Monday, December 17, 2012

Pediatricians and Guns

As one of the many people stunned and saddened by the horrible events in Newtown, I wanted to take a minute to discuss where the American Academy of Pediatrics stands on guns. I am deliberately not addressing more about the tragedy because there is so much that could be said, but this blog is where you visit for medical/finance posts.

AAP Statement on Firearm Related Injuries Affecting the Pediatric Population October 18, 2012. "The absence of guns from children’s homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. Adolescent suicide risk is strongly associated with firearm availability. Safe gun storage (guns unloaded and locked, ammunition locked separately) reduces children’s risk of injury. Physician counseling of parents about firearm safety appears to be effective, but firearm safety education programs directed at children are ineffective. The American Academy of Pediatrics continues to support a number of specific measures to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on semiautomatic assault weapons; and the strongest possible regulations of handguns for civilian use."

Essentially, your pediatrician will counsel you that firearms are dangerous and should be stored unloaded and the ammo stored elsewhere - both of which are locked. We're serious about this because 3,100 children a year will injure themselves with a firearm - 120 of those injuries will be fatal. This does not include the number of teenagers who will commit suicide with firearms -over 1500 per year as firearms are used in 90% of successful suicides. So that is 1600 kids per year who die in what is considered 'preventable' deaths.

I recognize there are many legitimate reasons to own a gun. One of my friends did her residency in a military town, and EVERYONE owned a gun. I'm not a pacifist; I have a healthy respect for firearms.  I have been to the gun range, I grew up taking riflery at camp, and my entire family in Israel are/were members of the IDF. However, my job is to counsel a parent on the dangers of owning a gun with children in the home, the same as I would a swimming pool, a trampoline, and a bicycle. (Unless I'm in Florida where the fight over the ridiculous law preventing doctors from asking about guns in the home is still being fought.)  Owning a firearm is neither good or bad, but if you own one, respect its power and store it properly.

The AAP has a good resource page about talking to your children about disasters. I am lucky that my children are too young to know what happened, but it won't always be that way. May all those affected be held in our thoughts and prayers.

Tuesday, November 27, 2012

Formula Fact Vs Fiction - Part 2

We're about a week out, and Child2 is doing great with his surgery. Now I have time to return to the questions that I regularly get asked about formula.

What about Soy?
Nutrionially speaking, soy formula is pretty much the equivalent milk based formulas. People used to switch to soy if their infant is spitting up alot or they were concerned about milk protein allergy - which can result in cranky babies with blood in their poop. An allergic baby is reacting to the milk proteins which can come from the formula or via breastmilk if mom eats dairy. If the child didn't have milk protein allergy while breastfeeding, she/he doesn't need soy. Also, milk protein allergy often is cross reactive with soy so you aren't helped at all by switching to soy. I have met some hardcore breastfeeders who cut dairy and soy of of their diet for months with the hope their child would outgrow the allergy. (which they often do)

What about medicinal use of soy formula?
Soy absolutely has a place for certain medical conditions like a rare disorder called galactosemia - can't digest galactose - or parents who have ethical concerns with using animal derived products. On the flip side, premature babies are NEVER fed standard soy formula because it can prevent absorption of calcium and phosphorous - giving a child ricketts!

Should I switch formulas because my newborn is lactose intolerant?
No. Your infant is NOT lactose intolerant. Infants cannot be lactose intolerant; all infants are born with enzymes to break down lactose because it is a main component of breastmilk. Lactose intolerance refers to the loss of that lactose breaking up enzyme which occurs at about about a year of age. Many Caucasian populations keep a much higher concentration of that enzyme after 1 year old. Other ethnic groups do not keep so much. Truthfully, most lactose intolerant people have enough of the enzymes remaining that they can eat small amounts of dairy. If this describes you, four pieces of extra-cheese pizza or an extra large Dairy Queen Blizzard are not good options without enzyme replacement (lactaid) - though one small piece or a small cone may be doable.

What about Gentle/Sensitive/Low iron?
Welcome to another marketing ploy. This plays on parents belief that their child is lactose intolerant and the gentle formulas are 'lactose free.' As already discussed, not really the issue. It may give a parent a sense of control that they are trading formulas, but their child's spitting up/irritability will probably improve with time and or technique. These formulas still contain milk protein so if the child has milk protein allergy it won't make a difference.

Most pediatricians will roll their eyes outside of the exam room and let people change formulas because if the parent perceives something relatively harmless to be true, it's not worth the battle. For example, refusing vaccines is very harmful and needs to have time spent on that issue. Changing from a nutritionally sound standard formula to a nutritionally sound 'senstive' formula is safe and fighting it is generally not a good use of time for the doctor.

Low iron formula is not marketed in the US because it is DANGEROUS! The best iron bioavailability (gut absorbing) food is human milk. Human milk has a fraction of the amount of iron in commercial formula, but it is absorbed so well iron supplementation is not necessary unless there is an additional health problem. Commercial formula's iron is not absorbed as well and must have more iron in it to let babies reach a safe level. If you have located low iron formula, it was manufactured in a foreign country, and you are facing a HUGE danger of feeding your child a questionable, potentially non-safety controlled substance that could easily lead your infant to becoming severely anemic.

What about Nutramigen/Alimentum/Elecare/Neocate?
These formulas fall into the 'elemental/amino acid' based formulas. Each of these is an expensive, semi-digested formula for infants with major health issues that cannot safely digest normal formula or breastmilk. They actually smell like they are partially digested and taste horrible too. The closer you get to elemental (Neocate) the nastier it tastes/smells. No one should be using these formulas without the blessing of their doctor. Some of the things that would make a physican consider these formulas include severe reflux, consistent weight loss, failure to thrive, genetic disorders, digestive surgery, and cancer treatments.

My baby was premature - what about him/her?
It's standard practice in the United States to give infants with normal digestive systems milk-based higher nutrient higher calorie formula. Normal formula/breast milk is 20 calories per ounce. Neosure/Enfasure 22 are 22 calorie formulas with a different protein/iron/fat ratio than standard formulas because premature infants have different needs for growth and weight gain. The powdered formula can also be added to pumped breastmilk to increase the calories content to 22 calories. Preterm infants generally stay on these formulas at least six months with some adjustments for weight gain and gestational age. Infants with severe digestive system problems/surgeries will be put on special specific formula diets with consultation of pediatric gastroenterology.

Long story short, it is totally fine to buy generic formula because it is almost identical to name brands. Your child only needs formula till one year of age and the various stages and additives are generally marketing ploys.

Tuesday, November 20, 2012

Saving health dollars with paperwork

Just to follow up on my bill paying section, I wanted to give a little advice about dealing with insurance companies since Child2 is about to have outpatient surgery this week. (That belly button thing I posted about a while ago)

1) Get a referral: If you go to your primary care physician (PCP) for anything and you anticipate the need to see a specialist, ask for a referral AND get a copy of it. So if you are visiting your PCP to get a blood pressure check and you were thinking about seeing a dermatologist for a skin check sometime, physical therapy for nagging back pain, or plastic surgeon for skin tag removal, etc - ASK FOR A REFERRAL. It costs the doctor nothing except a piece of paper. It's great if you have a specific physician in mind, but if not, just get it on a prescription pad and take it with you.

2) Touch base with your insurance company: patiently wait on the phone to talk to a human being and ask if they cover X service and what the copay will be. Ask if there are limits to how much they cover and if you will be charged separately for hospital, lab, and office charges. Mention that you have a referral, even if you don't officially need one. Be nice; we'll discuss that in a minute.

3) Confirm your appointment and referral: When you set up your appointment with a specialist, make sure they have your referral on file. If they don't, give them your PCP's office information and bring your copy of the referral to the appointment. Everyone's office is interested in getting paid.

4) Review your bill and your insurance statements: If you get approved for a specialist or procedure, you should receive notice that you can see specialist Z for X number of visits. When you get your bill from the physician/hospital/lab (or all 3 separate bills), make sure insurance covered your visit. If you need to, ask for an itemized bill. Then call your insurance company and discuss what they did and did not cover. BE NICE. They get yelled at all day by irate people. If you are nice, they will be willing to refile claims for you, resubmit them, contact the doctor's office, or take it up with their supervisor.

5) Record name, date, and activity: Get the name and number of every person you talk to. Write it directly on the bill, '11/20/12 Talked to Sherry in customer services, will forward info to her supervisor and hear back in 30 days. 777-664-9041' Insurance companies and doctors office employees know each other and can confirm that type of information. Insurance companies generally will have an electronic record of this type of correspondence and will look toward that date you tell them in followup. It will also keep them from turning your over to collections.

6) Keep your records together: Come up with some type of filing system that keeps your medical bills in once place. I personally have a file on top of my desk that I keep the current projects in. I put sticky notes that say 'pending' on the ones that are in process. I move them to our general file system the main portions once they are resolved and shred the ones that were minor correspondence or extra copies.

Now for my true story. I was able to save somewhere in the range of $700 for medical bills during my pregnancy by calling and talking to hospitals, insurance offices, and doctors offices. I was in a car accident and had to be seen in the ER. Since I was pregnant, once they all agreed I didn't have a broken neck, they sent me up to OB floor. I was later asked to pay for the copay for the ER and then 'out of network' OB office costs because that was how the hospital charged for OB services. I was able to successfully get my out of network fees waived because it was an emergency visit and I didn't get to 'select' which OB was on call.

Furthermore, I had some bleeding at the start of my pregnancy and was referred to the high risk specialists. I was also going to VBAC, so when everything was okay, the high risk specialists kept me on as a patient even though I was not high risk at that point. I was just receiving normal care from their office. My insurance company would usually pay $6,000 for my entire pregnancy care and I'd be responsible for $300 as a bulk payment. However, since I kept seeing the specialists, I was getting extra bills for $50 after every visit. It took a bunch of phone calls, but I got the office to re-code for almost all of the visits and I only paid an extra $25.

Keep in mind, there was alot of waiting on the phone to get all of this done over a period of weeks, but it was WAY cheaper than actually paying all of those bills.

Thursday, November 1, 2012

Better Bill Pay in 5 steps

We just had a bit of a financially harrowing incident over a bill which has led me to create "Better Bill Pay in 5 Steps" so it won't happen to you. Anyone can accomplish this with 1 or 2 hours of work.

1) Electronic bill pay: Examine all the bills you're paying via checks or mail. Can it be faxed? Can it be paid electronically? Can you place it on autopay, and your bank mails the check for free? Are your student loans on autopay? You should get a 0.25% interest rate discount if you place them on automatic electronic payment for government loans. 250K loans at 6.8% over 30 years with a monthly $1630 payment comes to a total savings $40,000 and 27 fewer months.

2) Personal bill pay: Are there any bills that you can pay in person? This is much more likely to be effective at a local organization like a church, synagogue, landlord, or small doctor/dentist office than a larger organization that has its billing off-site/out of state. Combine it with a grocery trip and stop buying stamps.

3) Confirm your address: Make sure that any correspondence that needs to reach you has an appropriate forwarding address available. Bizarrely, the post office charges to do address changes online so ask for the paper forms. Then fill them out for any address you have moved for the last 5 years. Mail forwarding only works for one year and then needs to be renewed.

4) Consolidate/phase out your email accounts: If you have moved jobs/graduated school, it is very possible that your email address is still receiving mail. I recommend getting a dignified name of some type on gmail and filtering all your email into that. Whatever you do; if an email is going to be shut down or essentially unused, set up the auto-email informing mailers of your new contact information.

5) Know how to access all of your accounts electronically and check them weekly: This way you will know if any strange chargers appear or if your scheduled electronic payment suddenly stops. Even better, be familiar with when your electronic payments are scheduled versus when you get paid to know when you can put aside extra money or make the extra payment.

Now onto our story. Our out-of-state condo is undergoing a re-finance that will remove that pesky first-time homebuyer residency requirement. Our renter pays into the local account and the mortgage and condo association dues came out of that account on autopayment. Unfortunately, the condo association moved to a new management company last year, but we were never informed because they sent that information to the condo itself (haven't lived there in 4 years) and HubbyJD's law school email account. The old management company forwarded our checks to the new company every once in a while, when they felt like it. Then they just stopped and the checks expired so the money was credited back to our account. HubbyJD finally checked that account and noticed the credits.

He immediately followed up on the electronic trail in his old email and found we about to have a lien placed on the condo we were trying to re-fi! I had also made an extra $1.8K loan payment THE DAY BEFORE. He contacted the mortgage companies lawyer and straightened things out - provided we pay everything immediately. Fortunately I knew exactly where we were in our monthly banking cycle to come up with an extra $1.5K that afternoon. Since I run the household finances, I immediately enacted steps 1-5.

Monday, October 22, 2012

Formula Facts Versus Fiction - Part 1

As you know, JaneMD loves Part 1 and 2's. So here comes another one on formula . . . particularly since some people have expressed some interest in more about newborn care/prices

Real conversation in the outpatient office:

Patient's Mom: My baby spit up alot since I changed to step 1 formula at 2 months. So we tried the sensitive formula; she was still gassy. I tried soy for a few weeks and she seemed better, but after she had a big spit up, I went out and bought some Alimentum now that she's five months.  She doesn't like it very much, but she's stopped spitting up. I know she's lactose intolerant.
Me: How many ounces were you feeding her at a time when she was 2 months old?
Patient's Mom: Eight
Me: How many ounces does she take now at a time?
Patient's Mom: Six or seven

This mom has fallen into a trap that I think of as 'The Great Formula Lie.' This mom had no idea she was taken in by advertising and false claims. She spent alot of money and time switching formulas for spitting up when if she had not overfed her two month old, took some precautions like sitting her baby upright after feeding, or asked her doctor, she very likely would have it avoided completely. 

So in this two parter, I will discuss major lies - I mean 'selling points' that marketing trying to use on you.

#1 - Stepwise formula:
Ah, Enfamil. Even though I was a solid breastfeeding mother for the first 7 months of life, you continued to send me formula samples. Your advertisements said things like 'I am not a baby, I am an infant.' All ridiculous lies. I appreciate that you sent me a sample of Newborn and Step 1 once a month, though because it was free.

I once set those Newborn and Step 1 cans next to each other and examined the ingrediates and nutrients. Essentially exactly identical. The ONLY difference was Newborn had 75 units of Vitamin D and Step 1 had 60 units per 5 ounces. That is all. The entire difference. Both claimed to have prebiotics, both claimed to have DHA and ARA. 

Well, Vitamin D must make a difference, right? Not really. Your child is recommended after the age of 3 months, if breastfeeding, to get 400 IU of Vitamin D daily. Step 1 formula would require drinking of 33 ounces and Newborn formula would require 27 ounces a day. The newborn formula claims to be used 0-3 months, and the step 1 is 0-12 months. Except you don't need vitamin D supplement until 3 months of age and then you don't really need the newborn formula, or you could buy all newborn formula since the difference is so small.

I grabbed Walmart formula and guess what - it is completely identical to Step 1 Enfamil! Everything is the same - including its claims for DHA, ARA, and prebiotics. This is because the US FDA controls what is in formula and it must meet a certain requirement so all formulas, Enfamil, Similac, any generic are nutritionally, for all intents and purposes, the SAME. In fact, there are no studies that show outcome (IQ, growth, and so forth) over any type of formula in a normal child. These claims are like stating that using a 'Graco' carseat over a 'Costco' carseat will make your child more likely to graduate college.

Enfamil also started sending us 'Enfagrow' stage 2 powder for kids older than 1 year old. However, there is no reason to be giving formula to a normal child after he/she turns 1. The label claims to be much better than whole milk - though hilariously the first ingredient is whole milk. If you are still feeding your child formula at a year, you are failing introducting new foods.  Your child should be taking up to 24 ounces of milk a day and all the rest of his/her nutrition should be from FOOD. Not formula! For much cheaper, feel free to feed your child whole milk and give them a chewable vitamin with iron once a day. Many kids can be picky eaters, and this is just to bolster any nutritient they may be missing.

#2 - Marketing through fear:
The label on the advertisement for Enfagrow reads "Enfagrow Preminum Toddler or Milk? **You decide**" (It really said that.)
Translation: You are failing your child if you do not buy this formula. Even better, they have a random well groomed woman in a white coat holding her glasses. I assume, since she is unlabeled, not wearing an ID, and testifying her love of Enfamil, she is a model portraying your friendly pediatrician. (Similac is has similar ads; I just happen have the advertisement on hand)

Look at the claims on a typical can of formula. You'll see they claim improved brain growth, size increase, and all sorts of other things. As I said, since formula is controlled through the FDA, all of the differences between the standard formulas are going to be minimal. You can't fail on any of them. We did all Walmart formula for the first child and are currently using Enfamil because I get it free as a hospital employee.

Don't be confused - there is nothing wrong with using formula. Not everyone wants or needs to breastfeed and that is OK. Just don't fall for the marketing that tries to convince you one is better than the other.

To be continued in Part 2 next week where I'll discuss various types of formula that are out there.

Saturday, October 6, 2012

Glorious resident lifestyle continued

It took a little longer than planned to get my post up because of the Jewish Holidays. The High Holidays were upon us and had all sorts of no computer rules. In order - Rosh Hashana: repent, eat big meals, Yom Kippor: repent, don't eat at all, and Sukkot: celebrate by eating all meals in a hut with no roof for a week - hence today's photo of 'hospital sukkah'.

Returning to the actual planned content of my post: In Glorious Resident Lifestyle part 1, I established that I worked hard and was paid badly as a resident. So what exactly did I do during my 30 hours of call?

My typical call day as a 1st year pediatric resident:
6am: arrive and get sign out about events that happened on my patients overnight.
6:30-8am: examine and talk to each patient. Update patient record (daily notes) on 3-10 patients depending on census
8am-9a: attend educational conference if possible, continue to write patient notes.
9a-12noon: round on all patients with whole team - 12 to 30 patients. Leave group to perform procedures - deliveries/lumbar punctures/cpr/central lines
12noon-1pm: educational lecture. take sign-out from person who was just awake 30 hours.
1pm - 5pm: complete patient work, perform procedures, admit new patients, sign out all other team members
5pm-6am: continue patient work for 12-30+ patients, perform procedures, admit new patients, 10pm nursing/patient check. Possibly sleep in call room if kids stable. Possibly sleep at desk outside of unstable kids room. Possibly sleep not at all.
6am: sign out other patients to rest of team.
6:30am-8am: see all patients, write all notes
8am: educational lecture, try to stay awake
9am-noon: round on patients again, try to finish all work to sign out by noon at 30 hour limit.
noon - 6pm: sleep
6pm: HubbyLawStudent arrives home. Based on business of call night and cleanliness of apartment,  may or may not have an arguement.
9-10pm: go to bed because it starts again at 6am

Staying awake for 30 hours was the worst and hardest part. I was usually pretty good until about hour 20-22, and then my productivity died horribly. Sure, I had a call room that I could possibly have slept, in theory. Winter is the worst because of RSV season leads to a huge number of hypoxic - not getting enough oxygen - infants. July is hard because the new interns need alot of attention and guidance. June is probably the least busy pediatric month, everyone has the most experience and kids are out of school avoiding germs.

That was as an intern. As a senior resident, you got to do 12 hour shifts instead of calls - except you would be scheduled for 13 shifts in a row with 12 hours off in between each one. With the new 60 hour work week, that averages out to 5 x 12 hour shifts per week. Nurses, btw, work 15 x 12 hour shifts over a full month which is like 3.5 per week. They would also get paid overtime or night-shift differential, which residents do not.

If you thought that sounded rough, imagine being a surgical resident. They have schedules like that for 5 or 6 years. You can pretty much cut out my lunch or rounding time and replace it with 'surgery' for hours on end. OB? Replace lunch or lecture with 'wait for babies to be born/c-sections' which they do for 4 years. Pediatrics, family medicine, ER, and internal medicine (among others) are considered pampered lightweights.

 This says nothing about what it was like emotionally to be a resident. You were exhausted, you were in charge of training the other interns and medical students. You had to achieve a certain number of procedures to graduate and pass various national exams. You had to deal with blood, puke, pee, poop, and pus. You were sometimes belittled or yelled at by attendings, nurses, other residents, fellows, and parents. Whole blogs are dedicated to how alone and powerless you often felt. It's not a suprise that arguing with my spouse got mentioned as part of my post call ritual.

As an attending hospitalist, I have a WAY better schedule. I work around 50 hours a week, with some call at a lower risk facility. I also get paid twice as much as a resident, which is still considered pretty low, even for a lower paid specialty like pediatrics. I could have added 20K to my starting salary if I had joined a group practice or wanted to work more.

(I'm lucky because pediatric subspecialists are generally overworked and understaffed because they take 3 more years to educate after residency. There are whole metropolitan areas where there is ONE pediatric geneticist for 2 million people. That means they are on call 365.25 days/year, can't take vacations because if a kid with adrenoleukodystrophy gets a stomach virus, they have to be available to manage the correct fluids and treatment.)

If you want a TV representation of what residency is like, I would recommend Scrubs as your look into our lives.

To end on a funny Scrubs-esque note, here are 10 Things that I actually heard during Sign-out.
Be warned - partially funny and partially cynical. Remember, these are from people who were awake for 30 hours.

1. That asthmatic patient, did you forget to tell me he was missing two limbs?
2. To the Jewish doctor - This Orthodox Jewish family has all these weird rules on Saturdays. Do I need a social work consult? (No)
3. We'll just say this family is pretty 'concrete.'
4. This patient weighs about three Kentucky Fried Units.  (450 pounds)
5. Her/his mom handed me a book on the vegan/gluten/dairy/sugar/preservative-free/all natural/organic diet she uses on her child.  We're treating him/her for malnutrition.
6. We had a Soap opera baby today. The woman didn't actually have a child but have been lying about it for three years and now theoretical father wanted to see imaginary child.
7. I could tell you all twenty meds the specialist put them on, but they haven't taken any for three years.
8. Child is fine; mom left to go use cocaine. CPS is waiting for her when she gets back.
9. This child was stabbed in the vagina by a rhino. Not a real rhino, a rhino statue at the museum.
10. Don't open the security bed, even if the delusional psychotic teenager seems better. He just beat the cr@p out of his mom, and it took 4 security guards to tackle him on his last escape attempt.

Sunday, September 16, 2012

Glorious resident lifestyle of the not rich or famous

You are sitting in the pediatric ER with your child that may or may not have appendicitis. First, you saw the medical student who talked to you for 30 minutes. Then you saw a tired looking pediatric resident who talked to you about the exact same thing for 15 minutes. Then you saw a much more awake pediatric ER attending physician who talked to you for five minutes, agreed to admit your child, and get a surgical consult. 30 minutes later, the surgery resident sleepwalks in, presses on your child's belly and mumbles that he's getting a CT of the abdomen with a blood draw, and wanders away.

D@mn, you've been here 3 hours and what the heck? Why did those residents look so tired and am I seriously expected to leave them in charge of my child?

Before discussing the actual resident lifestyle, let's lead with resident compensation. The federal government pays teaching hospitals $200,000 to train each resident per year. The resident is actually paid, pre tax, in the $40-50K range. Med students pay $40-50K for the privilege of training.

During my residency, I had an 80 hour work week and no call lasting more than 30 hours. New regulations recently moved the limit to a 60 hour work week, no first year call over 18 hours, and no later year calls more than 24 hours per the schedule. Some leeway is given for emergencies and unstable patients.

How did that translate into actual money and hours? Well, I made $40k my intern year. I worked 80 hours a week while on service, did not have any holidays off, got three weeks of call free vacation and one call free month. That averaged out to 70 hours a week for 49 weeks - 3430 hours a year. Taxes/insurance took about 20% of my salary, no 401K for such lowly peons. That led to $32K over 3420 hours - $9.35/hour. That is similar to a McDonald's manager, except a typical resident is 27 and already completed 4 years of college and 4 years of medical school.

Oh, I got two $5 coupons for hospital cafeteria food for each call night. An 80 hour work week required call every 4th night, which I got to do for 45 weeks of the year. 45weeks x 7 days/4 days is 79 calls x $10 = $790 in 'food' perks. Yes, just like the McDonald's manager.

How anyone can pay off their $150K+ in loans on a salary of $9.35/hr and $80/month in 'food' perks just boggles the mind. Does anyone have that much self control when working 80 hours a week? If you were wondering, the 60 hour work week essentially will remove call free months for everyone, so do the same calculation with 60 hours - $10.88/hr with less food perks.

So what was my personal resident financial lifestyle like? I lived across from the hospital, so I didn't ahve a car. I was supporting first 2, then 2.5, and then 3 people on my salary alone. (Remember HubbyJD was originally HubbyLawStudent?). I packed my own lunches and used my cafeteria cards to buy food that I took home. Keeping kosher, I was able to take milk, cereal, fruit, hot chocolate home with the plastic silverware in $5 increments every 4 days.

Stay tuned for more glorious residency lifestyle next week . . .

Monday, September 10, 2012

BJ's and I agreed to see other people

If you didn't know, BJ's offered their 3 month trial membership this summer. With my family of 4, I was not certain I would shop there often enough to make it worthwhile to buy a membership. I assumed that the 19 Kids and counting people used BJ's . . .

In my 3 month trial, I went to BJ's 4 times. The first two times I bought the objects I was scouting to see if I'd like them in bulk. On my 3rd visit, like a good scientist, I took my shopping list from Walmart to BJ's, recorded all the prices on similar brands, and then put it in a spreadsheet to compare my savings. I also examined which items and brands BJ's vs Walmart vs specialty grocery store carried. The last visit was the big purchase when I spent $350.

The good: I was able to buy challah (Jewish bread), kosher salami, and stuffed grape leaves for rock bottom prices I could not find anywhere else. I went a little wild and bought ALL of their two loaves of challah for $5 compared to my local grocery stores $7 per loaf. Similar issue with the salami - I bought all of it they had in stock and put 20 loaves of bread and 30 12oz salami in my fridge. I bought bulk plasticware, nuts, cups, and nice paper plates. I had enough storage space that I may not have to do that again for another year.

The so-so: I was able to find peanut butter $0.50 cheaper per container than Walmart. Not too exciting. I was underwhelmed by their bulk oreos, frozen vegetables, and Mrs. T's Pierogies. I found deodarant cheaper by $0.25 a container, if I didn't care about the brand. Morning Star Farms products cost almost exactly the same since Walmart started selling the 8 pack burgers.

The bad: CFLs were $0.60 more expensive per bulb than at Walmart! BJ's bulk diapers were more expensive than Walmart bulk diapers. Black beans, chick peas, and lima beans were $0.10 per can more expensive than Walmart-even though they come in six packs. Bagged sandwich bread was not cheaper than Walmart. Bulk fresh fruit - apples, oranges - were all cheaper at Walmart. Whole wheat nutrigrain waffles and egg beaters were the exact same price. Walmart brand protein bars were cheaper than the namebrand ones sold at BJs. They had very narrow brand selection and few whole-grain choices.

I also noticed how tempting it was to 'overbuy' things. Look, paper towels in bulk! I should buy those . . . except we use rags instead of paper towels and just wash them. There were tons of products I almost bought and then remembered that I did not miss the object before I saw it at BJs and it didn't have a place in my house. I think having so much on hand would tempt me to make larger meals and consume more items. For example, you make a tray of brownies for dessert on Monday (bought in the Duncan Hines brownie mix 4 pack) and have half left over - which you end up snacking on all week and put on some weight. Or you can use spend cut the recipe in half of the 5-minute Chocolate Mug Cake, even cheaper.

Quick, buy 30lbs of whole wheat flour . . . nevermind, don't need flour now that I froze all that bread . . .

Once I stocked up on my specialty kosher items, the difference in cost between what I regularly buy at Walmart and BJ's wasn't worth the temptation to overbuy. I am hoping that the next few months grocery bills will be lower because of this, but that remains to be seen. Should I ever need bulk purchasing of those items, I have some friends who shop there regularly and are happy to buy for me.

Tuesday, August 21, 2012

Buyer Beware parenting/health magazines

It's been busy with my little anklebiters, but I know I haven't done any frugual-health posts recently. While perusing various topics, one found me in the mail.

Cosmo 2 years for 15 dollars!  Health 2 years for 13 dollars! FREE GIFT! It was a DEAL. And FUN! And per Cosmo - SEX!.

It appeared that my subscription the Fitness is a great opportunity for Hearst to advertise the rest of its line to me. Considering how much the magazines cost as an impulse buy at the grocery store, I could just write a check and get a DEAL FUN SEXY GIFT. However, my better sense prevailed because of a few facts. First of all, I am no longer in Cosmo's target market. I'm married with kids - I don't need monthly advice on figuring out what his posture tells me about his commitment.

Health had a different challenge. I have read the magazine and it's heavy on the gimmicks, light on the actual science. Many people do not realize that the lay press vastly over reports on studies and likes to make wide sweeping statements from very little understanding of research. One study that made the news last year was on how many years apart having your children affected their autism risk showed a very small increase of risk if your children were under a year apart - except that they did not control for multiple factors. Every pediatric autism specialist and neurologist rolls their eyes each time they hear about it.

Here is how the laypress reported it along the lines of "Autism risk doubles for children less than a year apart." (I will go on at length in some future post about what their data reallys says - but if you are wondering if the risk of autism is 1% in each child, they found that under 12 months could possibly increase the odds to 3% - in California from 1992-2002 during the same time they widened who they accepted for autism)

This leads me to children's magazines like American Baby and Parenting. Not only do they report headlines like that, they also have articles titled like 'unlock your infant's genius level gifts/telepathy' They recommend expensive products as if they will give your child an advantage. They regularly report or distort things into pseudoscience. they'll quote a pediatrician and then a naturopathy 'expert' or personal trainer in the same article as they had some type of group consensus, when in actuallity most of it was taken out of context.

Hilariously, midway through a particularly painful reading with some ridiculous quote in American Baby from a physician, I was thinking to myself 'what kinda of yahoos do they interview for these things?' I turned to the next article and saw my own boss quoted.

Next, I turned the pages past the 'serious' story that quoted my boss, and the next three pages were about purchasing the best new family car/van. Not a single vehicle was priced under $20,000 and there were no suggestions for good used vehicles. Truthfully, the article implied that you were doing your child a disservice if you didn't buy this years model - even though there is VERY little difference between a 2010, 2011, and 2012 Honda Odysessy minivan.

Have no fear, the next article was about breastfeeding success and some of the objects you should be purchasing to maximize your success. First, Dr. Sears complained that women weren't practicing 'natural' breastfeeding and reaching his minimum goal of 1 year of breastfeeding. (The AAP itself recommends  4-6 months, the AAP counsel on Breastfeeding recommends 6-12 months if possible) He implied that if you really focused, you could be Super-mom and make it a year and everyone was just weakwilled wimps. (I shouldn't be surprised by the anti-vaccine star of 'The Doctors.') The following pages featured some fabulous objects aforementioned Super-moms should run out and buy to achieve 'natural breastfeeding' - a $150 nursing pillow, a $65 'modesty' breastfeeding cover, $30 per bottle BPA free, organic, 'doctor recommended' bottles.

HubbyJD found it hilarious that the next page of featured products had a sidebar column entitled 'How to save money when you welcome your new baby.'

So my best advice about magazines related to 'health' or child-rearing is to avoid them. The health and advice tends to be sensationalized and made into soundbites. Practice critical reading and thinking about what the various claims are recommending. Remember that the magazine is also interested in selling the 'featured' products, even on pages that aren't specificaly identified as ads. You don't need most of the products they are selling and lots of the advice is not helpful or well researched. Your pediatrician can probably recommend you to a few worthwhile books that should be more unbiased.**

Also public service announcement, Pertussis outbreak is ongoing over 16,000 cases in 2012 in the United States. Pertussis seems like a cold to an adult but can cause huge problems for infants and children - 20 babies in California died last year. Please get vaccinated, particularly adults who have contact with children. 

*** Disclaimer: I read this book in residency and am not one of the authors. They both have children and attempt to address common questions like bottles/pacifiers/poop/traveling on an airplane.

Tuesday, July 24, 2012

Reworking the budget

So I severely undershot the budget in a few ways. Before Child 2, I was making 5.1K and we were paying about 4.6K in expenses. I imagined I would have enough money to just add Child2's daycare to take up the rest of that $500-600 and then add $300-400 on in new rent. I sat down and recrunched all the numbers - which I had been too busy to do for a few months. It was scary.

Instead of our $5,400 I imagined, we were spending $6,400!

Salary $9,500/month - $6,400/month expenses = $3,100 - $1,600 minimum loan payment - $1,300 savings = $200.***

At that rate it would take us 16 years to pay off the loans. (20 years without the extra $200 a month in payments) It would also cost another $150,000 in interest.

*** I ignore our FSA reimbursements in these calculations because we weren't filing them regularly and two months we spent over $7,000.

Where did the budget go so wrong? Even though we spent less than $30 a month eating out, we were still spending $920 on tolietries and food. I even estimated a little down on this number since alot of the moving expenses were included in this. Also, the personal expenses included clothes, hair, car, and dog expenses. We spent at good $100-200 dollars/month on the dogs alone between end of life care and dog sitting. I splurged right before Child2's birth and got my hair colored -$150. We spent alot on 'onetime' wedding expenses $450, which some people would put as part of 'entertainment.' We ended up on some charity mailing list and ended up giving away $450 in charity a month.

So I did some more number crunching. Our income went down from $10K because of our FSA's. We should get about $500 back per month. The dog expenses are gone which will decrease our personal expenses. While we aren't buying more apartment equipment anytime soon, I know something would certainly always come up and plan accordingly. (Look, our microwave just burned out, $50 at Walmart!) I recognized I needed to set aside money for holiday and birthday presents for the year - that is $900 of our monthly new onetime expense budget of $300/month.

Here's how things look now.

Actual Monthly expenses
New Monthly Budget (JaneMD salary 4.9k )
Rent + gym + housecleaning $1188
Cellphone + internet $160
Car lease $190
Home/car insurance $125
Daycare $670-770
Utilities $160
Car Gas $150
Groceries/Toiletries $800-1000
Personal expenses $500
Charities/religious $400
Onetime expenses $300
Bank autosave feature $42
Total budgeted monthly expenses $4685
Actual spending $6405
New budget $5680

Our new budget decreased by $750 from actual expenses. Little things have changed. I got an employer discount on our internet. Our phones will be someday paid off, dropping that expense by $25. I watch our grocery bill like a hawk and move things into appropriate categories, like the microwave. We have an upcoming vacation to see our families, which is already budgeted for ($500), but I'll be coloring my hair with my mother (savings of $140). I also made our FSA reimbursements a major part of our budget, thus making sure they always get filed.

Salary $9,500/month + FSA $500/month - $5,650/month expenses = $4,350 - $1,600 minimum loan payment - $1,300 savings = $1450. 

At that rate it would take us under 8 years to pay off the loans and save $60,000 in interest.

A message from HubbyJD: I appreciate my wife, JaneMD, and all of her hard work at our budget and finances, especially since she does my accounting for free. I want to be financial independent and get all our loans paid off. I do draw the line at the beer austerity measures that she has recently enacted. Someone please tell her I can buy 2 twelve packs a month of Guinness.

Thursday, July 5, 2012

Stopping the hemorrhage

Okay, so JaneMD has been a bad blogger. She also has been a bad part of the FI community/anti-consumerism because it has been a rough few months.

As a start, Child2 will not be needing a big surgery and he's 4 months old. Child1 got referred to physical therapy for failure to walk and then learned how to walk a week later. We lost both of our dogs in the past months - one died, the other was returned to a rescue organization because it stopped getting along with Child1.

Things spun a little out of control with a move, second kid in daycare, and three out of state trips.

The good financials Feb-May: We got our full safety deposit back on our old apartment - $1000. We found out we were overcharged by the electric company for a year - $303. We had a delayed flight and got two free round trip tickets to be used at some point in the next 12-18 months. HubbyJD finally submitted our FSA forms and we got $2000 back pre tax. I opened a new FSA and will get around $100 a month back pretax. We examined out internet bill and got an employer discount by $7. We used our tax refund to pay off the last higher interest loan on graduate school - about $6000 on a 7.9% loan. We have now paid about 40k of our loans off in 10 months.

The bad financials Feb-May: The move, the new rent, the car, Passover, the trips, the visitors, doubled daycare, and the pets. Daycare doubled - $675 extra a month. We spent $1000 on end of life/dog sitting charges. We needed car repairs, $450. We had to pay 'personal property tax,' $350. Rent with utilities went up by around $600 for an apartment more than twice the size. Passover is one week a year and has special food that costs 2-3x normal. I cringe in shame because our grocery bill in April was $1500. We also had three weeks work of visitors since April to feed and included all of our  apartment expenses in that grocery bill.

The new apartment: we had to come up with a $1500 security deposit, and our rents overlapped by one week $350. The only thing we outsourced was the movers ($700), but I moved the kitchen the night before. We also had some friends help us pack and unload to make the movers as efficient as possible. Other friends volunteered to watch Child1 and Child2 for free during the move.

The bigger issues involved furbishing the apartment. I don't mean buying new stuff - I mean there weren't curtains or curtain rods in the apartment. Of that $1500 grocery bill, $200 on curtains for the entire house, $40 on carpets, and $250 for a full bed. My dad paid for his visit by installing and hanging 20 curtains. We also craigslisted a desk, an entertainment armoire, a bunkbed with 2 mattresses, a night stand, and a toybox for a total of $230. Some of that we paid in cash by selling off our own stuff on craigslist; we probably got $100. So total moving and housing expenses = $1420 (700 moving, 720 furnishings)

The trips: Hubby JD and Child1 flew to a wedding alone - ticket $300, hotel $180, taxi ride $88. Yes, a family member picked them up from the airport, but made no arrangements to get him back. Since he didn't have a car, he had to stay at the wedding hotel, and then pay a taxi to get him to the airport. Then we took a family trip while I was on maternity leave in a minivan $550 for 7 days and gas $200 in 30 hours of driving. Second wedding next month was $650 for tickets, hotel $80, rental care $30, and gas $30. Hilariously, the first wedding for two people cost $618, but four of us on a similar trip cost $790. We easily could have saved $100 if I'd just had him rent a car and picked a different hotel.

Want to know the damage after all of that? It was bad - an extra $6000 more than planned spent over those 4 months . I was able to account for $5000 in the above expenses. We got about $3000 in deposits/reimbursements, but that was still nowhere close to where we wanted to be.

I know trips and weddings will come up, but this was ridiculous to have it all happen at the same time. It was awful to watch our money bleed out like that. These were cousins' weddings who had flown to our wedding so it would have been an awful slight to not attend because 'JaneMD and HubbyJD couldn't afford it.' That would not have gone over well. Hubby JD also claims he is never moving again.

While I understand it's the 'one time/emergency' expenses that got us, but things like that will always come up. Time to review the budget and try to adjust to what we actually spend. And then evaluate where to cut things out.

Wednesday, May 2, 2012

Too poor on 100K?

Here is a follow-up to my last finance article - which I saw in March and wrote the post during my maternity leave.

Remember Mr. 350K? Here is Mrs. 100K and her complaints about feeling broke.

Why have I chosen to highlight this woman's post? Because their basic financial situation is very similar to what we use my salary for, except her household makes more money. I exclude HubbyJD's salary because it is essentially dedicated to loans, though it makes my tax bill higher.  She discusses being unable to afford things and feeling poor at 100K. She makes it sound like she's suffering greatly that she has to spend money on things she considers necessities. I just wanted to compare our situations to prove how she's not even close to understanding much about cutting her budget. For comparison purposes, I'll use my take-home pay of 5K and assume her take home is something like 5.5K, even though its probably higher

To summarize Mrs. 100K's situation: her household makes over 100K, has a mortgage in Florida, and pays the tuition of her two kids in community college. It appears they have no credit card debt and own at least one car fully paid off. They pay an extra $250 a month on their mortgage payment and contribute 10% to retirement. They are paying their son's $300/month new car loan so he can deliver pizzas. Yes, you read that correctly. Neither of their sons are taking out student loans and she does not mention any scholarships. She did say that her younger son couldn't find a job.
Housing: Her: $1222 + 250 a month. Me: new apartment $1485 per month. Both places are 1800 square feet. She is upset the housing bubble burst, but it doesn't appear that they have any plans of moving anytime soon and aren't behind on their payments. They are paying an extra $250 per month, even though they are not underwater. Do they understand that the extra payment doesn't lower their current payment, just shortens the end of their loan? It doesn't even put you ahead a payment in the event of job loss.

Utilities: Her: $350. Me: estimated $200. At my new apartment we will have to pay electric only, though $200 is high ball guess since we just moved. (I supposed in her neighborhood adding water, sewage, and trash would up it by $150.) I suspect $350 is very wasteful if its all electric, even in Florida. You don't have to run the air conditioner all the time.

Car expenses: Loan: Her $300. Me $190. Insurance Her: $350. Me $110. Gas expense Her: $500. Me $150.  I don't understand why she didn't buy her son a used car. No one expects the pizza delivery guy to have a snazzy car, even in nice neighborhoods. You can get a decent looking compact for much less if appearance is a concern. Since there isn't any other mention of other car payments, they should have at least another car for everyone else to use. They don't sound like they are car sharing or being creative at all about that. They obviously aren't driving the new Domino's electric car from my picture.

What are they doing that they spend $500 in gas? Commute to work? Letting her college-age sons drive the car? Do they contribute gas money either? How about their friends? She's paying their insurance. Her rate is actually relatively good for 4 drivers, 2 of which are college males. It's implied neither were stunning students or they would be in college elsewhere on scholarships. The sons don't seem to be buying into that responsibility either.

Food: Her: $1000. Me: $600. She is not just providing the 'basics' like she claims. They are going out to eat regularly and probably buying lots of convenience items. I say that because she says they are not 'eating at upscale restaurants or buying gourmet foods.' So she's not eating at the new trendy restaurant; its Applebee's and Chili's. It doesn't sound like she's working on cutting costs their either. No comments about making taking lunches to class or work.

Internet/cable/phone: Her: $175. Me: $35. That number she provides sounds like a standard package you can get from the her local provider. I'm sure they have cell phones, which she didn't include or she'd have commented on using all prepaid phones. It's likely they have a 4 person family plan. Do you need a landline? Do you need cable? Can you call your Internet provider and get a decreased amount of service? The students should be using the Internet for studying, not huge amounts of data like online MMRPG/Youtube that take up lots of bandwidth. Can't they use the Internet at school too?

Education/daycare: Her: $1250.  Me: $1250. Both of us spend about $15000 a year on education or daycare. She doesn't want her kids to take out loans, but it doesn't seem like she pushed them to pursue grants or scholarships. I assume the kids are living at home and I don't buy the younger son not getting a job. They live in Tampa; McDonald's is always hiring. Her older son could drop him off at McDonald's on the way to deliver pizzas in the new car.

Missing information: I don't know anything about her health insurance or how much they actually spend on clothing and household supplies that are not groceries. She also mentions that they bought 'stocks' for their son's college funds. When? How much? The stock market is recovering, but what kind or return can she expect on them in a few years?

I tacked her reported expenses at $5447 a month. Add in another $500 for cell phone and other purchases puts her around $6000. This is an extreme low-ball estimate since my budget is $1200 a month for charities, personal expenses, and onetime expenses.

This lady needs to start cutting back on some things. She can easily go out to eat a little less and drop $100 a month. Work in some energy conservation with the thermostat and save another $50 on utilities. Bundle driving together and get some money from the boys for their car use for another $100. Drop the landline, drop cable, and renegotiate your Internet and get $75. Send your youngest to work at McDonald's and get $100 a month. Make both your kids apply for some scholarship or grants. Even if you get $1000 per kid each year, that is about $160 each month.

Total savings with a little work: $585. She could easily double or triple that it if she put in more work, sells the new car, and stops the extra mortgage payment.

So, no, lady, you are not poor, but you are concerned with keeping up with the Jones's. Truthfully, you have things way better than the rest of the US without credit card debt and being ahead on your mortgage payments. You are even saving for retirement and paying for your kids college. (Whether or not covering your child's college is a good idea can be intensely debated elsewhere, go read The Millionaire Next Door.)

If you feel like also being annoyed with this, you can also read the MMM blog for a recent post or read the forum where they discussed this in the 'AntiMMM' section. Oh, and don't forget to congratulate NoMoreHarvardDebt for his recent escape from student loans. . . I may be a bit jealous.

Tuesday, April 17, 2012

I worry too . . .

You may have noticed that the blog posts are less frequent than before. That is for a few reasons. As you know, I had Child2, moved, went back to work, had Passover, and a delay in getting our Internet service back. We also had to let go of both of our dogs - one died and one finding a new home. Even more, we are also having health issues with Child1 and Child2.

So you thought pediatricians didn't go through this type of thing? We do. In some ways we have an even harder time because the burden of knowledge is so crushing.

Child1 is behind on his gross motor (not walking) and verbal skills (babbling, not talking). He's also the bottom of the growth curve. We are scheduled for an early intervention evaluation from the local infant services group. They'll come to our house to evaluate him and determine if he needs additional therapy. I sit around and wonder if I've failed him in some way that all three of these things are going wrong.

Did I fail to stimulate him enough? Did exposing him to 2 languages by visiting Israel and speaking Hebrew for the first few months of life mess up his verbal acquisition? Did I feed him too little from birth onward? (All of his food is now spiked with olive oil or carnation instant breakfast.) Should I get him sweat tested for cystic fibrosis? He coughs every once in a while - does he have occult pneumonia from cystic fibrosis or inhaled foreign body? Should I get him retested for lead - even though his level was fine at 12 months? Was our apartment too small?

Child2 has a patent urachus - a connection between his bladder and belly button that oozes fluid and pee out of his bellybutton. If left untreated, it could lead to multiple damaging UTIs and cancer. Correction is surgical. The radiologist told us it wasn't too severe so I should wait for my urology appointment to make any decisions as they are often observed. I stare at his bellybutton obsessively now looking for signs of infection.

Should I have gotten the ultrasound sooner? Should this have been caught on prenatal ultrasound? Did the time I mistakenly ate some chicken that I thought was hot ended up being cold contribute to this? Was thirty feet not far enough away from the portable x-ray machine they use in the hospital - even though radiation doesn't cause this? What will I do if he needs surgery? Should I have insisted on an immediate appointment? He's cried for 10 minutes - am I missing an infection?

Then I ask myself what I would tell a patient. "Child1 is above average in his fine motor skills and has great eye contact. Kids develop at different rates, so see if early intervention as an unbiased observer, thinks anything needs to be done. You have plenty of time to step in and someone is going to be the 3rd percentile. Child2 has a relatively common well known generally uncomplicated abnormality. It was even a regular question on board certification testing. You got your testing done by the head of pediatric radiology and he recommended observation with pediatric urology. You have an appointment with the best pediatric radiologist in 300 miles."

It's comforting to know, but as a parent you'll still worry, no matter what.

Thursday, April 5, 2012

Carseat Roulette - Part 1

Everyone has heard a word problem similar to this one.

Once upon a time a farmer went to market and purchased a fox, a goose, and a bag of beans. On his way home, the farmer came to the bank of a river and hired a boat. But in crossing the river by boat, the farmer could carry only himself and a single one of his purchases - the fox, the goose, or the bag of the beans.

If left alone, the fox would eat the goose, and the goose would eat the beans.

The farmer's challenge was to carry himself and his purchases to the far bank of the river, leaving each purchase intact. How did he do it?

Okay, we all know, take the goose across first, then go back and get the fox, return the goose to the first side, get the beans, and then go back and get the goose.

Here is a new modern version:

Congratulations, JaneMD has had her second child. Child1 is in a convertible carseat. Child2 is in an infant carseat. HubbyJD is 6 foot 2 inches tall. The American Academy of Pediatrics and the US department of transportation has recommended that children remain rear facing till 2 years old, thus increasing the size required by Child1's seat. The safest position is the middle seat. The LATCH system can allow use of the middle seat only or both side seats without the middle. Neither carseat can touch the driver or passenger seat. Both carseats need to hold the children at a 45 degree angle.

What arrangement of carseats will be possible in JaneMD's compact car so HubbyJD can get the children to daycare?

Keep in mind that I am a board certified pediatrician with a bachelors and an MD. I always buy new carseats and check to make sure they have appropriate oversight and are without recalls. I always READ the MANUAL.  The fire department and I are great friends since I have had them install my carseats personally 4 times in 3 months. (Hubby JD often moves them, my pregnancy and recovery did not allow me to do so).  If I'm struggling to get my seats in the safest position, one can only imagine how everyone else is doing it.

The biggest issue is undoubtedly the size of the convertible carseat. While rear facing, it forces any of the front seats to be pulled pretty far forward. When Child1 outgrew his infant seat, pre-Child2, we couldn't fit the convertible seat in the middle because it shoved the driver's seat into the steering wheel. It had to go behind the passenger seat. This was extremely uncomfortable for JaneMD while in her 3rd trimester and worse for HubbyJD at his height.

Adding Child2's carseat was difficult, even with fire department assistance. The massive convertible seat prevented installing the infant carseat in the middle. The convertible carseat used the LATCH anyway, so Child2's infant seat had to go behind the driver. Sadly, this still pulled the driver's seat too forward for a taller guy like HubbyJD.

You should get a minivan!

Funny you should suggest that. We actually just rented a 2012 Dodge Caravan with Stow-and-Go seating for a 1 week trip. (Our compact wasn't going to make it on any drive over 15 minutes with all of us) That should have solved all the problems, right?

Wrong. We installed the infant seat behind the driver and the convertible seat behind the passenger seat. Both front seats had plenty of space. One problem. The two carseats BLOCKED both side doors. I had to climb from the front passenger seat into the center aisle to get to the back seat to breastfeed. Let's not discuss the issues of changing diapers in the back of the rental car. HORRIBLE.

After the first half of the trip, we attempted to readdress the issue as we had made most of the reason for getting a spacious minivan useless. Next we stowed the seat behind the driver, installed the convertible behind the passenger seat, and installed the infant seat in the back.

Wrong again. The back seat isn't perfectly centered so you could not actually sit next to the infant seat. The convertible seat on the passenger side blocked access the the larger seating space on the back side.

So we rearranged again. The barely workable situation ended up like so. Infant seat with base in captain's chair behind drivers seat. Passenger side captain's seat stowed in floor. Convertible seat installed rear-facing in back middle seat. Jane MD able to sit on passenger side in way back and breastfeed while at rest-stops. This barely worked because HubbyJD could barely fit into the drivers seat as the infant seat prevented him from sliding the driver's seat back fully.

Tune in next week for Part 2 of carseat roulette. Next planned article - Poor on 100K?

Wednesday, March 21, 2012

A VBAC Story - Part 2

Continuing the discussion of the Vaginal Birth After Cesarean section. Now Part 2 . . . 
This is not my c-section; I actually searched vacuum delivery.

My VBAC story:

My induction took about 2.5 days, and it was very painful as the medications make labor when your body hasn't naturally arrived there. I had an epidural most of the time, which is generally necessary in case they need to quickly move into a c-section. They put extra monitors on my uterus and the baby's head. The same resident was always on the dayshift as I had 3 different attendings. She admitted me and broke my water 24 hours later which really started moving labor along.

By the morning of the third day, I was ready to deliver except Child2 had not fully descended. Also, Child2 was having 'variable decelerations' which is when the baby does not recover normally from each contraction. Early decels are normal, late decels are a danger sign the baby isn't getting enough blood, and variable decels are in the middle. They are often caused by the common issue of nuchal cord (cord around the baby's neck), but they can be harbingers of much worse problems. The OB team was getting concerned about how long my induction had lasted, the lack of descent, and the variable decelerations. They were seriously contemplating performing a c-section. In their eyes, it was a little like watching someone run into a brick wall over and over when they could just open the door. (If that metaphor was confusing, if my induction was not moving forward, I was going to need a c-section anyway. Rather than wait for things to get unstable, c-sectioning me while stable was much preferred.)

Fortunately for me, my second resident had my back and thought we could continue trying to push. She and my nurses told me I was a great pusher - I did ask her if she was telling the truth since I've been at many deliveries of women who are horrible pushers and get told the same thing. She assured me I was, but she really wanted me to get further along so she could convince her attending to hold off on the c-section. (Her attending knew we were pushing and was coming to see us last after the rest of the team finished rounding on the rest of the patients.)

At this point, my husband was a little freaked out, particularly when the resident said that we might have to vacuum deliver the baby since Child2's head looked like it might need a little aid. The attending came in and watched me push for a little bit and asked what I thought about a c-section or vacuum delivery. I said the equivalent of "I'm going to keep pushing until we get to late decels. I'm not scared of a nuchal cord or a vacuum." The attending was ready to discuss the risks and benefits of vacuum delivery until she remembered that I was the pediatrician who attended vacuum deliveries daily. I did ask that the pediatric delivery team come to my delivery just in case.

Now, if you've never been in labor, during contractions they have you push for a count of 10 three times per contraction. As they turned up the pitocin for stronger contractions, I was pushing for a count of 10 five or six times. Then suddenly they were breaking down the end of the bed and moving my legs into delivery position. I asked if they needed a vacuum still and they told me 'no.' Hubby JD wasn't sure he believed them and stood at the end of the bed. (OMG, I can see his head!!)

Three more pushes and Child2 was out. The resident unlooped the nuchal cord before cutting it - Hubby JD doesn't like blood much so he wasn't cutting it. Child2 was immediately handed off to the pediatric team who had to suction out his nose and mouth and give him a brief amount of oxygen. His apgars were 6 and 7 at 1 and 5 minutes and he was crying so I wasn't worried while the OB's sewed me up. At 10 minutes his apgar was up to 8 and he appeared stable enough to come to me, which was fine - and I reassure the team jokingly that I knew the signs of respiratory distress.

I was very happy with how things turned out; I recognized that my OB resident had a big part of that since she really fought for my VBAC. I even wrote her program director an email, highlighting how important the resident was to my delivery. (You should do that anytime you have particularly good service.) I jokingly told the attending that she could email all the doctors in her group with my result. One of the other OB residents, with whom I had trained, came by and told me she would have definitely c-sectioned me.

I wasn't upset that the OB team was close to doing a c-section. It's their job to assure the safety of the patient (me) and the passenger (Child2). Not everyone can or SHOULD do what I said or did. I am a medical professional who works significantly in labor and delivery. It is my particular area of expertise, and I would have been the first to ask for a c-section if anything more worrisome had occurred. I also had trained some of the OB residents in pediatrics or entered training with the senior OB residents. On the flip side, I would never have asked for a similar amount of leeway on getting my appendix taken out or my tonsils.

To speak briefly to the economics of VBAC versus c-section, a VBAC generally has a shorter recovery time because it has less limits on activity since it did not involve surgery. There are cases where it could be worse, like if the baby's head really tears up the vagina coming out - a 4th degree tear is pretty seriously painful. My hospital stay was not that different than a scheduled c-section. I was there 4 days, 2.5 for induction, 1.5 post delivery. A c-section generally is 48-72 hours post delivery. VBAC will probably cheaper from an insurance standpoint because it doesn't involve OR fees. My breast feeding wasn't significantly affected by either one, but I did have less time with lactation to confirm my milk coming in.

Hilariously, I spent my day prior to discharge peppering the OBs and nurses about vaginal delivery recovery. we'd spent so much time discussing the risk of c-section, we never discussed it would be like if my VBAC was successful.

Thanks for tuning in. After my next post, there may be a little delay since we are moving this week and I may have less time/possibly be without internet access.

Next post: Carseat Roulette - challenges of fitting 2 carseats into a tiny car!