Dr. Thompson's Blog

Recurrent Hip Dislocation in Childhood Neuromuscular Disorders

With the emphasis now on high tech medicine in medical school and residency training programs, teaching practical information seems to be almost a thing of the past.

I was recently contacted by a parent who was trying to find the best medical care for her child. The infant had been born with a neruomuscular disease and had multiple orthopedic problems. I knew the orthopedist who was following the child and was aware that he had been trained in the treatment of children with cerebral palsy, but seemed to have  little or no understanding of neuromuscular diseases. According to the baby's mother, the doctor was planning to operate on her child's hips to put them back in place. Unfortunately, that would most likely mean the hips would again come out of the hip sockets because of the weak muscles surrounding the hips.

I have seen several children with neuromuscular disorders who have had their dislocated hips operated on to no avail. The hips eventually come back out of the sockets, so the surgeries were useless. It is sad that a child and the child's parents have to go through an unnecessary painful procedure. Neither pediatricians, neurologists, or orthopedists in the U.S. are given much training in childhood neuromuscular disorders. Fortunately, there are still a few orthopedists who have had fine training in these disorders. Dr. James Drennan in New Mexico is the author of a book about the orthopedic treatment of neuromusuclar diseorders. He saw this child for me and advised against any hip surgery. I was greatly relieved, but was sad that so many other American kids would have unnecessary surgery because of the lack of their doctors' training in pediatric neuromuscular disorders.

Where Have the Good Pediatricians Gone?

In the past, pediatricians spent time with their parents and taught them both the art of parenting and the practical aspects of raising children. Now I am getting an increasing number of complaints from parents across the U.S. about their pediatricians. The primary complaint I hear is that the doctors, both men and women, seem to either know little practical pediatrics or they don't want to take the time to teach their parents what they know. I know that many medical school and residency programs for pediatricians are geared only to the care of ill children. I am constantly amazed at some of the things parents tell me or e-mail me that they are told by their pediatricians.

Yesterday I made a house call on a child whose mother had been one of my pedatric patients. The little boy  was to take a long airplane flight with his parents today and they wanted to be sure his ears were o.k. since he had had a recent ear infection.

After I checked the little boy's ears, I asked the mother about her second child who is greatly overweight. I inquired  what their pediatrician said about the weight and the mother said, "Well, really nothing." Then I asked about what the little ten-month old was eating. I found out that he was still getting a bottle in the middle of the night and that he had a problem eating solid food. The mother said the pediatrician had simply sent her to an occupational therapist to help with the feeding! I was appalled. The mother added  that the child seemed to have problems with anything other than liquid in his mouth. I told her that there are children with oral sensitivity and gave her several ideas about how to get him started on solids, how she could brush his teeh without a fight, and how to stop the middle of the night bottle. I suggested that she call or e-mail me with questions rather than going to the  O.T. As doctors  we can create very anxious parents and anxious children if we  don't start doing a better job.

Plastic Baby Bottles To Be Reexamined by F.D.A.

Parents seem to have more and more to worry about these days. Now the F.D.A. has decided that they need to look again at the studies concerning the addition of bisphenol-A to some plastic baby bottles. The substance can also be found in metal can linings, as well as plastic food containers.

Several researchers have been found that there is a possibility of an effect of this chemical on the brain, the heart, and the liver. Animal studies have also shown there may be a reason for concern. The largest manufacturer of reusuable baby bottles, under the brand name of Avent, has said they will not sell any more bottles containing the chemical, known as BPA, after December 31st. Unfortunately, there are still many bottles available in the stores. (New York Times 12/24/08).

Many parents are very careful about things such as foods their children ingest and will be careful about watching for these bottles. However, there are other parents who seem to have little concern about one of the greatest causes of danger which is childhood accidents.  I just saw a young mother with two small children on bicycles at a busy crossing. Neither child, nor the mother, had on helmets. If this mother had cared for post-accident chidlren as I have, she would have never gone out of the house without helmets, at least on the childrens' heads.  Sometimes parents focus on the little things and forget the really big things.

Medical Student Shortage and Residents Training

As our population grows, it is estimated that we will have a critical shortage of medical students unless enrollment in medical schools increases. Rebecca Voelkler in an article in the  Journal of the American Medical Association (12/17/08) notes that by 2020 if the present rate of medical school enrollment continues, that there will be a shortage of 85,000 to 96,000 physicians. Then there is the additional problem of the classes that contain fifty-percent women. If the women doctors don't chose to practice or just work part-time, as seems to be happening a lot these days, we will have an even worse shortage of physicians.

In addition to this possible shortage, there is another problem involving the training of physicians. There is growing concern that the long working hours presently required during the training period are the cause of many errors becasue of the young doctors' fatigue. Yet the residents today have a far easier time that many of us had in our internships and residencies. I worked every other night during my training period, which meant I worked  about 34 hours each shift. Often we could try and sleep at night, but were always on-call. Yes, we had to learn how to cope and most of us did.

Of great concern to me is that  hospital administrators are making very large salaries in many cases, but not paying their board-certified, in-hospital doctors well. Yet these doctors are expected to work very long hours. Anesthesiologists are critical in a hospital  and yet many work very long hours for little pay as compared to administrators, who may have only an MBA or RN degree.

Single Payer Health System Vs. National Health Service

I listened to an interesting talk last weekend given by a practicing family physician. He cleared up a lot of misconceptions about single payer health coverage. This is not health care where the doctors are employed by the government as in England and some other countries. Instead, hospitals, clinics, and doctors can negotiate their own fees. What a single payer system would do is decrease  large administrative costs, as well as the enormous profits of the insurance companies.

The doctor passed out a handout from Public Citizen which gave the following information: One point that was noted was that "As early as 1991, the Government Accounting Office concluded that if universal coverage and single payer features of the Canadian system had been applied in the United States that year, the total savings (then estimated at $66.9 billion) would have been more than enough to finance coverage for the millions of Americans currently uninsured."  Now that the cost of health care is so much more than it was then, think of the savings that could occur.  Big car companies say they have to add at least $1400 to the cost of each car becasue of the health insurance costs they have to pay for workers. Other businesses, too, would save enormous amounts of money on health insurance for employees.

The government would also have much more ability to control costs because the drug companies and insurance companies could not longer be able to gouge us. A board would oversee the insurers and programs like the Medicare Advantage program, which is so lucrative for insurance companies, could not longer charge extra rates. It sounds as though this is a program that should be carefully scrutinized by the new administration.

Possible Good Health Care Changes in 2009

With the tremendous loss of jobs that is occurring, people are also losing their health care insurance. We know that at at least forty-five million people have no health care already, but so far no statistics have come out about how much worse the problem has become.

Hopefully, with the appointment of former senator Tom Daschle to head the Health and Human Services Department and the White House Office of Health Reform, there will be some positive changes.  Mr. Daschle's appointment is probably greatly worrrying the CEO's of the insurance and drug companies. Hopefully, they will no longer be able to have free rein over how much they charge people for their insurance policies and drugs.

It has been reported that Mr. Daschle wants to establish a Federal Health Board. This board would make decisions about what drugs, treatments, and medical devices could be covered under insurance programs paid for by government funds. It is also reported that he wants to start a federal insurance program. I'm sure the heads of the insurance companies have great concerns about this and their lobbyists will be out in full force after January 20th. (New York Times 12/12/08).

Senator Max Baucus is also interested in health care changes and has suggested a "health insurance exchange" where people could compare and buy insurance policies. He, too, would be in favor of a public health insurance policy. Senator Baucus would also add  restricitions to what insurance companies could do in the way of denying coverage.  (New York Times-11/12/08). 

I sincerely hope that Congress will have enough resolve and backbone to not allow  lobbyists defeat these new programs.

Report on Complementary and Alternative Medicine

With the increasing lack of access to good doctors and the high cost of medical care, parents are turning more and more to non-traditional ways to try and keep their children healthy.  Even if good medical care is available, many parents and adults try alternative medical care that has no real hope of doing any good. I can remember the father of a patient with Duchenne dystrophy who was having his son treated with light therapy and magnets. Unfortunately, he was so sure this would cure the eight-year-old that he didn't do what would have made a difference, ie. stretching the contractures and keeping the boy as active as  possible with swimming or other exercise.

Another mother had her daughter taking twenty-two herbal medicines and vitamins that filled the teenager up so much that she started losing more and more weight. Once all these herbs and vitamins were stopped and the girl was given a good diet, she began to be much healthier and happier.

A report on alternative and complementary medicine in the AAP December News summarized how these are being used in children. It is interesting that thirty percent of healthy children and about fifty percent of children with chronic conditions are being treated with non-traditional medical practices. I  disagree with the statement in the report that this is not due to dissatisfaction with doctors, but is just because parents want to keep their children as healthy as possible. To some extent this is true, but a large percent of parents are so dissatisfied with their pediatricians and family doctors that they are trying other ways to keep their kids healthy.

I was remarking last week at a holiday party how wonderful my patients' parents  were when I was in private pediatric practice because they rarely called me in the middle of the night. The parents knew I would see their child immediatrely if they were concerned. A woman remarked  "There are no doctors you can call at night these days." I replied that if that was her experience she definity needed to change doctors. Many doctors do simply refer children to the ER and don't get out of bed. This is a very bad practice because ER doctors are not trained in the care of kids except for accidents and injuries.

Beware of Ayurvedic Medicines Available on Internet

With all the concern about the addition of melamine to milk and animal products in China, there is now a new area of concern. In the December American Academy of Pediatrics newsletter, there is a summary of an article by RB Saper from the JAMA. In the summary, it is noted that "twenty-one percent of Ayurvedic medicines purchased via the Internet contained detectable lead, mercury and/or arsenic, according to an analysis of 193 medicines made by 37 different manufactures."

Metal-containing products were found in 20.7 percent of products. Ninety-five percent were sold by U.S. Web sites. If children are given these medicines, they are at great risk. An adult can handle the metal-containing products much better, but children should  never, ever be given  medicines or products that have not be checked by the F.D.A. Hopefully, under the new administration there will be much stricter control of unregulated herbs and medicines. Otherwise, we will continue to have childrens' deaths from kidney failure and other organ damage due to some of these unlicensed products.

Preventable Hearing Loss in Kids

I was delighted to see the article by Jane Brody  in the 12/8/08 New York Times. She discusses how loud noise is robbing our kids of their hearing. I have never understood this addiction to very loud music. Many times I have walked out of a store where the music was  so loud that it gave me a headache. Ms. Brody in her article notes that hearing loss in increasing in our kids and The Children's Hearing Institute says "one-third of the loss is caused by noise".

i think parents and grandparents have to be increasingly vigilant about what children are hearing. The loud noise can be from toys, headphones, and the environment. I was at a writers' holiday party on Saturday where the music was so loud it was hard to hear what anyone was saying. I asked  one of the people in-charge if they could get the musicians to turn down the volume, but it didn't happen. I think people are reluctant to request that music be turned down, but perhaps if we all did it, it could make a difference. I suspect one of the reasons that many people talk so loudly in restaurants and airplanes is that they have some hearing loss. I always carry ear plugs in my purse when I fly, so I can read or sleep in peace.

Not only is loud music the cause of hearing  loss in our kids, but it is also due to the inadequate care of ear infections by pediatricians and family doctors. Many physicians simply prescribe antibiotics for a child's repeated ear infections, rather than doing a myringtotomy and draining out the pus. If they don't know how to do one, a child should be referred to an ear-nose-and throat doctor. Repeated ear infections can cause scarring of the ear drum  with subsequent  hearing loss.

Good and Bad Proposed Changes in Health Care

Recently with the advent of the new administration, there have been many articles and discussions about what needs to be changed in our current fragmented and totally inadequate health care system.

On the plus side is the announcement by the FDA that they are recruiting 130 new employees and plan to open offices in Europe, India, Latin America, and the Middle East. The plan is to inspect and get samples from more foods coming into the U.S.

Another positive change is that drug companies can no longer access patients' records to see what drugs specific doctors are prescribing. This should prevent the drug companies from marketing their most expensive drugs to these doctors, which of course they want to do. When I see Sally Field on TV advertising Boniva to prevent bone loss, I want to say to her "Do you know that a single pill costs almost $100?" The actress has always been one of my favorites and I'm sure she has no idea that Boniva costs so much for each pill.

On the negative side, one of the recent suggestions by a professor at MIT, Jonathan Gruber, is that all primary care be given, not by physicians, but by nurse practitioners, RN's, and physicians' assistants. This is frightening to me, particularly with children. Kids can become ill very quickly and since these non-physicians usually have little pediatric training, kids are going to get most inadequate medical care. There is a great deal more to taking care of children than just giving shots and writing prescriptions. Let's hope our country never starts offering this kind of third world medical care. Our kids will be in great danger if this happens. Of course, those with money will see doctors; only the children of tho parents who cannot afford a physician will pay the price.