The Doc Smitty’s New Home

I just realized that I had never officially posted on my old blog in order to alert people that my blog has moved!

Come over and check it out on it’s new home: http://www.checkupnewsroom.com/thedocsmitty/

The Flipped Check-Up

When we moved to Irving and I decided to join a practice in Lewisville, I realized I wanted to know more about the schools in the area and get a feel for the culture of the teachers that would be teaching my patients and kids.  I searched online and found great and encouraging information about Carrollton-Farmers Branch, Irving and Lewisville school districts.  I also looked up several teachers and administrators.

While I expected to get good information, I never expected to learn a concept that I hope to incorporate into my medical practice, but that is exactly what happened.  I followed an educator on Twitter (@LaurenBibby) who is the Technology Integration Specialist for Lewisville ISD (@LewisvilleISD) and she has since “introduced” me to a concept known as the flipped classroom (even though she doesn’t know it yet).

Wikipedia describes flipped learning as “a form of blended learning in which students learn new content online by watching video lectures, usually at home, and what used to be homework (assigned problems) is now done in class with teachers offering more personalized guidance and interaction with students, instead of lecturing.”

So, students watch lectures at home in the afternoon then come to school the next day to do homework and other projects during class time.  This gives the teacher time and opportunity to address what the student doesn’t understand from the lectures rather than have students turn to their parents for their Calculus homework (when dad had trouble passing Algebra).

So, how does this apply to me and my practice?

I’d like to have more patients to do “flipped check-ups.”

In the flipped classroom, student listen to lectures at home and come prepared to do work and application related to the material.  In a flipped check-up, parents would read and learn about the upcoming checkup (check out this page on my blog: Check-Ups for an example), develop specific questions and then allow me to get into deeper, higher-level education when they come in for their check-up.

Yes, contrary to the stereotype, you did just hear a doctor advocate that his patients do on-line research prior to their visit (but I want it to be good information).  In fact, it’s the reason I started my blog in the first place.  I wanted my patients to be able to access my advice (in effect, access me) when I wasn’t there beside them to answer their questions.  I wanted them to have a place to go that had accurate recommendations that fit with my philosophy (so, why not have them actually be my recommendations, right?).

Here’s an example of how it could go:

Family has 4 months check-up scheduled.

They review the 4 Month Check-Up Blog Post.

Family comes in for a 4 month check-up.

They say, “We read your blog 4 month check-up blog post and are ready to start solids and he seems to be developmentally ok but we did have some more questions about helping him sleep through the night.”

This allows me to touch on the other areas for clarity and completeness but spend the majority of the rest of the visit discussing in depth about sleeping and some options for sleep training (or not, depending on the family’s preference).

When the child is older we could cover the topics located in my Masters in Parenting Series to cover some topics of development more deeply.

So, this leads me to some questions for you…

1)     Is this something you’d be interested in?

2)     If you wanted to do it, how could I make it easier for you?

Some Essential Questions to Ponder

 

I know just by seeing the picture above I’ve peaked a significant amount of interest…

I get asked a lot about essential oils.  I answer very little. Why?

The answer is simply that we don’t know much about how or if they work.  Except for anecdotal stories about how they have helped certain people in certain situations, no one has done a large studies to truly evaluate their effectiveness or safety.

The main explanation for why they are used is that people (parents) are simply looking for something that’s an alternative to using what I’m going to call from now on “conventional” medicines.

Going forward, I’m not going to rely much on my knowledge as a doctor, I’m just going to be using common sense and asking a series of questions that I hope will get you all thinking.

What is medicine?

This is the dictionary.com definition: any substance or substances used in treating disease or illness.

Doctors prescribe conventional medicines that enter the body from many different avenues.  I have patients that take Zyrtec (cetirizine) by mouth, inhale albuterol, sniff steroid nasal sprays.  There are conventional medicines that are delivered topically but they aren’t as commonly used (especially in kids).  The most common example was the Daytrana patch for ADHD but I haven’t seen it used in years (I’ve never prescribed it.) because topical medications can have unpredictable rates of absorption which makes determining how much medication actually gets into the system difficult to estimate.  I only really use topical creams for things that need to be treated topically (rashes).

I see friends recommending essential oils on all my social media accounts for many different ailments and it’s not always clear to me what they are recommending-topical application, diffusion or ingestion.  But, if medicine is “any substance or substances used in treating disease or illness” and medicine can be inhaled, applied topically or ingested, then why aren’t essential oils considered just another type of medicine?

What does it mean that they are more natural?

Another discussion that is centered around essential oils is that they are more natural.  I get this concern.  In a world where everything is processed (down to a lot of our food), why wouldn’t you want something that is more natural for your family?  However, just because something is natural, doesn’t mean it’s a good thing…

Let’s take formaldehyde.  Parents cite this preservative as a reason they don’t want to use conventional medicine. I’m not particularly concerned about formaldehyde because it is a by-product of metabolism inside our own bodies.  It is formed during metabolic processes and can then be converted into CO2 and exhaled or urinated out.  Keep in mind that it is a known carcinogen when the dose gets to high but we know (from history) that it requires a very high level of exposure to get to the point where it causes cancer.  Ultimately, the concern I have with formaldehyde is this…it is commonly used as a reason by families who don’t vaccinate even thought it’s made in the body (Is there anything more natural than that?).

A more simple argument against using essential oils based on the reason that they are more natural is this: “Oh, it’s more natural? Well, so is marijuana.”-@mrsdocsmitty.

Do doctors prescribe medicine for every little thing?

I commonly hear this: Doctors just want to prescribe a drug for everything.  I want something different for my family.

The whole thing that motivated me to write this post was a posting I saw on a social media account last week: It is a picture of a line of essential oils across a bathroom counter (about 10 bottles-not sure if they were all used this morning or not) and part of the caption below: “He uses oils for allergies, eczema, acid reflux and stress.”  I’m not attacking this person at all and I’m not actually sure who it belongs to (so don’t take it personally).  But, does trading a “conventional” medicine for an essential oil make any difference?  Are essential oils becoming the new “take one for everything”?

I personally have occasional struggles with allergies, acid reflux and stress but I might take medicine allergies or reflux every few months. I do modify my diet, sleep habits and exercise to help with reflux and stress.  Therefore, taking essential oils would not be an alternative to taking a medicine for me at all because I’d rather take nothing.  I think people assume that because I’m a doctor, my wife and I shove medicine down ours and our kids throats for just about any and every symptom imaginable. This is simply not true.  Our kids occasionally get cetirizine for allergies (on average less than once a month), acetaminophen or ibuprofen (on average less than once a month) and my asthmatic gets inhalers (1-2 days per year).  They take antibiotics only when absolutely necessary. Other than that, our kids take vitamins every day.

So, be wary of using the reasoning that doctors use medicine for everything.  Some may, but this doctor doesn’t and I don’t consider it any different to be using an essential oil for every little thing.

Do doctors stand to benefit when they prescribe a medication?

Fortunately and unfortunately, I don’t practice medicine in a time where I can get flown to Hawaii for a long vacation with my family for prescribing a certain medication.  I’m very glad I didn’t because working in that environment would have been very difficult.  When I first started practice, drug reps could bring lunch and some pens but even these two practices have stopped.  At this point, I have no incentive to prescribe a medication except the desire to see my patient improve.  In fact, soon I will be incentivized to not write for medications as insurance plans become more focused on cutting expenses by decreasing their cost of prescription drugs (I will be encouraged to use cheaper alternative when available but nothing is cheaper than not writing for anything.).  So, the argument that doctors are pushing drugs in an effort to profit is simply not true for most doctors.  There are doctors who are paid consultants and speakers for drug companies, but most are not.

Now, think for a second about your Young Living or doTERRA rep. How do they stand to benefit when they recommend a treatment for you?

Finally, for my distributors and reps out there: Are you practicing medicine without a license?

This is the definition of practicing medicine without a license from Michigan (I’m sorry I couldn’t find the one from Texas for my Texas people):

An individual who practices or holds himself out as practicing a health profession subject to regulation without a license or registration or under a suspended, revoked, lapsed, void, or fraudulently obtained license or registration, or outside the provisions of a limited license or registration, or who uses as his own the license or registration of another person, is guilty of a felony. For the purpose of the offense of practicing medicine without a license, the “practice of medicine” means the diagnosis, treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint, or other physical or mental condition, by attendance, advice, device, diagnostic test, or other means, or offering, undertaking, attempting to do, or holding oneself out as able to do, any of these acts. (emphasis mine)

The last part is the interesting part: the practice of medicine means the diagnosis, treatment, prevention, cure or relieving of human disease…by attendance, advice…or holding oneself out as able to do, any of these acts.  You’ll have to read it closely for yourself to see what you think.  Think about what would happen is something did go wrong with one of the oils you recommended or sold. Would your company back you?  Maybe you should ask them and see what they say.  Many people feel that the reason that the most profitable essential oils companies are structured as direct marketing is because the company can hide behind their individual representatives’ claims.

Now that I’ve kicked the ant pile, I will now sit back and see what happens.  People who know me personally know that I am one of the most open-minded pediatricians they know about calmly weighing evidence on either side of a discussion or debate.  I try very hard not to bring my preconceived ideas into consideration when I make a decision.  I have extensively studied essential oils personally and am confident that, at this time, I cannot recommend them for my patients until further studies come out regarding efficacy and safety in children.  I just pray now that you will consider my questions in the same way I have considered yours over the years.  Regarding comments on this post, based on the way I have structured this blog to provide relevant and scientifically accurate information, I cannot allow the comments to become a marketing ploy for essential oils.  If you want to debate some of the logic or concepts that I have presented or cite real scientific evidence, that is fine, but I will not allow comments that tout anecdotal evidence of how essential oils have helped you or your family.

Sneezing-Help in a Flash

        

It’s so annoying walking outside on a sunny day and being attacked by a fit of sneezing or when your 2 yo is watching Thomas the Train and has a complete meltdown “I got BLESS YOU all over my Kindle.”

Why do children sneeze?

1. To clear irritants out of the nose (stimulation of hairs in nose)
2. Allergies (as a result of histamine)
3. Sunlight (a genetic reflex in ~20% of people)
4. Just because (sneezing in newborns is common for no apparent reason)

People commonly list sneezing as a concern for their children during visits.  Unfortunately, it’s not a very helpful symptom in getting to the bottom of what is going on.  Sneezing by itself is not an illness and when there is an underlying cause you can usually tell by all the other things that are going on…

If you want to treat sneezing each of the causes does have a cure:

1. Help the child learn to blow their nose
2. Give your child an antihistamine (we use Zyrtec or Claritin)
3. Never go outside
4. Don’t have a baby

Why I Am a Pediatrician

I would say it’s because I told my 4th grade teacher that I wanted to be a pediatrician and I’m too hard headed to admit that I’m wrong but that might over-simplified.

 

That would also discredit the fact that I told my mom one time that I could never be a pediatrician because I couldn’t deal with babies screaming all the time.

 

In reality, my goals and reasons for doing medicine and pediatrics have changed over time and I’d like to walk you along that journey to give you an idea.

 

This is complete transparency so no judging…If you plan to judge, just move on.  Seriously, quit reading.

 

Junior High and High School

 

I’m smart.  Smart people do things like being a doctor or lawyer.  DAs don’t make any money and I’m not sure I could defend people for murder that I know are guilty (I read too many John Grisham books).  So I guess being a doctor makes sense.  I followed a radiologist for a day so I figured, why not radiology?  They used to be listed as big wage earners and low stress (not even sure if that’s true anymore-haven’t had a reason to look in a while).  I didn’t think about it at the time but when I followed the radiology we spent 90% of the day locked away in a dark room staring at some pictures (on an old fashioned light board-this was 15 years ago).

 

College

 

I had a great opportunity to work as an intern in the Children’s Ministry at the church I attended.  I would love to say that I applied to the job because I liked kids a whole lot but it actually had a little more to do with the fact that it paid $1000/month and really only required me to work 2 days a week.  I had to be available to build sets and brainstorm and do whatever else my boss might randomly ask during the week but the calls were pretty infrequent.  What happened during that time is that I happened to really grow to like kids.  I developed skills in interacting with them that I would’ve otherwise never had.  I walked them through family issues and other problems, learning along the way that I really did want to work with kids.  I was still pre-med and convinced that medicine was right for me so it seemed pretty natural that Pediatrics was the way to go.

 

Medical School

 

I loved just about every rotation I did in medical school.  I liked OB, especially delivering babies but couldn’t really imagine myself doing pelvic exams all day every day.  I liked surgery but wasn’t really all that great at it.  I loved psychiatry and would have strongly considered it but tucked away at the back end of my 3rd year was my pediatrics rotation.  I had saved it till the end of all the primary rotations so that I could experience everything else with an open mind (and have something to look forward to).  

 

For the first time in pediatrics, I was able to sit alongside a sick child and scared family and see what it takes to interact with them in a way that shows you are capable but sad that they are experiencing what they are going through.  (Ok, so most of that was by observation since you really don’t know much of anything as a 3rd year medical student but still.)  So, at this point my mind was set.

 

Residency

I was sure when I entered residency that I needed something a little more “exciting” than general pediatrics but I also wanted to do something where I had a close relationship with my patients.  I was convinced that Pediatric Oncology was the right fit for me.  I was prepped to start extra training when I completed residency and excited about some research I was involved in about ALL and Downs syndrome.  You can read more about it here (but why would you want to?).

 

 

 

 

And Then

 

Plans change and I was recruited to join on in the practice of my old pediatrician in Abilene. Of course, I was never going to do that but if any of you know my old partners, you know that they can be particularly persuasive.  I was able to see just how interesting general pediatrics could be and learned the joy of walking through those steps with parents as they learn how to be, well, parents.  

 

I love walking into a room where mom has a list of questions (no, really).  What that means is that I am going to get to provide relevant answer and suggestions that are important to that family right then.  I can talk for about 10 minutes straight at each check-up with my own advice but who cares?  There are a few things that I make sure and cover but those things pale in comparison to what concerns are on my parents’ minds.

 

 

Now

 

Now, I have 3 children all under age 5 so I’ve been through a lot of my own parenting journey.  I know the fears associated with a hard fall and a large, rapidly expanding goose egg.  I know the joys of celebrating that first poop in the potty.  I also know how confusing all the different advice you can get out there can be.  There are so many messages out there.  You receive wanted (and un-wanted) advice from the internet, news, books, friends and family (am I leaving anyone out?).  Often the advice is directly contradictory.  

 

So, where do you go?  I hope you would turn to me.  Why? Because that’s my reason for doing pediatrics now.

 

I want to help you go through their own journey and make the best decisions for your family.

 

I want to provide solid evidence-based advice.

 

When there are multiple right answers (there often are), I want help you gather your information and let you decide.

Vs Retail Clinics-Are We Going to Whine or Win?

http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/44450

I noticed the headlines rolling in Monday about the AAP updated policy statement regarding retail based clinics.  The one above particularly caught my eye.  Something about the tacking on of “Again” caught my attention.  It came across to me like we (pediatricians) were perceived to be saying something that was unnecessary, maybe even that we were just complaining. 

Throughout the day, I monitored my Twitter feed and read some articles discussing the issue.  Fortunately, I didn’t see a whole lot to confirm my (perhaps defensive) concern that we would be perceived as whining about the emergence of urgent and retail clinics.

But, the guideline and the response from the retail clinics got me thinking.  Currently we seem to be doing OK in the public perception but how much longer does that hold up?  Are our statements going to forever be met with an understanding or is there eventually going to be backlash about our perceived inflexibility.

There are many things that parents want in medical care for their children but I believe this debate boils down to 2 main issues:

Quality

Convenience

Quality

Pediatricians claim, in the policy, that retail based clinics create a decrease in quality of care for the following reasons:

• Fragmentation of care
• Provision of episodic care to children with special health care needs and chronic disease
• Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
• The use of tests for the purposes of diagnosis without proper follow-up
• Possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles, strep throat, etc)

I do believe these are concerns that do need to be addressed by the urgent care and retail people.  I have written about many of these previously: My Questions for Urgent Care Clinics

The AAP policy statement goes on to make recommendations for principles with retail clinics (my thoughts italicized):

• Supporting the medical home model: RBCs should support the medical home model by referring the patient back to the pediatrician or other primary care physician for all future care.  (Is this realistic?  They might even say that they will but will we eventually tell our patients that they should have just used the retail clinic for this complaint because it was simple?  This won’t happen and I don’t know why we’d expect them to refer back to us either.)
• Communication: The AAP recommends that RBCs promptly communicate with the patient’s pediatrician or other primary care physician within 24 hours of the visit.   (This seems logical and important.)
• Using evidence-based medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP.  (Again, a reasonable and critical expectation.)
• Contagious diseases: By providing medical care to individuals in a retail-based setting, RBCs must take the necessary precautions to prevent the spread of contagious diseases.  (While many pediatricians do this, it is not universal and we need to do a better job of providing well and sick waiting rooms.)

Many of these concerns are addressed in the quote from the article:

The Convenient Care Association, a Philadelphia-based retail clinic association, took exception to the AAP’s claims about its members’ work.

“Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care,” Tine Hansen-Turton, JD, the association’s executive director, said in a statement. “Additionally, the industry is very focused on quality care, and EHRs are also used in clinics to monitor evidence-based practice performance.”

Whether or not you agree with the assessment, they do provide an answer to many of the concerns that the AAP has raised.

Convenience

The second major issue I see arising as a result of the conversation is about convenience.

Let’s imagine that the retail clinics drafted a policy statement that addressed their concerns regarding care at pediatrician’s offices.  Some of their concerns might go something like this:

• Lack of same day illness appointments creates unnecessary overnight suffering for parents and children.
• Small waiting rooms create difficult environments for parents managing active kids.
• Minor complaints should be seen by mid-level providers and escalated as necessary to the physician.
• Parents’ schedules are malleable and need the flexibility of walk-in appointments.
• Parents need the ability to have their children seen outside of their typical working hours to avoid lost income.

These are some of the benefits of convenience that a retail clinic provides that many of us currently do not or we meet it in some trivial way that does not provide a real solution for families. 

Don’t get me wrong, we have come a long way.  Improving the patient/parent experience has always been a focus of pediatrics and will continue to be for years to come.  But, there is some reason that our patients are using these clinics (and why we have to issue statements about them) and I would guess that for the most part it’s a convenience issue. 

So, we’re still missing the boat (and an opportunity) somewhere.

The Race Is On

The way I see it, the race is on.  One of two things are going to happen.

1. Retail clinics are going to figure out solution to our perception of their decreased quality of care and the public will know about it.  The quote from Tine Hansen-Turton, JD tells me that they are already far along in their thinking and ready to make strides to improve their quality of care.  They can’t afford to stop trying because it means their future success or failure.
2. Pediatric offices are going to figure out a way to meet the demand for patient convenience that is currently being met by the retail based and urgent care clinics.  We need to make ourselves agile enough to meet the demands of convenience as they arise in the future.  We can’t afford to stop trying because it means our future success or failure.

Which is it going to be?  Are we going to whine or win?

Nosebleeds-Help in a Flash

Nosebleeds are very scary for parents but there are few nosebleeds that have concerning causes.

The most common causes of nose-bleeds are: dry air and nose-picking (or both).

Many children will have allergies which dry out the tissue inside.  This causes cracking with minor trauma or picking.  It is well supplied with blood vessels, it will bleed like crazy.

Make it Stop!

1. Hold the soft part of the nose just below the bridge for FIVE minutes.  If  you stop to check, it can start again because the cracks open.
2. Do not have the tilt their head back unless you think they would like the taste and feel of swallowed blood in their stomach.  It doesn’t help.
3. If still bleeding after 5 minutes, it can be helpful to put something cold over the nose to help constrict the blood vessels.
4. If you cannot control the bleeding, go to your doctor or the ER.

Preventing Frequent Nose Bleeds

1. Run a humidifier
2. Spray nasal saline spray or put vaseline in the nose
3. Clip the child’s nails short and smooth

Concerning Signs

If any of these are present, you need a doctor visit:

• Fever
• Weight loss
• Easy bruising
• Small red dots all over

Ankle Injuries-Help in a Flash

 

Photo credit Jacob Moore (elementmotif.com and oilfieldimaging.com)

 

Another weekend down, another injury free weekend at 4 yo t-ball so that I haven’t felt compelled to out myself as a pediatrician to my son’s team.

Ankle sprains are one of the most common sports injuries in older children/teens.  All sports (except running) have some side-to-side movement that any “graceful” athlete can tip over and hurt themselves.  Even if your child avoids tripping over themselves, they can step on bases and other children’s feet.

What do you do with a sprained ankle?

• Rest-No need to completely restrict movement.  Should be allowed to do what they can (walk, run then sport when pain improving).
• Ice-Apply 20 minutes twice a day.
• Motrin-To help with pain and inflammation.

Who needs a doctor’s visit?

• Pain is severe
• Pain in lower leg bones or bumps at the side of the ankle
• Unable to put any weight on the foot

Who needs a brace?

Only those that have had repeat ankle sprains.  Bracing after the first sprain is unnecessary and potentially harmful. 

I would only recommend bracing in conjunction with your doctor.  Too many kids are wearing braces around indefinitely with no plan.

Warts-Help in a Flash

 

Warts are one of the most annoying problems.

They are not caused by holding (or kissing) frogs but, instead, are caused by viruses.

The virus that causes warts is contagious but that does not necessarily mean that if your child touches a wart they will get one.

Warts will go away on their own without treatment (Say it with me now.)   It never feels like that when it’s your own child, but I promise they will.  It may take 6 months to 2 years but they will go away.

There are many strategies for taking care of warts at home. 

OTC Meds

1. Bath or shower
2. Use an emery board to file the dead skin on the surface
3. Apply the topical wart remover
4. Cover the wart with a band-aid

Duct Tape

Place a strip (or ring if on the finger/toe) over the wart.  This strategy may take weeks or months of coverage to work but it does work (studies even show it)

Wart removal can be done but I only recommend it for warts that are painful or in a location that makes activities (writing, etc) difficult. 

The most common types of removal are freezing and laser therapy.

Frequent Urination-Help in a Flash

Has anyone ever said this before?

First you’re annoyed, then you start to get a little more concerned.  Could something be wrong?

This is usually normal and will go away but there a few things to think about:

Urinary tract infection

It will usually be accompanied by pain with urination, fever or belly pain.

Diabetes

The child will also typically have increased thirst or hunger and weight loss.  It is pretty unusual to diagnose diabetes from frequent urination in young children but I have had a 2 year old in my practice that was so not impossible.

Both of the above require a urine sample so going to the doctor is a must.

Abnormal Voiding

The most common cause.  Two reasons, the child is not emptying their bladder when they do go (usually nervous about missing something) or they have gotten in the habit of going as soon as they feel the slightest stretch on the bladder. 

You can help with these problems by having your child go “just a little bit more” after they go and by asking them to wait a minute or two after they say they need to go in order to go.