What’s New?

18 Jun

So much…

I’ve finally moved my practice up to the Lewisville office.

If you know anyone who is looking for a pediatrician in Lewisville, Plano, Frisco, Flower Mound or any of the surrounding area, please be sure and send them my way:

Cook Children’s Lewisville

713 Hebron Parkway, Ste. 232
Lewisville, TX 75057
972-316-7400 phone 
817-347-6868 appointments

In addition, Cook has assigned me a new role.  In addition to seeing patients in Lewisville, I will be the new Medical Advisor for Digital Health for the Cook system.  It will basically mean I will be doing all the stuff I love to do and have been doing for over a year…I just paid to do it!  So, this blog will eventually be phasing out over time.  I will transition my writing over to my new blog which will live somewhere on checkupnewsroom.com.  I am also looking to do some more video and other things as well so stay tuned for further developments.

Thank you so much to everyone who has subscribed to and read my blog.  It is truly an honor that you would spend your time reading anything that I write…I will let you know when the new blog is live!

Re-Writing My Colic and Reflux Posts

2 May

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My post on colic and my post on reflux have been two of the more popular posts I have written.

In case you don’t memorize all my posts and recommendations (shame on you)…here’s the main takeaways for treatment of colic: 

  1. Carrying the child – Many children with colic calm with being carried.  Devices that help you walk with the child and still do some stuff around the house can be helpful.
  2. Change in environment – Getting the child in the car or going for a walk can help.
  3. Swaddling – Nice constant pressure is helpful to any baby (including those with colic) when they are fussy.
  4. White noise – The radio in-between stations or the clothes dryer.

A recent study in JAMA Pediatrics studied the use of probiotics in almost 500 children and its ability to decrease crying time and spitting up.  Comparing placebo to Lactobacillus reuteri showed decreases in crying time per day (38 vs 71) and spitting episodes per day (2.9 to 4.6).  The significant good news to me is that there were no side effects noted.

A couple of problems I have that prevent me from going all out on this recommendation:

1) A crying time of 71 minutes in the placebo group is probably normal and not technically colic (although decreased crying time is decreased crying time).

2) Other studies have been done with the same probiotic (smaller and not done as well) that did not show a difference.

3) Perhaps some spitting up and crying are normal and I am not interested in medicalizing/treating what is normal.  It tends to set up the idea that everything (even normal symptoms) need treatment which is simply not true.

ACL Injuries-What You Kneed to Know

28 Apr

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Photo courtesy: SMSMF Pep Program

Teenagers are some of my favorite patients I see in my office.  I enjoy watching them transition from children who turn to mom for answers to my questions to young adults who confidently interact with me as they prepare to be on their own.

I especially love hearing what they are passionate about.  I like to hear about the clubs they are active in, the sports they play, even their boyfriends and girlfriends.

Because I played sports growing up, talking about sports is very natural and easy for me.  If you need more evidence, check out my physician profile on Cook Children’s Lewisville page.  I know what it means to be so wrapped up in a sport that it seemingly means your whole life.

I played mostly basketball and tennis in high school but tennis was where I excelled.  I made the state semi-finals my freshman year and was excited about a chance to take it all my sophomore year.  After an early morning car crash and a broken arm, that chance went out the window.  This was a very difficult time as I wrestled with identity issues, after all, I was “that guy who’s good at tennis” to so many people. 

Of course, my injury was “unavoidable” but research is showing that a common injury in athletes, particularly girl athletes, can be prevented.  ACL tears are the most common “serious” injuries in female athletes.  They most commonly occur without contact from a sudden stop or turn.

The amazing thing is that studies have shown that simple exercise and strengthening programs will help to prevent this injury.  A recent policy statement from the AAP affirms this and recommends this training program for girls participating in “dramatic” sports including soccer, basketball, volleyball and cheerleading.

A large study published in the Archives of Pediatric and Adolescent Medicine showed decreases in lower extremity injuries, ankle injuries and number of surgeries required.

There are many options available but I found this one from the Santa Monica Sports Medicine Research Foundation to be simple and is fully available online.  It requires 15-20 minutes 3 times per week.

If my little girl decides she wants to play, she will be required to complete a program like this.  If your coach is not implementing an ACL prevention program, ask them.  If they are resistant, please get your girls doing this on their own time ASAP.

The Doctor Will See You Now…ish-It’s the Patient’s Fault

23 Apr

Before you jump all over me, I have already outlined why I think we (doctors and medical offices) are the biggest part of the wait time problem. But, there are some reasons why you are part of the problem…ok, let me soften it up a little bit…

Here are 3 ways you can help avoid long wait times at the doctor’s office:

#1-Don’t request peak times during the day.

Every office has busier times and not as busy times throughout the day. If you don’t know when they are for your office, ask the receptionist when you check in if there is a time when the waiting room is less full. No one wants to get up and get kids ready early for an 8AM visit so if you will, you probably won’t have as much of a wait. Every single parent of a school aged child wants their child to be seen after school.  We simply cannot accommodate those patients in a reasonable time during the 1.5 hours we have that a typical office is open after school times.  We can help by extending hours (and I think more offices should) but if your child is not in school please book an earlier time or expect longer waits.  Alternatively, you can drop the emphasis on perfect attendance (I’ve written about this before also: Roll Call-Doc Smitty’s thoughts on perfect attendance policies).

#2-Don’t request peak times during the week/year.

If you need a sports or camp physical, it can usually be done in the spring or early summer.  If you wait until the week before school starts you’ll be thrown in the mix of all the other procrastinators who have waited until the last minute.  Even if your child isn’t school age or needing a school physical, keep this busy week in mind.  There’s no reason to come and see us for a long standing problem that week, just wait one more week and enjoy the fact that the office is quieter the first week of school (also use STAR testing weeks-it’s like a ghost town).

Mondays are always busy in a pediatric office.  In addition to the standard check-ups, same day illness, etc there is a build-up of illnesses from the weekend that need to be crammed in.  Plus, stuff always seems to happen on a Monday, amiright?

Don’t come in on “miracle days.”  Dr. Strong (my former partner) always called the days before holidays miracle days.  The conversation usually goes something like this…”I wouldn’t normally have come in but we’re going to be getting on an x (plane, cruise ship, long car ride) and I wanted to get something done sooner or try to prevent y from happening.”  There are lots of problems with this logic…First, illness is no respecter of your vacation.  Rhinovirus could care less if you bought trip insurance for your trip to the Caribbean.  Second, many illnesses in pediatrics are viral which means that avoiding a bad trip is more a function of bad luck than anything I can or cannot do.  So, the moral is, don’t come in expecting a miracle and if you have something that can wait, wait.

#3-Come ready with everything.

Here are a few examples:

Bring your insurance card every time you come.  We took our 4 year old to see his doctor 2 weeks ago and his insurance had been inexplicably canceled.  (It’s like the plumber with a leaky faucet.)  Things change without your knowing it.  If you have your card and we have the latest copy on file, it’s easier to get issues straightened out.

If you can’t bring your child, send a detailed note with your concerns so it doesn’t go like this…Me: How long has this been going on?  Aunt June: “You know, I’m not really sure…let me call mom…oh, she’s not answering…I’ll try her work number…”

Bring a shot record to the first appointment.  There are shot records available online and they are usually accurate and up to do which is great, when they are accurate and up to date.  If they aren’t, finding shot records is a disaster.  Offices typically won’t do it the same day so you have to come back once we have them…if we ever get them.  People do shots differently (especially at 1 year and beyond) so I can’t always predict what they’ve had.

These are some examples of things I can think of that you can do (or avoid).  What tips or tricks have you learned?

The Doctor Will See You Now…ish-Why It’s My Fault

22 Apr
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Painful wait times at the doctor’s office… It’s an old story with few exceptions.

As a dad, I have to deal with many of the same issues of parenting that you deal with: sleepless nights , fevers and holding my kids down for shots (My wife did it once, I think, then she promptly retired from this job.).  However, waiting at the pediatrician is not something I have to do.  So, I can’t truly empathize with you on this one….

Because you guys know me and know I’m not one to defend the status quo…I’m going to go ahead and defend the status quo a little bit.  Or, at least, sound like I am (whether I am or not).

Here are some (in my mind) acceptable reasons why wait times are long:

  • Scheduling – Doctors, pediatricians specifically, are often over-scheduled.  We generally come out of school with the same amount of debt as our doctor friends who have entered more “lucrative” specialties.  The only way to make up some of the difference (and pay back our loans) is to see more patients.  Thus, patients are scheduled closer together.  This normally does not cause problems…but stuff happens.
  • Emergencies – If you have a doctor with hospital privileges (especially one who goes to deliveries), emergencies will happen.  Getting called to a C-section can ruin an entire afternoon for a busy pediatrician.  Great partners (like the ones I had in Abilene) will try to pick up the slack while you are gone but it is a strain on the whole system.  What about other little “emergencies”?  The teenager who reveals during their well child exam that they are depressed and suicidal.  The 6-year old getting an MRI for headaches that turn out to have been caused by a brain tumor.  Yes, I could assign those conversations to someone else by referring to the ER or the specialist, but wouldn’t you want it to be your pediatrician walking you through that?

Here are some (in my mind) unacceptable reasons why wait times are long:

  • Too Much Time Out-of-Room for the Doctors – I heard a story once about a doctor whose patients complained that his wait times were too long.  He in turn complained to his staff that they were too slow.  Come to find out, every morning, before he saw any patients, he sat down at his desk and read the entire paper, cover to cover.  He had patients waiting 15 minutes completely ready for him to see but was sitting in the back office.  15 minutes might not be terribly inconvenient but that 15 minutes, on a bad day, will turn into 30-45-60 minutes that could have been avoided.  Reading the paper may not be much of a temptation these days, but spending time on the computer doing other stuff is huge.  I have to make a point not to be on Facebook, Twitter and other social media during patient care time.  I do my social media and blogging before patients arrive and at lunch.
  • Poor Work-Flow in the Office – In Abilene, I had a very hard working MA and LVN (shout out to Nikea and Beth!) that understood how important this issue was to me.  There are other ways to know if work-flow is the problem but one thing is certain: if you can’t see your first patient of the day in time, then there’s something wrong.
  • Chronic Over-Scheduling – While I do understand the issues related to scheduling, I don’t excuse the doctor for always having a schedule such that they run behind every day.  Something can be done.

Now, you can read over this and take it however you want, but keep this in mind: you almost always have a choice in medical care.  Unless your child needs a specialist for which there is only one in town or you live in such a rural area that there is only one provider, you have a choice.  When we make any choice, we prioritize what’s important…someone might choose to see a doctor they love and tolerate the fact that their wait times are longer (but continue to complain on Facebook about it-I get it, it’s ok). Other people might drive more miles to see one they love. The choice still lies in the hands of the parents.

Ultimately, waiting anywhere is hard.  Waiting in the doctor’s office is especially hard when you have a sick child, no one slept the night before, and the only appointment available was right in the middle of nap time.

I promise to keep working on those things that I can do in order to shorten your wait time and you can stay tuned for tomorrow’s post:

The Doctor Will See you Now…ish-It’s Your Fault (Not Really, But Here’s How You Can Help)

The Flipped Check-Up

17 Apr

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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

11 Apr

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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?

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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.

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