A Few Thoughts on Our Healthcare System

I entered medical school in the fall of 1989 and have been intimately involved in the United States' healthcare system in one way or another ever since. And the financial part of it still makes no sense to me so I cannot imagine how confusing and frustrating it must be for folks who do not interact with the system on a daily basis.

In our family, we have two persons with the same diagnosis which has required treatment since early infancy to prevent permanent brain damage. The variations in how this has been covered or not covered through the years seem mostly like an exercise in randomness, even though we have always been fortunate enough to have insurance. There have been times when their treatment was completely covered and free to us. At most other times, it has not been covered and we have often paid more than $10,000 a year for the same treatment.

We recently had a situation in which these two people with the exact same diagnosis and the exact same insurance were prescribed the exact same thing. For one of them, it was considered a covered service by our insurance and cost $27 per month. For the other, it was denied by insurance and the same amount was going to cost more than $1400 per month from the same supplier. After many phone calls and letters by our healthcare providers, the insurance company agreed that it was a covered service for both of them.

The second confusing piece of this is that the insurance company does not actually pay the supplier anything for the prescription. Because it is a covered service, we get the contract price of $27 and the rest of the cost is written off by the supplier. So why are they willing to accept $27 if we have insurance but would charge us $1400 if we didn’t?

We never know from one year to the next whether we are going to get prescriptions filled cheaply or need to pay thousands of dollars for them.

I once participated in a General Assembly committee hearing in Richmond addressing the issue of insurance coverage for treatments for genetic metabolic disorders. After I had spoken, an executive of an insurance company stood at the lectern and assured everyone that his company provided coverage for treatment for a certain disorder. Since we had coverage through his company at the time and were being denied coverage for the disorder in question, I knew this was not true. I do not think he was intentionally lying. I think he just didn’t know. But since the hearing rules said that once a person spoke they were not permitted to speak again, I could not point out this inaccuracy.

I think the helplessness I felt as I sat in my seat in that hearing room probably is shared by many folks as they encounter the illogical behemoth that is the American medical system.

 

 

Some Thoughts on Picky Eaters

Many children are picky eaters, especially in the toddler and preschool years. This is a frequent concern I hear from parents. Often it comes in the form of “Johnny won’t eat anything but chicken nuggets.” Some parents give the child what he wants, fearing that if they don’t, he just won’t end up eating enough. The problem with that approach is that if he knows he can hold out for the nuggets, he is not likely to try other things but will just wait until he gets what he wants.

My advice is usually not to worry too much about it and don’t turn it into a battle. Making the child sit at the table until he cleans his plate never seems to work and just upsets everyone involved. I suggest presenting him with healthy foods and then letting him choose to eat it or not, but not giving him an alternative meal or snack if he turns his nose up at dinner. The response to this is often “But he’s got to eat something!”

Yes, he does, and he will. When he gets hungry enough, he will eat. The key is being comfortable with allowing a child to miss a few meals along the way if necessary. We have a genetic, metabolic condition in our family which has severely limited the food options for several family members. But even with limited options, they always ate enough of what was available to them (and chicken nuggets were not an option). In almost twenty years of practice, I can only think of a couple of otherwise healthy children who refused to eat enough to maintain normal weight gain and growth.

Some children truly have feeding issues that make it difficult for them to eat certain foods. This can be a physical problem with their anatomy or inability to handle certain textures, anxiety, developmental disorders such as autism, or isolated eating disorders. In those cases, referral to feeding specialists can be helpful.

But for most children, I think simply presenting them with healthy options and then letting them decide whether to eat or not is a good option. At some point, when they get hungry enough, they will eat.

Why I Admire My Dog

Sometimes I wish people, myself included, were more like my dog. We got Wags at the SPCA when she was a puppy. She is now 14 or 15 years old and doesn’t move very fast and can’t see or hear very well. But she is the sweetest mammal on the planet.

Sometimes she wanders away from home and we need to go find her. When we do find her, she always trots towards us with her tail wagging, like maybe she was looking for us. The one time she didn’t come right to me, I knew something was wrong even though I couldn’t see her very well in the dark woods with my flashlight. It turned out that a large flap of skin had been torn from her underside and was dangling on the ground. As I carried her back home, she didn’t protest in any way but just nuzzled her nose up under my chin.

Recently as I was letting them in for the night, our other rambunctious beagle just ran into her and knocked her flat on her side. She didn’t make any fuss but just got back up and trotted in with her tail wagging. When she tries to sniff the cat and gets hissed and swiped at, she just turns around and walks away as if nothing happened. When she doesn’t want to go outside and I make her, she doesn’t resist.

When we get home, she trots out to greet us, tail wagging (at least if she is close enough to hear us drive up which needs to be pretty close). She gracefully endures the constant unwanted attention of our other dog.

I think if there was a canine version of “the fruit of the spirit,” she would be the poster child for it. So today I am going to endeavor to be like Wags – no barking or growling at others, lots of tail-wagging, and just getting back up and continuing on if I get knocked down.

Doctors Are People Too

In case anyone wondered, physicians are actual people. We are subject to the usual foibles of humanity – pride, selfishness, impatience, anxiety, fatigue, and our own personal biases to name a few. Hopefully these tendencies are mitigated by professional standards, a desire to help people, and the pursuit of objective evidence.

There was a time in my career when I was working far too hard. I was perpetually exhausted and it wasn’t unusual for me to walk into a room to examine a child and have the mother say “Dr. Sauder, are you OK?” One night I was making hospital rounds after a long day in the office and the grandmother of one of my patients said to me, “Dr. Sauder, you look like you could use a hug.” We must have been an odd sight; an older African American woman and a younger (at the time) white doctor embracing on the pediatric ward late at night. I am sure she never realized how much that buoyed my spirits.

Doctors, being human, make mistakes. Interestingly, I have found that people have often been more forgiving of my actual mistakes than my perceived mistakes. And as with most things in life, circumstances are often not exactly as they appear on the surface. There have been times that I have heard things in public about physicians or events that I knew weren’t true but I could not correct them because I would have needed to compromise a patient’s confidentiality to do so.

Clearly the days of regarding a doctor’s word as gospel truth are long gone, as they should be. We have years of training and experience in our chosen field and are dedicated to doing the best we can for our patients. But we are also human. And it is important for us and for our patients to remember that.

A Thought Experiment on Herd Immunity

You may have heard of the concept of “herd immunity.” I am not referring to anything having to do with groups of large, hoofed animals, although I suspect the concepts would apply to them as well. What this refers to is the resistance of a population to a disease.

Let’s consider a highly-contagious, fictional disease by the name of Sauderosis. Assume we have a vaccine for Sauderosis which is effective in preventing the disease in 90% of the people who are vaccinated and subsequently exposed to the disease.

Imagine a school with one hundred students who have all been vaccinated against Sauderosis. Since the vaccine is 90% effective, ten of the students in the school will be susceptible to Sauderosis if they are exposed. If there are 20 students in each class, that means two students in each class who are susceptible, so there is not likely to be a widespread problem with the illness in the school, even if someone comes to school sick with the disease.

Now consider that same school if only 50% of the students are immunized against Sauderosis. There are now 55 unprotected students in the school, all 50 who were not vaccinated and five who were (10% of the 50 immunized students). That would mean there are, on average, 11 students in each class who are susceptible so there is a significant chance of a large outbreak if the illness is introduced to the school.

Now imagine your child has an underlying medical condition which makes him more likely to have complications of Sauderosis. If he gets this illness, he is likely to end up in the hospital and may even have life-threatening complications. Which school population would you want him to be in?

Random Thoughts While Running

This is another blog post that really doesn’t have anything to do with pediatrics but for some reason was what I was thinking about while running today.

A few months ago, one of our vehicles had a flat tire. For a variety of reasons that I won’t bore you with (in part because I can’t remember them), the only time I had to change the tire was late on a Saturday afternoon. But when I went to take off the flat tire, one of the lug nuts was stripped and the wrench just kept slipping off. I really couldn’t figure out what to do and knew we needed to have the vehicle available Monday morning.

I texted a friend for advice and called around until I found one tire place in town which was open for another 30 minutes. I pumped up the tire with the bicycle tire pump, threw the pump in the back, and headed to town hoping for the best.

After I arrived safely, it took them about ten minutes to remove a nail, patch the tire, and get it pumped up again for me. We chatted about college football while they were doing it and I was ready to leave in no time. When I went to pay, the charge was $10. Forty-five minutes earlier I had been in a panic trying to figure out what to do and these guys saved me. I told them to charge me more but they insisted $10 was the charge.

That made me think about how we determine the value of things. The guys who fixed my tire possess equipment and knowledge to know how to patch a tire. That is a valuable thing to a guy like me who does not know how to do it himself.

We all have our own niche and expertise and need to value that in each other. When I have a patient who needs more help than I can provide, I refer them to a doctor who specializes in the problem they have. When an oak tree fell on our garage roof, I called guys who could remove it safely. If I want to understand a scientific issue, I read things written by the scientists who work on it. If I have a problem with the house, I call a contractor. When my snowblower quit working, I called folks who know how to fix snowblowers. If I don’t know which E&M code to use for a visit, I ask our office manager.

We all depend on each other for different things. I know some really handy and talented people but I don’t know anyone who can get through life all on their own. At the risk of sounding preachy, it reminds me of I Corinthians 12:14 and following which talks about the need for every part of the body to do its job for the body to function properly.

So look for the value in others and acknowledge it. It will make their day and it will help you appreciate them more.

What's the Deal with Artificial Sweeteners?

One topic which seems to be talked about a lot without much definitive data is the effect of artificial sweeteners.

There are six low-calorie, artificial sweeteners approved by the FDA – saccharin (Sweet’N Low), aspartame (Nutrasweet), Ace-K, sucralose (Splenda), neotame, and advantame. These compounds work by stimulating human sweet-taste receptors while providing minimal to no calories. They are excreted unchanged from the body so have been considered to have no direct physiologic effect.

However, there have been concerns about indirect effects such as alteration of the gut microbiome (the bacteria living in the intestinal tract) and the dissociation of sweetness from calories. It is hypothesized that these alterations could result in changes in the way our bodies process nutrients and govern our sense of hunger and satiety.

There are studies which have shown weight controls benefits when drinking beverages with artificial sweeteners instead of sugar. Other studies suggest that artificial sweeteners may actually increase the risk of weight gain and type 2 diabetes. Results differ depending on the study group and it is difficult to tell how the results in one study group apply or do not apply to groups with other characteristics.

So it is difficult to draw any definite conclusions. But there are two things I know for sure on this topic. Drinking sweet drinks such as soda, sweet tea, and sports drinks add a lot of unnecessary calories. A 16 ounce soda has around 250 calories in it. To burn that many calories, one would need to walk or run approximately two miles. It is much easier to skip the soda than to add two extra miles to your daily workout. The second thing I know for sure is that water has no calories and is great at quenching thirst.

So next time, reach for the water instead (assuming your water source is clean and free of harmful substances which is another topic for another day).