU that day, including nurses, NNP’s, and two doctors in training who will never forget our time spent holding their infant while he fell asleep forever in the loving comfort of our arms.  Rainbows are not just a collection of colors as we look out upon the horizon; they are promises for our hearts.  I hope this family has seen much happiness and light since this day.  As physicians, we will never be able to prevent all suffering; however helping to heal another human being is absolutely priceless.  It is one of the precious rewards of being a physician.

Saturday, June 18, 2016

Slowing Down...



I have been posting a daily anecdote to catch up with the MommyDoc page on Facebook over the last two months.  It seems as if I am writing a new one every day, but that is not exactly what has been going on.  Yesterday was the last one that was published out of sync. 

I will continue putting up something new weekly and sometimes more often when I have extra time to write.  I wanted to ensure those of you who have been following this blog know I will keep writing, just the pace will appear to slow down a bit.

Hope you keep checking in to let me know what you think! 

Friday, June 17, 2016

The Importance of Eye Contact






The most difficult job as a pediatrician is combing through the finer details in a sea of “pink eyes”, to ensure a more serious illness is not lurking beneath.  Patients often want physicians to call in medications without seeing them.  Maintenance medications are very different than antibiotics or other types used acutely to treat a condition.  My policy is not to call new medications over the phone until laying eyes on the patient.  Below is one such exceptional experience where a little boy’s life depended on it.

It was a cold winter afternoon many years ago when an experienced mother of three called in because her son had pink eye.  She asked me to call in antibiotic medication because it was snowing and they had to drive 20 minutes to get to my clinic.  I felt guilty refusing her request, as if I was placing this family in danger asking they come to the clinic for such a ‘simple’ problem; yet I insisted seeing her son was necessary.

Upon entering the exam room, her son looked paler since I had last seen him.  He had been sick on and off a few weeks with fevers and a reduced appetite.  His eyes were definitely pink.  I listened to his heart and lungs, laid him back, completed a full examination, and then asked him to sit up.  He was holding his neck rigid and would not turn it without moving his torso at the same time.  He did not have signs of meningitis or other identifiable infection.  His throat was slightly red; a few swollen lymph nodes were present, but nothing else on exam to aid my diagnosis.

A neck x-ray was ordered and the radiologist called to report his pharyngeal area looked hazy.  She recommended a CT scan.  I agreed.  She called a bit later worried and concerned.  There was a large abscess in his neck and his airway was tinier than it should be.  She did not want to release him back to my clinic without an ambulance.  I called the family and she called for ambulance for transport to the hospital. 

I relayed the information to mom, who was amazingly calm, cool, and collected.  I explained she should not leave the radiology building; an ambulance was on the way to get her and her son.  He was very ill and required transfer to the nearest children’s hospital 45 minutes away.  She followed my instructions and arrived at the tertiary care facility an hour later.  He had surgery that night for a neck abscess that was 4 x 5 cm in size.  Thinking about the diameter of a child’s throat, there is little room for error with their small airway.

Afterward, the surgeon spoke with mom and informed her it is unusual to see an abscess of this size; the odd shape kept it hidden, making diagnosis difficult.  He wondered how she determined there was an infection in his neck.  She said she thought it was a case of ‘pink eye’, but her doctor refused to call in an antibiotic without examining him first.  He commented that decision had saved her son’s life.

This sweet brunette boy is now a tall and lanky teenager; every time I see him I am thankful for the decisions we made that night.  To refuse calling in an antibiotic without laying eyes on a child is the “right call” for me as a pediatrician and mother.  Some families have left my practice because they feel this rule poses an inconvenience.  There is NO substitute to evaluating my patients with my OWN eyes and there never will be.

I practice in my hometown and see patients in public regularly.  A father of a different patient stopped me at a birthday party my children attended to ask why I would not call in an antibiotic for pink eye without seeing and evaluating his child. (He was offered an appointment and declined.)  I smiled and informed him that was my policy and briefly told him the story. 

Medicine is both an art and a science.    


Thursday, June 16, 2016

Defensive Hiking and Unintentional Drowning



Many high school classmates at Klahowya Secondary School are devastated by the loss of an 18 year old boy who drowned in Kitsap County recently while hiking and fishing with friends.  18 months ago, another teenage boy drowned while hiking under similar circumstances.  My heart goes out to the families who lost their beautiful sons.  Most of you know my older sister drowned in the waters off Brownsville in June 1975; so this issue is near and dear to my heart.  Both young men accidentally slipped and were dragged into fast moving water, known in statistics as ‘unintentional drowning.’

In 2007, 52% of water drownings occurred in natural bodies of water as opposed to pools.  Statistics show drowning risk increases substantially after 15-19 years of age and males account for 88% of drownings in natural water settings.  In 2000, while hiking in Estes Park, CO, I was taking a picture from the top of a waterfall and slipped into the water myself.  The first fall was a 5 foot drop and I landed squarely on my right hip, which was uncomfortable to say the least.  Luckily, I was able to get out of the water at that point. As I looked over the next fall, it was a 30 foot drop.  An accident like this could happen to any of us while hiking here in the Pacific Northwest. 

Ledges and waterfalls are where most serious injuries and deaths occur.  People underestimate the danger.  They slip on the slick algae covered rocks and fall into fast moving water.  Others try to cross the stream above the waterfalls, fall in, and are swept over the falls.

Teenagers take defensive driving courses to ensure safety while driving and be more aware of obstacles. Talking with them about “defensive hiking” might help prevent one more injury or death. There are no official recommendations for children hiking near fast moving water in the pediatric literature per se, so I imagined what I would say to my own three sons as teenagers going out hiking for the day.  The list below contains general recommendations, and in no way is meant to minimize the losses experienced by all of you who knew and loved these two young men.  

1.      Know the terrain, be aware of and avoid drop-offs and hidden obstacles near natural water sites.  On uneven ground, slow your pace and take your time.

2.      Do not walk in the water near the edge of the falls or stand on rocks close to fast moving water.

3.      Constantly scan the trail ahead, looking 10 or more feet ahead to pick out the best route

4.      Know the local weather conditions and forecast before hiking, swimming, or boating. 

5.      Avoid walking around in the dark or fading light without a good light source.

6.      Learn CPR, these skills could be life-saving until additional help arrives.

7.      Use a buddy system and never hike alone near water. The young men hiking together did the right thing trying to reach their friend and unfortunately were not successful.

8.      Avoid alcohol consumption.  50% of natural water drowning fatalities in 15-19 year old males involves alcohol.  Slowed reaction time can truly make the difference in survival. 

I am a pediatrician with a background in public health, so I cannot help but look at these recent tragedies and wonder if there is anything to learn and teach our kids in order to prevent another untimely tragedy.  Maybe my sons would roll their eyes and call me ‘overprotective’, but maybe they would thank me at the end of the day when they return home to their parents who loves them. 


Wednesday, June 15, 2016

Boys and Weapon Play. Will it Make Them More Violent?



We are obsessed with Legos in our house.  The other night I handed my two year old son a Lego “man” of his very own and he said “oh mom, (disappointed sigh), he does not have a weapon.”  This ‘lack of weapon’ situation seemed like a big deal; who taught my 2 year old son the word ‘weapon’ anyway?  And why does it matter?  He should see the Lego men I grew up with in the 80’s; they had blue or red bodies and those bright yellow heads.  Did they even make guns for Lego men three decades ago?  I cannot remember. 

It made me wonder if boys are genetically and environmentally hardwired for gun play.  Throughout most cultures of the world, young boys are fascinated with war and weapon play.  Research has shown boys tend to be wired for “dominance”; even male chimpanzees engage in rough-housing at younger ages.  Young children tend to view the world in a compartmentalized way, such as good versus bad and big versus small.  They enjoy engaging in scenarios where heroes fight villains, monsters, or other imaginary adversaries and win against all odds.  My son did not actually use the word gun; he said weapon.  Weapons are as old as time, but guns have not really been around that long. 

When a child uses an open-ended toy that can be made into anything imaginable, they engage in something called “free play.”  Play is an essential part of life for children.  Blocks, clay, sticks, and building materials encourage this creativity and innovation because they are not predestined to do one particular thing.  Unfortunately over the last few decades, more toys are linked to specific movies, television shows, or videogames and have a predetermined “script” which requires less imagination on the part of our children.  Make believe guns do not automatically come with a script. 

For this weapon weary mother, it was reassuring to find out no studies show boys who play with pretend weapons are more likely to grow up and become violent than boys who were not exposed.  (Did they not have sticks to play with in these studies?  Or noodles to make into light sabers?  Broom handles? Could they not chew pop tarts into the shape of guns? I always wonder where they find such benevolent boys for these studies.) Some studies have even demonstrated weapon play can provide a sense of stability and control that is beneficial for children experiencing loss through divorce, illness, or unexpected upheaval in their lives. 

For my own children, if one injures another, they have to spend some time sitting and thinking about what they could have done differently to change the outcome.  They have to explain the alternative strategy to me before returning to play with the other children.  I do try to be mindful of the fact sometimes children get frustrated with each other and need to develop better anger management or impulse control skills.  That is also a purpose of free play: to help children learn those valuable life lessons so they can develop into confident, compassionate, and resilient human beings. 

The take home point is weapons used in play can be fun and even constructive, but if used to hurt others can be damaging over the long term.  Teaching children the significant differences between the two is crucial.  So my slightly apprehensive self, did indeed, find the very important “weapon” for my son’s Lego man.   And yes, I confess, it was a small gun.  He made lots of “bang-bang” noises right after I handed it to him and it freaks me out less now than it did before writing this.     

Tuesday, June 14, 2016

My Response to Sarah Kliff: We Are Frustrated, Weary, and Stressed Too.




Sarah Kliff is a senior editor at Vox.com, where she covers health and issues in medicine.  On June 1st, she wrote an insightful article about her patient experience.  After careful thought, my response is below.



I am genuinely sorry about your chronic foot injury.  Thank you for your insightful article and feedback.  You are correct the system is fragmented and places “considerable burden” on patients to “coordinate their own care.”  You (the patient) and me (a physician) are now in the same boat, headed the same direction with the same goal (better health care system), however, we are still not rowing in sync – not yet.  We are on the same side.  We need to work together.  You are part of the media and a frustrated patient; I am just another run-of-the-mill discouraged physician, who cannot get my message across to the masses. 

I LOVE your description of “patient-centered” care; I have the SAME dream.  For 15 years, I have been a pediatrician in private practice in the small town where I was born and raised.  I love my patients like they are my own children.  Having a clinic with a nurse, lactation consultant, behavioral therapist, and social worker would allow me to provide seamless care coordination to my young patients no matter their station in life. 

Believing all children deserve healthcare, I am one of the few pediatricians who still accepts Medicaid patients.  I am paid a very small amount per visit.  If I hire a team to help with care coordination, I would have to divide the same small amount of money between five people.  Once MACRA gets going, I will receive $3 less for each encounter because I am in solo practice, which the Center for Medicare and Medicaid Services (CMS) considers not “efficient” enough for their way of doing business. 

You could say I am a physician obsessed with providing the best possible outcomes for my patients while reducing the footprint on their daily lives.  I may not be “efficient” enough for CMS, but I am very effective at what I do.  In 15 years, I have yet to admit one patient for an asthma exacerbation or dehydration from vomiting.  I see sick patients the same day and my families rarely go to the ER except for true emergencies.  It is astounding to me that my small clinic is not considered a valuable commodity in the health care world today. 

You see “value-based care” is a matter of perspective.  My small clinic does not see “adequate” volume for the insurance companies to determine if we are cost effective.  An insurance company executive would think I spend too much time with my patients, know them far too well, and ultimately do not bring in enough profit for their CEO to pass on to stockholders.  Sad, but true. 

Are insurance metrics valuable?  As you said, none of the current quality metrics take patient work into account. Guess what? They do not take physician’s work into account either.  Immunization rates are important to track in pediatrics.  A recent study in the Journal of Pediatrics (http://pediatrics.aappublications.org/content/136/1/70) determined physician intervention and additional communication did not change parental vaccine refusal rates.  So why are immunizations rates tracked as a measure for value-based reimbursement if they cannot be impacted by physician ability, time, or effort?   

But I digress.  My reason for responding to you is this:  I acknowledge patients are forced to work hard to navigate the system.  As physicians, we want to make patients’ lives easier, better, and healthier.  Our obstacle to providing superior quality care and transparency is that it requires physician-patient interaction, something not considered valuable to those controlling the health care system.  Health care is no longer based in human interaction; it is now based on a business model obsessed with numbers.    

The only point upon which I respectfully disagree is patients are not exactly the “health care system’s free labor”; more accurately, they are “free labor for the business of health care.”  Who benefits most by transferring the “healthcare footprint” to patients?  Physicians do not benefit in any way, shape, or form.  Creating barriers for patients to obtain medications, services, or care coordination increases our workload as well as yours.  The business machine benefits most from transferring the work to patients because they can generate considerably more income. 

If you were a patient of mine, obtaining your MRI report would be simple.  Call us on the phone and request a copy.  We have two employees in the front.  They would make a copy and you could have stopped by on your lunch hour to pick it up for your orthopedics appointment.  Of course, our office still has paper charts making things much easier and more efficient for you. 

My closing thought is this:  many years ago, primary care physicians dictated a brief one-page synopsis letter containing all of your pertinent information and mailed it to your specialist prior to your appointment in order to better facilitate your care.  That meant NO work on your part other than showing up to see the specialist. 

In my humble opinion, that type of communication provides tremendous value.  Paying more to a physician who provides services that benefit patients directly is a metric worth tracking.  If physician and patient can work together by rowing in sync on the same boat, maybe we could get those in control of the healthcare system on board with us after all.  Medicine is not a one-way road.  You are spot on about that. 









Monday, June 13, 2016

In the Trenches with Influenza A



Yesterday I saw a child I have known since before she was born and her mom confessed she was newly pregnant!  She is a few months older than my oldest son.  She is a charming, beautiful, and lovable child who always brings me joy, even when she is not feeling her best.  Her smile lights up my soul, but her tears and suffering break my heart.  Her parents and I have shared some intense experiences in the examination room over the years. 


Needless to say, we are bonded.  I completely broke down sobbing when I gave their son his 5 year shots a mere 10 days after my brother died unexpectedly.  They simply cried with me and hugged me with a compassion most physicians can only dream about experiencing from their own patients.  I am lucky to have this family as a part of my practice. 

Her mom sent a message to me yesterday morning that she was diagnosed with the flu and thought her daughter might have influenza.  My heart sank.  I asked her to come in to the clinic when we opened in the morning.  This little girl represents the true face of pediatric healthcare on the front lines today.  She is completely healthy and thriving, yet has contracted the influenza A virus, which is a serious threat to her well-being.  Her mom, who also has influenza, said “I have never been more sick in my entire life.”  That pretty much sums up the entire Influenza A experience. 

This season, Influenza A is presenting the worst clinical signs and symptoms I have ever seen in 15 years of practice.  Completely healthy children are being rendered unable to function and appear terrifyingly ill.  Fevers of 104-105 are routine in my clinic daily, accompanied by red eyes, cough, body aches, and a miserable look in their eyes.  Bring your children in, please.  This is when they need to be evaluated.  After spending the last month doing more nasal swab testing for influenza than I have done in the last decade, I can look at my patients and tell if they have influenza A or B.  Those with A are severely ill appearing and those with B are miserable, but safe. 

To be honest with you, as your pediatrician, I am scared out of my mind I am going to lose another one of your children before this season is over.  I hope I am hiding my distress from parents when you see me in my office.  Please know I am trying to conceal my feelings.  I do not want to alarm you because you need to focus and stay strong for your child.  I am giving you my best advice by recommending lots of clear liquids, managing fever and pain, resting, and watching for symptoms to worsen before they get better.  It feels a little like practicing medicine on the western frontier in 1880.

Children are at their absolute sickest this winter; this devastating disease is like some kind of natural disaster with no end.  I may be immunized against the influenza virus, but it has me utterly terrified as I helplessly stand by watching children become so dreadfully ill.  The loss of one child this season has left me feeling raw from grief and traumatized at the same time.   Please bear with me as I continue to sort through my unease while caring for your children and aiding their recovery from the clutches of Influenza A, a disease I now hate. 

Some of my stories appear out of order because this site is catching up with those written and published since January 2016, when I first began MommyDoc on Facebook.  The article above originally appeared this past winter. 




Sunday, June 12, 2016

The Post-Partum Struggle: My Letter to Every First Time Mom





Welcome to my office and a whole new world of parenting.  I am excited and privileged to be part of your journey.  If you feel like you have absolutely NO idea what you are doing right now, that is completely normal. Frustration at being milked every hour, wanting to cry every 10 minutes, and being overwhelmed by the love you have for this new human being that is predictable feelings too. 

You are going to experience loss of a part of yourself and life as you knew it will be different.  Some of these events are amazing, like that first smile from your baby.  Many of these milestones, though, can be just plain hard.  The next two decades will bring unexpected challenges, heartache, and disappointment, but also beautiful, unparalleled surprises. 

Let us get back to right now, looking at your newborn.  Happiness and love are sometimes not automatically part of the equation however, exhaustion, doubt, fear, and frustration most certainly are.  Talk to me about that.  I am here; I am listening.  I will try to help you be the best mother you can. 

There are NO stupid questions. I love to answer all of those “new mom” questions, though probably at more than one visit.  I will guide you to the best of my ability as long as your children are under my care.   I will share my own stories if you ask.  Some of them are pretty hilarious as I have navigated my own way through motherhood.  There will never be judgement from me at any time.

There are NO wrong decisions you make on behalf of your child.  I know you are doing the best you can.  I have been there; right where you are right now.  After four children, I have made countless mistakes and learned so many lessons.  There will be stumbles along the way.  EVERY mother wants to throw the baby out with the bath water, run screaming from their house, and nap for 7 days straight without interruption sometimes.  Those feelings are totally and completely normal.  

The reason I am writing you this letter is the world tells you having a baby brings you nothing but overwhelming joy.  The truth can be far different than that.  You may be experiencing post-partum depression, but just because you are not bubbling over with delight at your baby does not make that true.  Part of parenting is patience.  You and your newborn will find your own comfortable rhythm in time.

Until that happens, I am here and many resources exist in this community for you and your baby.  Do not be afraid to seek them out.  We have a New Parent Support Group at Kitsap Community Resources in Bremerton and Port Orchard.  Hope Circle meetings for all mothers, Nurturing Expressions offers a support group in Poulsbo, and La Leche League are active in many Kitsap County locations.  Please feel free to add some I have missed below. 

Our practice, Silverdale Pediatrics, now offers ALL newborns one home visit for you and your baby.  There are many providers in this community ready to help, all you have to do is ask and let us know you need it. 

Saturday, June 11, 2016

When the Patient-Physician Relationship Can Be Transformative





Watching the health care system morph into something unrecognizable, I still believe the physician-patient relationship is THE MOST powerful therapeutic force in medicine, yet its value has been overlooked by those managing health care reform.  Administrators and bureaucrats ignore the importance of continuity for both the patient and the physician, to our detriment.  When your doctor KNOWS everything about you, they can provide the BEST quality care possible.  Let me tell you about an extraordinary patient-physician relationship that has kept me grounded throughout my career.

Garrett is over 6 feet tall today; it is hard to believe the night I met him, he was the same age and size of my youngest son right now. A completely healthy boy having a severe allergic reaction to a Penicillin shot received in Wyoming was being airlifted to our hospital in Denver for intensive care. On call that night in the PICU, I remember exactly what he looked like as he rolled through the doors. He was stable, breathing on his own, and had swollen and cracked lips.  

I remember thinking he would improve quickly, but instead I spent 90 days caring for this child and the experience was like riding a roller coaster.  His allergic reaction was not entirely relieved by epinephrine, so numerous complications ensued.  He was intubated multiple times, spent weeks on a ventilator, suffered a cardiac arrest requiring chest compressions, received multiple rounds of antibiotics, had pneumonia,  a chest tube placed between his tiny ribs, and even a fungal infection by the time he was on his way to recovery two months later. 

At the beginning of my third year I became a supervising resident, Garrett was transferred to my service. I knew his story better than any other doctor in the hospital.  The next 30 days was spent rehabilitating all he lost while lying in a hospital bed.  Many afternoons I sat with his family talking, teaching and learning, crying, and sharing hopes and dreams.   It was the closest patient-physician relationship experienced during my three year pediatric residency. 

He continued to become stronger each day through physical, occupational, and speech therapy.  The only evidence remaining of his ordeal was a small divot in his lower lip and a hoarse voice from damage to his vocal cords after being intubated multiple times.  The day he was discharged home was among one of the happiest in my pediatric career. 

Many local pediatric specialists tried to determine how an antibiotic shot that had saved millions of children over more than 5 decades triggered such an unusual immune response.  We still do not have those answers today.  I have never seen anything like it before or since; the specialists in practice 50 years had never seen anything like it either.  It is unlikely I will ever see a reaction like this throughout the remainder of my decades in practice. 

His family and I have continued a close relationship for the past 15 years.  His older sister is a sophomore in college now and Garrett will graduate from high school this year.  There have been achievements and setbacks in both our lives.  His mother and I made decisions about his care over the years together and had many conversations when there were bumps in the road.  They attended my wedding and have watched my children grow up despite the 2,000 miles separating us, because of our deep bond. 

Seeing a child through life-threatening illness and having them survive has sustained my heart and soul as a primary care physician.  Unfortunately, this relationship is being attacked on many levels by people who are not patients, parents, or physicians.  I am a better doctor because of my connection to Garrett and his family. 

Above is a picture of Garrett with me at my wedding (I am clearly more excited about it than he is!)  My relationship with this young man, his sister, father, and especially his mother are the foundation of why I became a pediatrician in the first place.  Filled with doubt in my darkest moments, his story of triumph always brings me comfort and hope.  It reminds me there will be losses and saves, but the life-long, enduring R-E-L-A-T-I-O-N-S-H-I-P is what makes it all worthwhile. 

Friday, June 10, 2016

Furniture or TV Set Tip Overs




The statistics are compelling.  According to the U.S. Consumer Products Safety Commission, a child dies every two weeks in this country from a tip over incident involving a TV, a piece of furniture, or a combination of the two.  Every 24 minutes a child is admitted to the emergency room because of a TV or a furniture tip over.  

There have been 3 deaths of young children over the past two years due to IKEA dressers falling over.  Most recently, a 22 month old boy, named Ted McGee died when he tipped one of these dressers on top of him during naptime.  His parents did not hear the furniture fall or his crying, which could have happened to any of us.  Seven months ago, IKEA made recommendations to anchor dressers they designed to the wall in order to prevent injury to children. 

A new study suggests more children are being injured by toppling TV sets and most of those accidents could have been prevented if the TV sets had been anchored to the wall.  Dr. Michael Cusimano, the lead author and a professor of neurology, education and public health at the University of Toronto found that toddlers between the ages of 1 and 3 years often suffered head and neck injuries, according to the report published in the Journal of Neurosurgery Pediatrics. "People have done the physics," Cusimano says. "The heaviest TVs falling a meter onto a small kid’s head are equivalent to a child falling 10 stories. These can potentially be fatal injuries."

Young children are often unattended while watching TV.  “It's not unusual for a curious child to climb up onto a piece of furniture that holds a TV,” Dr. Cusimano says. The child can knock the TV off balance and it can crash down on a child’s head.  Between 2006 and 2008 there were 16,500 injuries and between 2008 and 2010 there were 19,200. To get a better sense of the cause of the accidents and how they might be prevented, the lead author and his coauthor combed through the medical literature for studies that examined injuries caused by TVs. One of the most telling statistics found 84 percent of the injuries occurred at home and three-fourths of them were not witnessed by adult caregivers.

Unfortunately, I have personal and professional experience caring for a young child severely injured by a furniture tip over.  This type of injury had one of the most tragic outcomes as there is no way to repair the damage done.  Just a toddler at the time, my patient climbed up on an entertainment center and pulled it over.  The large TV set permanently damaged this beautiful child, who never recovered even the most basic life functions. 

Many years later when I became a new parent, I immediately ran out to buy every strap and L-bracket the hardware store had available to bolt every piece of furniture to the wall, large or small.  I could not sleep until the television had been securely anchored as well.  Gratitude goes to my husband for putting up with my neurotic approach to injury prevention. 

Interestingly enough, one additional dresser purchased a few years ago escaped my L-bracket obsession and has tipped over on one of them when all the drawers were opened.  My child was able to yell for help but was helpless while pinned underneath.  It is a reminder; this type of household injury could happen to each and every parent.  

The take home message is to be safe, mount your TV on the wall securely and anchor all heavy pieces of furniture too.  If something heavy must be placed on a stand, then at a minimum, it should be fastened also.  There are straps that can be purchased at your local hardware store and many assorted sizes of L-brackets available that are both effective and economical.

It takes about five minutes for each item to be stabilized adequately.  The consequences of children playing and climbing on unstable, unanchored furniture can be tragic. We cannot protect children from every possible injury mechanism in their lifetime, but this is one we can take into our own hands.  If we know better, we can do better.  Good luck. 


Thursday, June 9, 2016

A Good Night: How to Train Your Baby to Sleep




As a pediatrician, the most common question asked by parents is “How can I get my baby to sleep through the night?" After 15 years in practice and my own experiences as a mom of four, I will share some insight.

My oldest child magically slept 8 hours and NEVER woke in the middle of the night after 8 weeks (do not be jealous, there are a few more kids to go.) Seven years later, he still sleeps through anything, including the fire alarm, which is not necessarily a good thing. My second was a blonde haired, blue eyed cutie who threw up during and after every feed. At 2 am, in the pitch dark, he would choke; I would hold him over the garbage can to throw up and get right back to nursing without missing a beat. Two months, four months, and six months came and went. He continued to eat and throw up at 2 am and eat again at 5 am. When he was 11 months, I was pregnant with number three, working, taking care of a two year old and utterly drained. I decided to ‘teach him to sleep independently’, otherwise known as “cry it out.”

Crying it out (CIO) has recently been found not to have damaging effects on babies; it is safe and effective.  At 2 am, that first night, he cried for two hours and I was sobbing the entire time. The next few nights crying lasted only 30 minutes; followed by four blissful nights of 8 hours in a row. A week into sleep training, a final night of crying for an hour at 2am. That night was very tough, but I stuck it out. He never cried himself to sleep again. Interestingly enough, when he sleepwalks now, it frequently occurs at 2 am.

Our third baby turned out to be a natural nighttime sleeper, just like my oldest. By 8 weeks, she was down for her 8 hours and almost never woke in the middle of the night. I always knew having a daughter would be amazing! She is my favorite child to sleep with still because she is like a rock and does not move a muscle all night long.

I had a 4 year old, 3 year old, and an 18 month old when the baby arrived, and to be honest, I do not remember a thing from the time he was born until he was 3 months old. That summer was literally about survival, theirs and mine. Since we live in a three bedroom house, the baby slept in our closet until about 6 months, when sleep training felt necessary to put him in a room with a sibling. My oldest still talks about when “we” sleep trained the baby because it was Christmas break and he slept on the floor of our room for two weeks, which he loved. I do not remember how long it took but the baby cried a few nights and then stopped. By January, both boys were in the same room and it has been fairly smooth ever since. Currently, three boys are in one room and our daughter is in her own.

Are they solid sleepers because of sleep-training or sheer genetic luck? The truth is, I have no idea. This is another do-what-feels-‘right’-to- you-as-a-parent things. Babies under 4 months of age should always be comforted when they cry for both nourishment and reassurance. Developmentally, once a baby is 4 months, they are medically able to go 8 or more hours without feeding. If exclusively breastfed, it may be closer to 6 months because human milk is digested faster and the stomach empties more quickly.

IF parents wish to do so, those ages and older are acceptable times to sleep-train. When you sleep-train, think about what you do that encourages a baby when he wakes at night: picking him up, nursing, and rocking him to sleep. None of these comforting things are bad for your baby, they just do not reinforce putting oneself back to sleep. A moderate approach is to remove some nighttime reinforcing behaviors in a gradual fashion, based on what a parent can tolerate emotionally.

“Crying all night in pain” is not recommended and not the essence of sleep training. Sleep training is parent and child dependent and is NOT medically necessary. Learning to put yourself to sleep is a skill and may be a developmental milestone, but every child develops at a different rate. Sleep training helped me feel sane and rested. I sleep trained two of my own children which basically makes me an expert with mine, but not necessarily yours. The decision to sleep train is entirely up to you.

A bedtime routine can be helpful. We do baths, fluoride, stories, brush teeth, and snuggles. Learning to put themselves to sleep can foster independence early on in life. Surprisingly, all of mine have said “its time for me to go to bed” at one point or another and they walk upstairs and climb into bed, confident in the knowledge they are tired and need their rest. Our job as parents is to give them confidence to know what their bodies need to be healthy and grow. Sleep training, while not for everyone, might be easier to think about as teaching your child good sleep habits that will last a lifetime.



Wednesday, June 8, 2016

Truly Wonderful the Mind of A Child Is…




I am fairly certain Yoda was a pediatrician at some point during his 900 years.  Star Wars has been an obsession of mine since seeing the first movie, IV: A New Hope, as a child.  In honor of the release of VII: The Force Awakens, I am paying homage to my all-time favorite movie character.

1.       “Truly Wonderful the Mind of a Child Is.” 

A classic mantra of every good pediatrician, fostering healthy growth and development of little bodies and minds.


2.      “Many of the Truths We Cling To Depend On Our Point of View.”

The absolute best answer every pediatrician should give when asked about immunizations damaging a child because they contain hidden toxins, chemicals, and preservatives. 

3.      “Size Matters Not.”

The value of this statement should be obvious, for my little patients and me as well.

4.      “If No Mistake you have made, yet losing you are, a different game you should play.”

This is such fitting advice for a parent struggling with either a toddler or teenager.

5.      “You Must Unlearn What You Have Learned.”

Medical school taught us professionalism, distance, and the value of science yet the moment you enter the world of pediatrics, all bets are off;  science has to become an “art.”

6.      “To Be a Jedi (Doctor) is to Face the Truth and Choose.”

Truth-telling is a reality for every physician.  Medicine is about communicating options to families so they may choose their own path. 

7.      “Impossible to See the Future Is.”

Best used on a daily basis while talking to parents.  It is difficult to predict exactly when a child will fully recover, fevers will dissipate, and they can return to school.  We do our best.

8.      “Already Know You That Which You Need.”

You know your child better than anyone else.  This advice to trust your instinct builds parental confidence and is our basic job as pediatricians.

9.      “Mind What You Have Learned.  Save You It Can.”

Best said to 11 and 12 year old children at their annual physicals.  They are about to embark on a phase of crazy hormones, emotions, and bodily changes for which there are no answers.

10.   “Once You Start Down the Dark Path, Forever Will It Dominate Your Destiny.”

Yoda would say this to teenagers making poor decisions:  drinking, smoking, and having unprotected sex.  There are always consequences for taking unnecessary risks. 

11.   “Do or Do Not.  There is No Try.”

Things worth doing are worth the hard work it requires to achieve.  Life is hard.  We must reinforce this important and valuable lesson to children.

12.  “Always Remember: Your Focus Determines Your Reality.”

When a child is struggling, whether it be at school, with disappointments or loss, or just life in general, this solid advice keeps them grounded. 

13.  “Save Them We Must.  They Are Our Last Hope.”

At the heart of every primary care physician is an eternal optimist who desires to make the world a better place.  We want to ensure every child is protected and loved by all who know them. 

After reading above, you may still think Yoda was simply a wonderful teacher and Master Jedi.  I believe he was much more than that.  He held children in high regard, worked hard to save many young lives, and never gave up hope for a brighter future.  So you see, Yoda must have been a pediatrician. 

And May The Force Be With You.