A "Minute Clinic" Visit for Your Kids?

Is there a 'minute clinic' in your area? One just opened in mine.

Housed in a CVS pharmacy or Target or Wal-Mart or Albertsons, these are health care dispensaries staffed by nurse practitioners and physician's assistants intended to care for minor, self-limited medical issues (like ear infections, strep throat, skin rashes and vaccinations).

Hmm... Let's see, I'll get some school supplies, milk and, while we are at it, have that pesky rash looked at. "You're sick. We're quick!" is their motto. Apparently there's gold in them thar hills. Consider:

• 25 states already have such clinics.


• No less than Wal-Mart has gotten into the act. They currently have about 75 clinics in 12 states and plan to open thousands more in-store medical clinics in the next 5 years.

Is this good idea? Have you or will you take your kids to a minute clinic?

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Here, as I see it, are the pros and cons. On the positive side:

• Patients can be seen promptly, without an appointment. No muss, no fuss.


• The charge is generally only about $50, much less than an emergency room or primary care doctor's visit.


• Most use electronic medical records so there can be access to previous visits at any site.


• Most parents are capable of distinguishing a minor illness from a potentially more serious one, as are the health professionals who are seeing them.

On the worrisome side:

• The providers don't really know your child. What if there are some complicating medical concerns they should, but don't, know about?


• Sometimes parents underestimate the nature and severity of the symptoms. Will the minute clinic, for example, be able to pick up early and subtle signs of meningitis?


• There is no physician oversight on-site. What happens if the child is too sick to be seen or there is some mysterious complication?


• Care is fragmented. Will your primary care provider ever even know about the multiple diagnosed ear infections?

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Alas, I can't find any good studies assessing the quality and appropriateness of the care delivered at such places. Of course, most of the time, things will go well. Most illnesses are self-limited and kids get better no matter what we do or don't do. It's our dirty little pediatric secret.

The real question is this: how often will the rare, but much more serious illness be missed? And what will be the effect of this further fragmentation of care on the general well-being of our kids?

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You may be surprised to hear I'm not necessarily opposed to minute clinics, as long as there are quality safeguards and oversights in place.

I think parents should have choices when it comes to their child's health care. Lord knows emergencies rooms are often an expensive, endless nightmare. I can see why you might want your child checked out quickly and inexpensively, instead of waiting in my office for an hour, only to be told "it's probably just a virus. Nothing to do." I can see why uninsured families might make use of this service, in lieu of more expensive health care services.

Also. it will be interesting to see how insurance companies deal with minute clinics. Sure, the price is right, but if your child was not sick enough to see a doctor, perhaps she was not sick enough to warrant reimbursable medical care and perhaps these clinics will make it too easy to seek care for trivial complaints and, they may reason, perhaps we shouldn't pay at all. Stay tuned for Blue Cross vs.Wal-Mart battle of the titans on pay per view.

I'm sure some of you are making or will make use of this convenient form of acute health care. On the other hand, some of you may want the comfort of seeing someone who knows your child, someone whom you trust, and someone who is more likely to pick up the unexpected, unusual cause of the symptoms. In such cases, the wait and expense of seeing someone like me will be worth it. It will be (and should be) your call.

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Have any of you used a minute clinic? What was your experience? If not, would you use one for your children? Inquiring minds want to know.

Related Topics:

• WebMD Video: Walk-In Clinics Revealed
• Retail Clinics Catch On in U.S.
• Parents Like Retail Clinics for Kids

Autistic Kids: Who Should Pay?

It's a war you can see coming, a war where there are no bad guys, a war that breaks your heart, a war for which you will be asked to chose sides . For the latest volley, see this article from the Boston Globe: Push on for Insurers to Share Autism Cost.

Watch this war heat up between two titans - the health insurance industry and the educational system. It's a border war. At issue is where to find the immense resources needed to pay for therapeutic services for autistic children.

You can see how the stage has been set for this looming battle:

• The numbers are huge. Currently it's estimated that about one in 160 (or about 560,000) children in the U.S. are autistic.


• Everyone agrees that the treatment of autism should begin as early as possible (sometimes as early as age 2 years) and that it needs to be intensive (say, 25 hours/week).


• Let's do the math. The American Institute of Research estimates the annual cost to educate an autistic child in public school is between $15,900 and $21,700. (The average annual cost for a students in public education is $7,600. If we say $17,000 a year per autistic student, that means the annual cost for educating 560,000 autistic kids would be more than $9 billion a year.
  

No exactly chump change, even in these outrageous times (hey, how about an autism bail-out?). So who should pay?

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What the School System Says:

We can't pay for this. We have a small lump of dollars to educate all of America's children. Every dollar spent on special education means one dollar less to educate typical children. We know that if they are to be helped at all, autistic children require intensive services (physical therapy, occupational therapy, speech therapy, applied behavioral analysis, to name a few). We simply can't afford it, or else we'll have to cut educational funding a lot for the vast majority of children.

Anyway, this is a medical problem, caused by a neurobiological problem. As such, it falls well within the purview of health insurance (just as mental health issues do).

Health insurance must pay the lion's share.

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What the Health Insurance Industry Says:

This is not a medical problem. The treatments are primarily educational, not medical. We pay for medically necessary care, not, for example, basic skills training. Sure, we'll pay for 60 days of physical/occupational therapy to rehabilitate an injured patient, but not daily therapy to educate a developmentally disabled child for 20 years. Additionally it's always unclear how much of these therapies are needed. Is 4 hours of speech therapy enough? Of course, more is better, but how much is enough? There is simply no good scientific evidence for the efficacy of almost all of the autism therapies. The treatment plan is therefore a decision best left to the child's teachers, who know him and his individualized needs.

The educational system must pay the lion's share.

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So, Who's Right?
First, it pains me that we even need to have this discussion. SOMEONE needs to pay for the intensive treatment. One clear measure of worth as a society is how we care for our most disadvantaged, needy citizens. And autistic children and their families are right up there. But who wants to pony up for the billions needed? Imagine how you would feel if you were the parent of an autistic child and couldn't provide the recommended therapies for your child because of the lack of money. That should never happen but - hello! - it does every day. It's shameful that we as a society still haven't (and likely won't) agree to provide the requisite services for these children and their families.

OK, so most agree that we need to pay for the therapy of autistic children and that it will cost a lot. Someone has to pay.

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Some states have entered the fray and passed laws mandating that health insurance companies foot much of the bill (see, for example, Pennsylvania which makes the insurance companies liable for up to $36,000 year in treatment expenses!).

One way or another, as the insurance and educational titans duke it out, you may asked to pay a share, either through increased health insurance rates or increased property taxes for schools. So again I ask:

Who should pay?

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Dr. P Weighs In:
I have to say (and to my own surprise), I am on the side of the health insurance companies on this one. I think autism is primary an educational, not a medical challenge. The wonderful autism teachers and therapists - not insurance companies - are in the best position to decide the nature and intensity of the interventions. They should be given the resources - through their own special educational systems - to provide those therapies without being in the terrible bind of robbing those dollars from much-needed services for typical and even gifted children.

The bad guy here is our woefully under-funded educational system and how we chose (or chose not to) fund it (property taxes - don't get me started). It's a non-system bound brother against brother, where if one wins, the other loses.

Frankly, I'm guessing that if there were adequate resources, the school systems would agree with me, as would most parents. Their current position of looking to health insurance is purely pragmatic and strategic - because that's where the money is and because, unlike the school system, health insurance companies can simply raise their rates and do not need to ask for a vote of the people to do so (which is usually rejected by disgruntled and older property owners).

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What About Now?
As this gets sorted out (if it ever will), parents of autistic children will remain in the untenable position of scrambling to get services paid for. Here are some questions to ask your health insurance as you advocate for your child's needs:

• What are the individual and family out-of-pocket deductibles before 100% reimbursement begins?


• How many visits per specialty (i.e. PT, OT, Speech) does the insurance allow per year for in-network and out-of-network providers mental health coverage?


• Most children with autism need physical, occupational, speech, psychological, feeding, social and behavioral (ABA) therapies. How well does your insurance company cover these therapies?


• What about coverage of supplies and equipment (e.g., augmentative communication devices.


• The squeaky wheel. If you feel you have the right to insurance coverage based on your policy, and you are running into problems getting that coverage, resubmit and even consider filing a grievance.
  

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It's so sad to me that we are even having this discussion and that part of my job is to help parents learn to game the insurance and educational systems to get their children the therapies they need and deserve. A she-bear advocate is, alas, what is usually needed.

Paying for this should be a no-brainer and not our current dysfunctional system where desperate parents are pitted against beleaguered, underfunded special education systems and recalcitrant health insurance companies. But here, alas, we are and, until such time this gets settled, likely to remain so.

Related Topics:

• Individualized Education Programs (IEPs) for Autism
• Autism Support Group Message Board

Is Your Baby's Bottle Safe?

DR. P UPDATE:
I wrote this only 4 months ago, but things are changing fast and, although I haven't really changed my position (that is, be a little paranoid), I thought a timely update was in order

Since May, 2008:

1. Many more manufacturers are promoting BPA-free bottles and containers, so they are much easier to find and lower in cost.


2. The good news: On 8/14/08 the FDA again came down on the side of the safety of the chemical BPA and concluded that, despite a paucity of good research, "an adequate margin of safety exists for BPA at current levels of exposure from food contact uses." Not to worry!


3. The bad news: A few weeks ago (9/08), the federal National Toxicology Program said it has "some concern for effects on the brain, behavior, and prostate gland in fetuses, infants, and children at current human exposures to BPA." Worry!


4. Two reputable federal agencies still duking it out in public! It's quite dramatic and unprecedented. But what is a parent or a doctor to believe and what should we do? Be confused! Be concerned!


5. Mindful of this controversy, the FDA is holding public hearings on 9/16/08, which I (and I hope you) will follow with interest.

Here's my original post, slightly updated, with my take on how to handle this quandary:

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It's a haunting image.

A beautiful infant gazes up at her mother with unblinking eyes, blissfully sucking on a bottle, absorbing both life-sustaining nutrition and her mother's love. Then, as in a bad horror movie, this idyllic scene takes a nasty turn and the bottle is unexpectedly shown to be evil, with poison seeping into the trusting baby's mouth.

By now you have read about the controversy about bisphenol-A (BPA), which is used to make plastic durable and shiny. BPA has been shown to be in the bodies of 90% of Americans and there is little doubt how it got there: trace amounts leach out of the polycarbonate plastic and into our milk and canned foods. But is BPA harmful?

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I've done my due diligence in researching this important question and can confidently report to you: the definitive returns are not yet in and it's just not clear and no one really knows.

On one side, in 2007 the FDA wrote it has "confidence that no safety concern exists for BPA in regulated food contact materials. Furthermore, the FDA has determined that the use of polycarbonate-based baby bottles and BPA-based epoxy coated cans used to hold infant formula is safe."

Others beg to differ, albeit with weak evidence and mostly on theoretical grounds. While everyone agrees that BPA has negative effects on laboratory animals, what isn't known is whether humans - especially very young humans - might be more (or less) susceptible to those effects. For that reason, the National Toxicology Program (part of the U.S. Department of Health and Human Services) recently disagreed with the FDA: "The possibility that bisphenol-A may alter human development cannot be dismissed."

And so - as often is the case - we are left to decide what to do with incomplete and conflicting evidence. Perhaps the small amounts of these compounds in our bodies will turn out to be harmless. Or perhaps not. Or perhaps we are focusing on the wrong chemicals, and it's really some new, as yet unrecognized, environmental exposure that will prove to be the real bad guy.

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Now that I've made you both paranoid and confused (my specialty), where do we go from here? The easy answer, of course, is to say: if the risks are unknown, why not just eliminate them altogether and protect our kids from even the remote possibility of harm?

I have to admit, I often subscribe to this view. But I also worry that hysteria about something that may prove to be non-toxic could lead to problems of its own (the all important "Law of Unintended Consequences"). Like what? Perhaps a spate of glass bottle injuries. Or the introduction of a new kind of super-duper material for baby bottles that, in 20 years, will be shown to be bad news.

Still, on this one it seems prudent to play it safe. After all, what is the downside of going green? So here's my advice:

• Avoid polycarbonate bottles containing BPA and phthalates by using glass bottles.


• When picking bottle liners or plastic containers, use polypropylene/polyethylene (#5 plastic which is opaque), not hard, shiny or tinted (#7) polycarbonate plastic.


• Look for "BPA-free" and "Phthalate-free" on cans and bottles. You'll be seeing this more now that consumers are demanding it.


• Avoid plastic/vinyl teethers for your infant to chew on.


• Avoid heating foods in plastic containers (which may increase the leaching of the BPA). Instead, use glass or ceramic containers.


• Wash all plastic containers with a sponge, by hand, with a mild dishwashing soap (not in the dishwasher and not with an abrasive sponge which scratches the plastic off).


• Learn how to read the "ingredients" of plastics. No-nos include abbreviations such DBP and DEP (phthalates sometimes found in shampoos and baby powders!), DEHP, DMP. DEHP. Look for #5 (polyethylene) and avoid #7 (polycarbonate) when you can


• Avoid using any plastic bottles with cracks or cloudiness.


• Choose foods packaged in cardboard "brick" cartons. When you can, eat fresh, locally-grown foods in season and save the canned foods for convenience or emergencies


• Can your own fruits and vegetables in safe glass jars.

Will this extra caution prove to be helpful?. Really, I have no idea. But, at this stage of the game, it seems a reasonable bet to make and, as we say in the trade, it wouldn't hurt.

Related Topics:

• FDA Eyes Bisphenol A Concerns
• Hot Liquid Ups BPA From Plastic Bottles

Technorati Tags: bisphenol A, BPA, polycarbonate, plastic bottles, baby bottles

Should We Lower the Drinking Age?

When I was a lad of 17, I went off to college from a state (Michigan) where the drinking age was 21 years, to a state (New York) where it was 18. (A national drinking age of 21 was not established until 1984.) One of my first official academic acts was to go to Theodore Zinck's, a local bar, and get totally drunk (for the first time) on sloe gin fizzes. All these years later, coming within 10 feet of this drink makes me nauseated by its cloying, sickly sweet aroma.

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I recently read of a new bid to lower the drinking age from 21 to 18 years. Lest you think this initiative came from some dizzy 18-year-olds, it is sponsored by 100 very sober college presidents. They contend that the higher drinking age actually increases binge drinking on campus.

I have to say, I was startled by their proposal which, at first blush, makes no sense. But because teen drinking is so worrisome and so important, and because these are smart thoughtful people, I decided to probe a little deeper, see how I felt about it and then, of course, report back to you.

Certainly, there is much common ground on this issue. Everyone agrees that binge drinking is an epidemic - often a lethal one - in our youths. Everyone agrees that anything that will cut down on mortality and morbidity and suffering due to drinking should be a national priority. Could lowering the drinking age help?

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The Problem
Be afraid. Be very afraid:

• 40% of college students report drinking in a way that would qualify them as having a symptom of alcohol dependence.


• 500,000 college students/year suffer some drinking-related injury.


• 1,700 college students die each year from drinking-related injuries.

In my experience, a major reason for these startling statistics is that teens don't just have a glass of wine or two. Instead, they head for oblivion in a hurry, guzzling so quickly they are drunk literally before they know it. Then it's a perfect storm of an astronomical blood alcohol level coupled with a pre-existing sense of invulnerability and bad judgment. The recipe for lethal accidents is complete.

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So Why Lower the Drinking Age?
Here are some of the arguments for lowering the drinking age:

• Adults over 18 years can vote, marry, sign contracts, serve on juries, and enlist in the military. How can we as a society then tell them they are not mature enough to have a beer?


• Some studies suggest that a higher drinking age barely reduces underage consumption. Worse, those under-aged youths who do drink are much more likely to do so behind closed doors and drink to excess in the short time they have access to alcohol.


• The higher drinking age gives alcohol the allure of "forbidden fruit" and serves as a badge of rebellion against adult authority.


• There were few differences in the incidence of drinking problems in colleges where the drinking age was 18 versus 21 years.

The bottom line is, according to the president of Johns Hopkins College: "Kids are going to drink whether it's legal or not. We'd at least be able to have a more open dialogue with students about drinking, as opposed to this sham where people don't want to talk about it because it's a violation of the law."

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The Other Side
Of course, many beg to differ - most notably Mothers Against Drunk Driving. They contend:

• After the National Minimum Purchase Age act of 1984, an estimated 1,000 lives were saved in 1987. From 1975 - 1996, the estimated number of lives saved reached nearly 17,000. (These numbers are hotly disputed and often attributed to reasons other than the higher drinking age).


• Raising the drinking age has decreased the number of DWI arrests, youth suicides, marijuana use, crime, and alcohol consumption by youth.


• The 1978 National Study of Adolescent Drinking Behavior found that 10-12th graders in states with lower drinking ages drank significantly more, were less likely to abstain from alcohol, and were drunk more often than students in states with a drinking age of 21.

(I'm really not doing justice to the either side here. For more details, see this collection of links presenting both sides of the argument from Santa Fe Community College.)

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So Who's Right?
To be honest, I don't know. I find the evidence confusing.

I don't have a dog in this fight. If lowering the drinking age will prevent alcohol-associated morbidity and mortality, sign me up. And if it increases same, I'm agin' it. Perhaps, the issue will be clearer over time as new studies emerge.

Since I'm ambivalent, my take is that the estimable college presidents have not made a persuasive case for lowering the drinking age. I'm open to their arguments, but remain unconvinced that, all told, fewer college kids and other youths will be harmed with a lower drinking age. And I worry that more will be.

So, for now, I vote no for lowering the drinking age to 18.

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Actually, Is the Drinking Age Besides the Point?
I suspect not much would change either way with a lower drinking age. Perhaps a more important cause of the problem is that (unlike sex ed) we don't try to educate our youths about responsible drinking at any age.

And that, moms and dads, I'm putting on you. Most parents put their heads in the sand and assume that their lovely teen is not drinking (dream on!) and ignore talking about it, lest it be interpreted that you are condoning their drinking.

What I do think would help is parent-driven education/counseling on responsible drinking. We could, for example, try to teach our boneheaded youths that, if abstinence fails (as it usually does):

• Never drink just for the sake of drinking, to appear cool or as a game or contest.


• Know when and how to say "when," even if your friends are not behaving responsibly.


• Don't drink on an empty stomach. Eat both before and while drinking.


• Drink slowly; know your limits and what it takes for you to be drunk. Don't aim to get drunk!
• Never, ever drive if you have been drinking. Never, ever allow yourself to be driven by a pal who has been drinking.

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Looking back, I wonder if I would still have gotten drunk quite so soon after my college arrival had the legal drinking age been 21 instead of 18. I have to say, I don't think it would have made a difference. I was going to achieve that rite of adulthood with my new pals, come what may.

In retrospect, I only wish I had gotten some counseling on how to handle this new temptation/responsibility (such as don't get drunk on sloe gin, go for single malt scotch) before that ill-fated night I went to Theodore Zinck's and headed for oblivion on the sloe gin express. Fortunately, I survived the experience. Alas, not all teens are so lucky.

Related Topics:

• Age-21 Drinking Laws Cut Traffic Deaths
• Teens' Drinking Habits Tough to Swallow

Technorati Tags: drinking age, teens, alcohol, college, binge drinking, health and wellness

Dr. P's 2008 Top 10 Back-To-School Tips

"BACK TO SCHOOL" - 3 words certain to fill your children's hearts with despair and yours with joy. As an annual rite of passage, it's a good time to take stock: How can you help your kids to make this school year academically productive, socially fulfilling, and safe as can be?

Here, in no particular order, are my top 10 suggestions. Feel free to share your own.

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1. Get organized! Plaster a monthly/yearly school calendar on the refrigerator to highlight upcoming events, deadlines, etc. Figure out and agree on morning routines: when to get up, bathroom rules and time, getting dressed, eating a decent breakfast, etc. in a "no nagging required / no whining allowed" environment.

2. Talk things over. Arrange a "planned discussion" with each of your kids to talk about academic goals for this year. Is there anything she is particularly anxious about? Be sure you include your expectations for performance - just make sure they are appropriate (if perhaps a tad high) and fair, linked to his/her talents and potential. If she's a brainiac, then good grades are reasonable to expect. If an average student, don't set the bar so high she is sure to fail. Remind her that what you really expect is for her to try hard and do her best, no matter what her final grades may be. Discuss expectations for completing homework. Construct positive (hopefully) self-fulfilling prophecies about the year. Reassure her that a lot of kids are anxious at the first day of school, but you know she'll handle this just fine, as she usually does. Remind her about the good things that happened last year.

3. Talk some more. What are his/her social goals? Is he looking to make new friends? How might he best accomplish that? What might be some of the social challenges this year? Ask about what's important for social status in school this year (it changes on a dime). What kind of clothes, shoes, backpacks, hair styles are in? It's important to give this some sort of adult perspective but - make no mistake - social status is very important to all of us and your kids are no exception. So don't belittle their feelings and desire to fit in, rather help them to achieve that within the values and aesthetics and monetary constraints of your family. Allow him/her to pick his/her own school supplies and clothes, but within an agreed-upon budget and your veto power in extreme circumstances (like too-sexy clothing). Click on the above image to read the very funny Onion parody of necessary school supplies.


4. Discuss and rehearse walking to school safety. Have your child walk (with or without adult supervision, depending on his age) to school if possible. It's great low-tech exercise and a wonderful time to socialize with friends in the great outdoors. Find a couple of reliable pals to walk with each day. Review pedestrian safety. Take a rehearsal walk or two, noting potential dangers along the way. Find a direct, safe route with the maximum crossing guard support. Be sure she always crosses at a crosswalk (or at least a corner). Be sure she understands to look for a green light and walk sign. Be sure she knows to stop at the curb, look left and then right and then left again (unless you're British), and listen while crossing all streets. Beware parked cars or other obstacles blocking vision of the street.

5. Go over appropriate response to strangers. Role play: What if a nice stranger came up to you and asked to help him to look for his poor, sad, missing dog? What if he offers you a ride on a rainy day? How about some candy, little girl? Does it matter what he or she looks like? You don't want to make your kids abduction-fearful, just stranger-wise.

6. If your child is taking a bus, the biggest danger is getting on and off. Go for a bus ride together and show him how to wait at the curb 10 giant steps away from the bus for the driver to stop, how to be in clear view of the driver at all times (don't walk behind the bus!), how to be very careful and make sure all oncoming cars have stopped and the driver has signaled it OK to cross. Be sure to pick a safe spot in the neighborhood for boarding and exiting the bus. Go over your expectations for conduct on the bus. Encourage him to feel safe to discuss any bad experiences on the bus (like bullying or teasing).


7. Don't overdo the weight in the backpack! Don't let your child tote more than 10-15% of his/her body weight in the backpack. Encourage him/her to wear both shoulder straps (to evenly distribute the weight) and to keep the straps tight, so the weight rests against the mid and lower back. Buy a lightweight (but of course, very cool-looking) backpack with padded shoulders, padded back and waist strap so that the bottom of the pack sits a few inches above the back of the waist. Teach your child to pack the heaviest items in the center. Encourage him/her to lighten the load in the school locker during the day. In a pinch, rolling backpacks are catching on (but are tough in the snow).

8. Go over potential bullying experiences with your child. Remind him this happens, but is mean and unacceptable and not to be encouraged. Tell him/her if it happens to talk, walk and squawk. TALK: tell the bully you don't like what s/he has done and that it isn't nice or fair, and WALK: Walk away. Bullies like victims who are passive and come back for more, and SQUAWK: Tell the teachers or parents. Bullies prefer kids who keep silent so they can go about their nasty business without consequences. As a parent, get the school involved in teaching about bullying.


9. Mention the unmentionable: toileting in school (if you don't who will?). For a surprising number of kids this is the most anxiety-provoking part of the school day. In great discomfort, they'll hold it all in rather than face what might await them in the bathroom. Remind them you expect them to ask to go in school whenever they need to go, and to tell the teacher or you if there are any problems in the bathroom. Role play what they might do if someone makes fun of them or offers a cigarette (or worse) in the bathroom.


10 . Whoops, can't think of a #10, so I'll resort to my usual:

Enjoy your kids! Enjoy the ride!
Some day soon you'll wonder how it all went by so fast and why you didn't appreciate it more as it was happening.

Related Topics:

• Back to School in a Wired World
• WebMD Video: Tips to Get Your Kids Out of Bed and Off to School

Technorati Tags: back to school, safety, pediatrics, health and wellness