Monday, May 30, 2011

Treating and Avoiding Seasonal Allergy Symptoms

This is what is in my medicine cabinet at home
It's spring and, in my office, we've been dealing with seasonal allergies for weeks. My nine year old daughter has them every spring. She can be just miserable with itchy, watery, puffy eyes, an itchy throat, a stuffy nose, sneezing, and congestion. For her, the eye symptoms are the worst.

This all started for her when she was about four. I came home after work and she was running frantically around the house rubbing her eyes and bumping into things. Her eyelids were so puffy she could hardly see out of them. It was then I realized I needed to take a more pro-active approach toward her allergies. I needed to keep them under control, to not allow things to get so bad again.

Sometimes I have families come in to the office season after season, surprised that their children have allergy symptoms again! Parents sometimes don't want to keep their children on medication all the time. They don't like medication, and don't think it's healthy for their child to take "so much."

I think, if these parents had allergies themselves and knew what it was like, they would just go ahead and give the medicine and never allow things to get so bad for their child. It is simply miserable to be itchy, sneezy, congested, with a constant runny nose or post-nasal drip.

You can do some simple things at home to help your child with seasonal allergies:

  1. Keep their bedroom windows closed during allergy season so the pollen doesn't get into their bedding and clothes.
  2. Bathe them and wash their hair in the evening if they have been playing outside all day during allergy season. This will wash off some of the pollen so they don't breathe it all night.
  3. If you have air conditioning consider using it during allergy season.
  4. Give your child a simple over the counter antihistamine such as loratadine (Claritin) or cetirizine (Zyrtec). Either of these will last 24 hours, have few side effects, and work great especially to prevent allergy symptoms. Even fexofenadine (Allegra) is now available without a prescription, but it is still pretty expensive and must be dosed twice a day. These medications will work best if you give them regularly during your child's allergy season.
  5. If eye symptoms are really bad you can rinse your child's eyes gently with some saline solution, and then use over the counter allergy eye drops regularly to prevent symptoms. Two of the drops I know you can buy without a prescription are Zaditor and Patanol.
  6. An occasional dose of diphenhydramine (Benadryl) can go a long way if things get out of control and you have to get the symptoms calmed down for the night.

So, don't be surprised if the allergy symptoms your child had last spring come back again this year! The same holds true for fall allergies. Go ahead and treat your child's symptoms and help prevent the symptoms during the entire season your child usually has trouble.

Allowing your child to suffer through the allergies does NOT make their immune system better able to fight the allergies! It just makes them feel terrible.

If you want to do something to try to actually reduce or eliminate the allergies you will have to talk to an allergist about immunotherapy. This is a long-term (2-5 years?) endeavor of year-round weekly or biweekly allergy shots. To many kids (depending upon their age and tolerance), this treatment would be worse than taking some antihistamine for a few weeks or months each spring (or fall).

Monday, May 23, 2011

Why Do Doctors Run Late Part II

This is part two on why doctors run late in the office—more specifically, why I might run late some day while you are waiting for me! The same scenarios I presented in the blog last week are explained here in more detail. I am trying to make you understand why things aren’t always simple when it comes to keeping to a schedule.

Please understand, I am not trying to excuse myself for running late. Hardly anything causes me as much stress as getting behind on my schedule and forcing others to wait for me. I always strive to keep to my schedule by having appointments scheduled in a way that allows enough time for the problem and number of patients to be seen in a time slot. I try to be efficient during the appointment. I even ask people to reschedule—especially if they are so late for a check-up (or similar non-urgent appointment) that almost all of the allotted time has gone by before they arrive.

I have had people give me analogies such as getting their muffler fixed, oil changed, or brakes replaced on their car—for these procedures they are given an appointed time, and apparently their mechanic sticks to the schedule. My first response to this is that people aren’t cars! People talk back to me, and have opinions and feelings about what is happening to them. Secondly, it is unlikely there would be an emergency repair a mechanic would have to make immediately (when they thought they would just be simply replacing the muffler). And finally, in my experience, mechanics haven’t been very good at sticking to the schedule when it comes to fixing any of my cars. Or what about any other appointment you have had scheduled, such as getting your hair cut? Your stylist can keep to her schedule, right? Again, a doctor’s appointment isn’t the same as getting your hair cut. Much is known ahead of time about what will happen in the salon (making scheduling more accurate), but the flow of an appointment with your doctor is often unpredictable.

So here are my scenarios—with more detail to give you an idea of why I often must just deal with the problem as it comes up, instead of cutting people off or making them reschedule an appointment. And I’m not even including the little things—such as the newly potty trained three year old who has to go to the bathroom in the middle of the appointment, or the child who vomits everywhere as soon as I walk in the room, or the adolescent who faints after her immunization, or the poopy diaper that goes up the back and onto the exam table.

1. My first patient of the morning is seven minutes late. She is sick and there are no other appointments available until after hours. The child cannot drive herself to the office and I don’t feel right about penalizing her because her parent did not make it to the office on time. It turns out the reason the parent was late is because the child was vomiting all over the place before getting in the car—the best laid plans to arrive at the office on time went awry due to unpredictable circumstances. Or, there was an accident and traffic was re-routed, causing the drive to take longer than usual. Or, the roads were icy. Or, they were just late—but it really isn’t the fault of the 5 year old with the high fever.

2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen. Mom is looking stressed and near tears, she won’t have a car that afternoon to bring the sibling back. I don’t have the chart, and have to request it. This is a really common scenario. I am asked to see siblings, or “just take a quick look in the ears,” or “just answer a quick question about brother’s potty training” many times throughout the day. How would you feel if you were in this Mom’s position? I don’t think you would be very happy if your pediatrician said “No, I’m sorry Mrs. Smith, next time you should think ahead and schedule another appointment for little Johnny. Have a nice day.” It would help me if parents could alert my nursing or front desk staff ahead of time so I could have the sibling’s chart, and so I could be aware from the onset that I must divide my time between two kids instead of using all the time for one. But it’s not very likely that I am going to refuse to see a sibling if it is for a simple illness such as a potential ear infection. Adding on another child (or even just a conversation about another child) at the end of the first child’s appointment may take an extra five to ten minutes. If I know about it ahead of time I can be more efficient.

3. A middle-school student is in the office for a sore throat. I do a brief history and physical exam, get a throat swab, and step out while the test runs. I return to inform the family the child has strep, discuss the illness, and write the prescription. I write a note to excuse the student from school, and another to explain the parent’s absence from work. As I get up to leave the parent asks their child to step out because they want to discuss something privately with the doctor. At this point I had thought we were finished with the appointment. But the conversation reveals that the patient is having some serious mental health problems and the parent needs some advice TODAY. This part of the visit turns out to be more important than the strep throat, and yes, it will put me 10 to 15 minutes behind in my schedule. Again, if I had known ahead of time I could have planned better—perhaps having this discussion while we waited for the strep test to run—but I can’t turn this person away just because the problem wasn’t scheduled into my day.

4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention. Obviously we could have allotted more time if we had known all of these issues, but isn’t it understandable why she had trouble telling this to the receptionist? Maybe her dad made the appointment for her, and he is sitting in the waiting room right now wondering if she has strep throat or mono. Meanwhile I am having a completely different conversation with his daughter. And then I will have to reach an agreement with the teenager about how we are going to talk about this with her dad, then dad has to come in and we have another conversation. This will add 15 to 20 minutes to the scheduled 10 minute appointment.

5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong. Now it is 2:12pm (her appt. technically ended at 2:10). I must arrange for her hospital admission. This will involve conferring with my office staff (five minutes), possibly collaborating with another doctor at my office to inform them of the admission and get their opinion (five to ten minutes), talking with other doctors and nurses at the hospital (minimum of ten minutes, may involve more than one phone call), and discussing the possible diagnosis with the child’s family and explaining the diagnostic and treatment plan to them (ten-twenty minutes). Now I am ending this child’s appointment at least 30 minutes (up to 50 minutes) after it had been scheduled to end. To those who are waiting, and feeling frustrated and annoyed, all I can say here is that I would give your child the same time and attention if they were seriously ill.

6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question about a preschooler, or a potty training question for a two year old. It could be questions regarding when to think about ADHD, school problems, how to handle a child’s grief over their grandparent’s death, how to help a child through their parents’ divorce, what to do about bed-wetting/constipation/soiling the underpants, how to get a child to sleep better, etc. Many parents wouldn’t think of making a separate appointment for these questions, but they are important topics that will take at least a few minutes of my time. It is always helpful if a parent can help me plan the time in the office visit by saying at the beginning of the appointment something like: “We are here because we suspect an ear infection, but I also wanted to ask you a question about potty training.” Or, “we made the appointment for back pain, but we have seven other things on our list to ask you about.” For those with a long list I will probably then ask them to prioritize in order of importance, and tell them at the beginning that they have a ten minute appointment and we may have to reschedule to discuss some of the other problems. If I don’t know about the list until I am finished evaluating the primary complaint it affects my schedule more.

I think there were at least four more scenarios in my original blog on this topic. There is enough here, however, to give you a general idea of how and why I can get off schedule. There are also some things you can do to help me stay on schedule. These would include providing accurate information to the scheduler about the main reason, and any other secondary reasons, for the appointment (including how long the symptoms have been present), letting me know at the beginning of the appointment about everything you want to discuss, and informing my office staff that you are planning to have me check a sibling in addition to the child who originally was scheduled for an appointment.

To those of you who simply cannot tolerate waiting, or who have such a tight schedule that it isn’t possible to run late, you might consider booking your appointments as early as possible in the morning or first thing in the afternoon. In general it is more likely I will be running behind as it gets to be later in the day. And my pledge to you is that I will continue to work on staying on schedule and being efficient during my office day—while still striving to treat each patient as an individual who may have important and unexpected needs. Ultimately I will try to treat each family as I would want someone to handle my own.

Saturday, May 21, 2011

Why Do Doctors Run Late?

You know how it is, right? You’re sitting in the waiting room with your child, bored out of your mind, while snotty nosed toddlers cough, sneeze, and wipe their boogers on every imaginable surface, including you and your previously healthy baby. You wonder if you have been forgotten, it has been 20 minutes, then 30. Finally you are escorted to an exam room, told the doctor will be with you shortly, and the door is closed. Claustrophobia sets in. It’s warm and stuffy, and there is no window. Your children turn into unrecognizable beings that must belong to someone else. They open drawers, pull out tongue depressors, rip off exam table paper, and spill crackers on the floor. Someone has to go potty. You’re not sure if you have time to make it to the bathroom and back—what if the doctor comes in right then? Finally you open the door to make sure they still remember you are here, take a step into the hallway to find the potty, and there I am—it’s your turn!

I have looked at my own schedule many times. While I can’t answer the question of why other doctors run behind on their schedules I have thought a lot about why I might get behind. I do understand it better, and have made improvements, but as many of you know, I have not solved this problem after fourteen years in private practice!

Why do I sometimes run behind in my schedule? From day-to-day this is the one thing that causes me a great deal of stomach churning, acid refluxing, and gut flip-flopping, head-aching stress! Often I will think back on my day, and if I have stayed close to my schedule and not finished too late it has been a good day. If I’ve run behind I’ll end the day feeling frazzled and out of breath, apologizing to everyone, and will go home to tell my family what an awful day I had.

One message I would like you to take home from this blog post is that I really do care about your schedule. I hate making people wait for me, and I am thinking about it constantly throughout the day.

I have done audits on myself. I’ll take several days and write down my starting and ending time for each appointment, and then compare it to my schedule. While it is fresh in my mind I’ll jot down any special circumstances that might have made an appointment start or end at a different time than it was scheduled. The first time I did this I was trying to find the one problem I was having that would explain getting off schedule. There must be something simple that could be adjusted, right? Perhaps it is just an improper scheduling issue?

What I have found when I audit myself is that there are MANY reasons I can get behind in a day. Most of them are UNPREDICTABLE. Most of them are UNAVOIDABLE if I am to provide good quality patient care. You must understand that it is my goal to provide the best possible care to each child in my office. I cannot sacrifice good care in favor of staying on schedule. I do set priorities each day, and at times cannot satisfy every need a patient has in one office visit.

Let me give you some examples of where things can go wrong, and why you might end up waiting for me. I, of course, have changed these scenarios to protect the privacy of my patients, but you will understand the general principles. I will use my NEXT blog to go into more detail about why each of these can affect my schedule so much, why I don’t think there are simple answers to each schedule-wrecking situation, what I do to try to keep myself on track, and what parents can do to help me stay on schedule.

1. My first patient of the morning is seven minutes late.

2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen.

3. A middle-school student is in the office for a sore throat. After the office visit is completed, and I get up to leave, the parent asks their child to step out because they want to discuss something privately with the doctor

4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention.

5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong.

6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question, potty training, ADHD, a child’s grief, parents’ divorce, bed-wetting/constipation/soiling the underpants, sleep, etc.

7. I was given a ten minute time slot for a patient with apparently just two days of headache, but actually it turns out this problem has been going on for more than a year, and also there has been ongoing problems with abdominal pain.

8. During one office day I received several phone calls from the hospital to tell me urgent things about patients in the hospital. I am interrupted from office visits with patients to take these calls.

9. My eight year old patient won’t cooperate for a strep test.

10. Someone walked in with an injury needing urgent treatment and didn’t have an appointment.

I will probably think of more. On any one day my schedule can probably handle one or two of these without disastrous effects. But some days, especially if there is an admission to the hospital, I just end up terribly behind. I can tell you that when auditing myself I see many different reasons throughout the day to explain how my schedule went awry. Sometimes there is a single thing, such as the hospital admission, that explains everything. But more often it is many different situations throughout the day which add up to put me behind. And I am certainly not just standing around drinking coffee or chatting on the phone with my mother while you are waiting for me.

As a parent there are things you can do to get your questions and needs addressed while still helping me to stay on track. There are times in the day when I am less likely to be behind in my schedule. And if, to you, the above scenarios seem easy to solve—then wait for my next blog and I’ll explain why they might be more complicated than they appear at first glance.

Friday, May 20, 2011

Has your child outgrown her booster seat?

New recommendations about booster seats for children state your child should remain in the back seat, in a five-point-harness car seat until the height and weight limits are out-grown. Then, your child should definitely be in the back seat, in a booster seat until age eight. In general, once your child is eight years old he should be 4 feet 9 inches tall before coming out of the booster seat. This will likely be until age 10 to 12! The front seat is for children who are ages 13 and up.

However, after age eight and before 4’9” tall there may be some car seat belts (in the back seat) that will properly fit your child without a booster seat. There are five steps to determine if the seat belt fits well without a booster:

1. Does the child sit all the way back against the seat of the car (their back and their bottom is up against the back of the seat)?
2. While they are sitting all the way back in the seat do the child’s knees bend comfortably at the edge of the car’s seat?
3. Does the shoulder belt come across the collarbone, between the neck and the arm?
4. Is the lap belt low in the lap, touching the thighs?
5. Is this a comfortable position that can last for the whole car ride?

This information originates from the American Academy of Pediatrics, and was printed in the spring 2011 newsletter (Volume XVI, No 1) of the Michigan Chapter of the AAP. Online sources of information can be found at ,, and

Wednesday, May 18, 2011

HPV Vaccination: Prevent Cancer!

Yes, it’s time to talk about another vaccine. I guess I really love this topic, or perhaps it’s just that I think it’s really important. The one I’m referring to this time is the Human Papilloma Virus (HPV) Vaccine. The purpose of this vaccine is to prevent genital (including cervical) and anal cancers, and genital warts. I recommend this vaccine for all middle school students. My oldest child started the series at age 12 and was fully vaccinated at 13.

One commonly recognized brand of this vaccine is Gardisil, which prevents four types of HPV: HPV 6 and 11, which cause genital warts, and HPV 16 and 18, which cause anal and genital cancer and precancer. A more newly released vaccine is Cervarix. It covers HPV 16 and 18. Neither vaccine covers all forms of cancer-causing HPV, but HPV 16 and 18 cause approximately 2/3 of cervical cancers.

Have you heard of Human Papilloma Virus? Did you know that the lifetime risk of becoming infected with this virus is 80%? Are you aware that approximately 20 million people in the USA are infected with the virus? And 18% of 14 to 19 year-old girls are infected? Did you know the virus causes cervical cancer, anorectal cancer, and genital warts? Yuck, right? It’s a sexually transmitted disease (STD) that causes cancer and is PREVENTABLE.

The vaccine was introduced to the general public in 2006. By 2009 44.3% of adolescent girls in the United States had received at least one dose of HPV vaccine, and 26.7% had received all three recommended doses. In Australia, during the first year of a national HPV vaccination program, 75 to 80% of targeted girls had received all three doses! The vaccine is now recommended for girls AND boys, ages 9 to 26.

The vaccine has a good track record when it comes to side effects. Adverse effects shown to be caused by the vaccine are headaches, low-grade fevers, and a sore arm. Adolescents have been known to faint after receiving the vaccine. This reaction can be seen after any vaccine given to an adolescent, and is not limited to the HPV vaccine. Claims of more serious adverse effects have not been substantiated or shown scientifically to be more common in vaccine recipients than in the general public. You can find complaints about the vaccine on the internet, of course, but much of this is hearsay or linked to attempts at legal action.

Why is the vaccination rate so low? The vaccine prevents CANCER! What I hear from my patients’ parents are comments such as these: “We’re not going to give THAT vaccine.” “It’s too new.” “My daughter doesn’t need it because she isn’t going to have sex before marriage.” “If we give the vaccine then my child will think it’s ok to have sex.” “It hasn’t been around long enough for me to feel comfortable.” “I don’t know how long the immunity will last, so I want to wait until my child is older.”

I would like to respond to these comments.

1. First of all, scientific studies have shown that a fairly high percentage of kids ages 14 to 19 are already infected with the HPV virus (18% of girls in one study), so it is quite possible your child could be exposed to the virus during his or her teen years. Waiting until they are older could mean they become infected with the virus before they receive the vaccine. And you don’t have to have sexual intercourse to become infected. HPV can be transmitted via oral sex (among other ways) too! Also, there is evidence that there is more long-lasting immunity when the vaccine is given at a younger age.

2. Studies that have examined the rate of sexual activity among teenagers have shown that providing information about STD and pregnancy prevention, and even handing out condoms, has not led to an increased number of teenagers having sex. To me, therefore, it seems unlikely that giving the HPV vaccine will cause teenagers to become promiscuous.

3. Millions of doses of HPV vaccine have been administered to date, with proven safety. The vaccine is not new; it has been given to the general public since 2006.

4. Perhaps your child will wait to become sexually active until they are married. After all, you waited, right? But you don’t get to control the sexual activity of your child’s potential spouse. HPV infection (except in the case of genital warts) is not visible to the naked eye, and there is no test that can tell you if someone is infected with it.

5. I don’t want to offend anyone, here. But you should know that it is fairly common for me to see teenagers in my office who are having sex, and I don’t think most of their parents know they are sexually active. Don’t be naive. A 2002 study showed that by ages 15, 16, and 17 30-50% of teenagers were already having sexual intercourse! Talk about relationships, values and expectations with your child. But protect their health. I, too, don’t want my daughters (and I would say sons, if I had a son!) to become sexually active at such a tender age—but I will take a practical approach when it comes to preventing such a serious disease as cancer.