family practice issues and general life events

Posts tagged ‘kids’

Parenting via Embarrassment

Over the past year, I have seen an increase in posts via Facebook, Twitter, and various websites advertising what a great parent this is.  Or look how I punished my kid.  My kid stole so I made him stand in front of a store with a sign, and then I posted it on Facebook, or the latest, the kid who was not grateful enough for a gift at church, had to sell the playstation under the tree and donate to underprivileged kids, and then parents posted on Facebook.  Parents that is not good parenting.  That is attention seeking, and it is your issue.  This is a terrible thing to do to your child.

While I agree that stealing is bad and there should be consequences, posting it online for further reinforcement is even worse.  Why?  Well as embarrassing as standing in front of a store admitting to a crime is, at least that goes away.  You take the picture and put it on both yours and your kid’s Facebook page (which you apparently were ok with them lying to have) is even worse.  These digital imprints should be thought of as forever.

Here is why.  I google every potential employee.  I check on Facebook what pics that they have that are public.  Anything you post online without privacy controls should be considered public domain.  Now when I look for people, I look at the pictures that they have public- is there an excessive amount of alcohol, are they acting inappropriate, are they saying anything I might not want associated with my organization, etc.  (I don’t ask for passwords, I am only obtaining what is publicly available.)  As a parent, guess what you have done, what could be considered as a juvenile infraction, well now it will follow your child forever.  

Your posting your child is ungrateful so we made him sell his xbox- well that is bad parenting all the way around.  Children learn how to accept presents and be grateful by example.  If they weren’t happy enough, well that is based on what you taught them up until that day, and while it should be addressed at the time, it should be done privately.  The selling of his other Christmas gift, probably was inadvisable, and not only didn’t teach the child a lesson, but was overkill.  And then posting it online of how good a parent you are- well that just shows you are attention seeking and needing approval.  It is not being a good parent, it has little to do with the kid at all, other than you chose to humiliate the child.  Kudos.  As if adolescence is not difficult enough.

As we gasp at the horrors that have taken place over the holiday season, maybe we should reflect on what is causing it.  Maybe it is the ever increasing need for attention.  Maybe it is reflected in the shows that are on television- where people are famous for little other than promiscuity and alcohol consumption.  Maybe the fact that the 24-hour news cycle thought it is appropriate to be there first instead of accurate, and continues to glorify those that commit crimes.  Maybe we should do the opposite.  Stop posting everything online, stop parenting by embarrassment, stop glorifying the “look at me” culture.  Your actions have consequences for your children, and farther reaching than you appear to realize.  While as parents you are going to embarrass your kids, do it by kissing them when dropping them off at school, or wearing horribly out of fashioned clothes, don’t do it by posting your lack of parenting skills online.

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The Obesity Epidemic

I don’t know if epidemic is the right word, since it is not an infectious disease, but the rate of growth that it is spreading (no pun intended) certainly mimics an epidemic. From “The Weight of a Nation” documentary recently shown on HBO 1 in 3 children that was born in the year 2000 will develop Type 2 diabetes” Those numbers may seem ridiculously large to the general population, but in my patient population in rural America, lower socio-economic population, it is hardly surprising, other than I might estimate it closer to 1 in 2. Scary, isn’t it? And I don’t think it is because I am a bad doctor, and I don’t think it is because of bad parenting (or at least not intentionally). It is a combination of a lack of education, loss of physical education, a loss of parks and ability to play outside, and the easy availability of fast food and other quick processed foods.

In my practice, I see all ages from 2 weeks to 94 (I think that is the age of my current oldest patient) And throughout the group there is a definite problem that spans the generation. Now am I going to focus on diet and nutrition with the 94 year old, probably less so, but on those that are younger it is very necessary. Today, I had a long talk (or three of them) with patients who told me that they didn’t know why they gained weight or didn’t lose this month. They aren’t eating anything. First of all, I am going to call you on that one. It is physically impossible to gain weight, if you don’t eat anything (I including drinking in the eating). Now once you become morbidly obese, your metabolism does slow down significantly, and it is more difficult to burn the calories that you do take in, but really you have to be honest with yourself about the intake.

Please stop saying that you eat a normal diet. You don’t. How can you? I don’t even know what a normal diet is anymore? The diets that get described to me when I finally get them to tell me what they are eating are far from my typical diet. A large slice of Cheese Pizza from Pizza Hut has 390 calories. (One slice) Multiple that by 8, and 3180 calories are found, which is more than anyone needs in a day, much less a meal. (And yes, I do have patients that eat that as their meal. Well, no, I don’t, it is a supreme pizza or pepperoni) And I am not saying that I never eat pizza, merely that it needs to be in moderation, it is not a terrible food, but really needs to be done in a portion size.

And a portion size can Fit in the palm of your hand. (Give or take) A serving size of meat is about the size of a deck of playing cards. I don’t care it you can eat the 72 ounce steak from the big Texan, that is 12 serving sizes of meat. Hardly healthy. I find that the type of meat you eat is less important than the size and method of preparation. Frying fish, takes out all the heart healthy benefits that are found in the Mediterranean diet. Those Omega 3’s are drowned in a sea of saturated fat.

If you go to the grocery store, a nutritionist that I know, told me shop the edges. All the unprocessed foods are on the edges, fruits, vegetables, milk, cheese, deli, etc. Even the frozen food section with the frozen fruit is often on the edge. You don’t need the mac and cheese, the canned meats, and the like. If it can’t go bad, it probably should not go into your body in any significant amount.

And at the very least keep track of the calories you are taking in. We are terrible as adults in estimating the amount of calories we consume. The journal of Clinical Nutrition estimates that we underestimate our calorie consumption by as much as one third. So if you think you are eating 1800 calories, it is very possible that your intake is closer to that of 2400 calories. Over time that adds up. We are not as bad as kids. Think about it, children who are not forced to clean their plates, tend to stop when they are no longer hungry. Those children tend to be leaner.

We have shut off our thirst mechanism, and instead believe it to be water. It takes 20 minutes for your body to realize that it is full. So if you eat slower and chew your food, you are bound to get up from the table eating less calories. However, during the day, that hunger pain you feel? Well if might not be a hunger pain at all, but your thirst mechanism. By the time you feel thirsty (dry mouth) you are already partially dehydrated. So I tell all my patients, make sure that you eat, in portion sizes, but if you feel hungry, take an 8 ounce glass of water and drink it, wait 30 minutes. If you are still hungry, then eat. This would cut down on quite a bit of intake.

I also see several people who say that they can’t eat until 10 pm, so that is why they retain their weight. Well, I am not quite as tied to the rule of no food after 7 pm for them. Why did this weight loss gem come about? Think about what the “typical” American does after 7 pm. They are tied, so they sit down and watch television. (For those of you whom this does not apply, well that is great) And what do you grab while in front of the television? Fruits and vegetables? Hardly- that is when the junk food comes out in the greatest quantity. Eating an apple at 9:02 pm is hardly going to ruin your diet, but eating a whole tin of Pringles and washing it down with a 20 ounce Mountain Dew, well that is not so good. There are legitimate reasons for not eating that late- reflux tends to be worse in those that eat within two hours of bedtime, and your activity level does decrease so their is some slowing of the metabolism, but seriously if you eat 1200 calories throughout the day, you will probably lose weight, regardless of whether you have your dinner at 10 pm or 5 pm.

And those sodas- just stop. They are empty calories and sugar. And the diet ones are less calories, but artificial sweeteners and both trigger your appetite and make it difficult to manage your portion size.

And for those of you in the South. That sweet tea, which is mostly sugar, well that is not helping either. It is not helping you hydrate, and there is little benefit from it. So other than occasionally, really don’t down it thinking that it is healthy.

And then the gorilla in the room, EXERCISE. At some point we as a nation stopped exercising. Our kids no longer get to play outside, Physical education programs are cut, and with the lack of exercise they see their parents doing, is it any wonder that our kids are growing larger? Type 2 Diabetes, a disease previously named Adult Onset diabetes is becoming more and more common in this group. And if they are not diabetic, they are insulin resistant so they are within 5 years of the diagnosis of diabetes. We have got to get our kids (and parents) moving. Kids learn more from watching their parents then from anything that they say. You can’t expect your kid to exercise, if you don’t get yourself moving. And it doesn’t have to be running. Walking is good, Bike riding, roller blading/skating, swimming or anything else that you find enjoyable. But get up and move.

I like to suggest a pedometer. They range in prices from around $5 to the $99 one from FitBit. I actually own the Fit Bit one, and while you might ask, “Why would anyone pay $99 for a pedometer?” I like mine because I can keep track of it online. Add to it the FitBit app for my iPhone, and I can keep track of my meals and my exercises, and they recently came out with a scale that will link with the site. Allowing for all of the sats in one place. It is nice, and convenient. But regardless, a pedometer is nice, because you can shoot for 10,000 steps a day. It is difficult not to lose weight if you take 10,000 steps in a day. And if you have that goal, you know where to shoot for. And that is something that everyone can do.

We all need to worry about obesity. Especially as it helps to escalate health care costs. There are great bariatric surgeries available but they are not without risk, and really wouldn’t you rather prevent the need for surgery and the complications of obesity for both you and your children?

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My data on the calories from a single slice of cheese pizza of 390 appears to differ from that posted on the Pizza Hut website of 360 calories. I should have gone to the website itself than using a different more general website.
As for the statement that diet sodas have less calories, it is true that they have no calories. I was more illustrating that drinking them over regular soda you eliminate the empty calories but recent studies are showing increase in the risk of heart attacks and may stimulate your appetite, and may cause you to gain weight in the long term. This is the result of a recent study from Harvard University

Obesity epidemic and school lunch standards

About 5 days ago, the USDA set guidelines for healthier school meals.  As a physician, I should get totally excited about that, but upon hearing the full story, I think my reaction is more of a what?  As the obesity epidemic reaches dramatic proportions, our children are not left out.  According to the American Academy of Children and Adolescent Psychiatry 16- 33% of children are obese.  This is a startling statistic but based on my patient population, I would estimate the number is closer to the 33% rather than the 16%.  But then again, I live in southeastern Oklahoma, and see a patient population of 45% Medicaid.  That is their primary insurance, it does not include those who qualify for Medicaid as a secondary insurance.  During medical school, I never imagined that I would be consulted by parents regarding their underweight child, only to determine he is the only one in the family that is on the growth chart and of a normal weight with respect to his height.  Or the number of children dragged in by their parents sure that their child has a thyroid problem, because it could not be that the only exercise the child gets is to get up off the couch to go to the bathroom between commercials, or that a large pizza is considered a serving size for them.  So I understand that obesity is a problem in our youth.  And I would applaud any efforts to help curb it, should those efforts actually make sense.

This is not an argument for whether I want to subsidize school lunches, food stamps or other government agencies.  These programs are in place, and for the moment, if we are to continue with them at least let their policies make sense.

Per the report found in Reuters  “The guidelines double the amounts of fruits and vegetables in school lunches and boost offerings of whole grain-rich foods. The new standards set maximums for calories and cut sodium and trans fat, a contributor to high cholesterol levels.”  And while I fully understand that, and the attempts to offer only fat-free or low-fat milk, and assure that proper portion sizes are given to children, I doubt that this is even possible to enforce much less implement.

My experience with cafeteria workers is that few if any realize what a proper serving size for an adult, much less a child.  I spend quite a bit counseling patients that serving sizes are roughly the size of their hand (since it is much easier to grasp and compare than carrying around a scale).  And currently, I have heard of schools allowing 2nd and 3rd servings to children.  With few exceptions there is not a child that ever needs a third tray of food.  (Those rare exceptions of underweight and active children this applies to the population that are not at that end of the spectrum)

Not to mention, the black market aspects that could foreseeable pop up.  Who is going to keep kids from bringing food from home?  I know it is being attempted in Chicago, but I remember sneaking brownies and gum into the classroom, where we weren’t allowed to eat as a child.  How are you going to determine if this is food from home, or from the cafeteria itself.

And the biggest reason that this will not work, the original proposal was blocked because potatoes were not initially allowed as a vegetable.  And pizza was also not allowed as a vegetable.  I like french fries and pizza as much as the next person, but let’s be real, health food they are not.  When the food manufacturers selling the food are allowed to dictate what constitutes health foods and what does not, there is a problem.  What child is going to pick an apple over french fries?  Will the school lunch still be able to meet the nutritional standards?  How precisely would those two be considered nutritional equivalents?

As a physician, I spend a lot of time talking to new diabetics and obese patients about their diets, and well pasta and potatoes appear to be the biggest contributors to the caloric intake.  It is what they learned from the USDA and their food pyramid.  The very same organization setting these standards.   The same organization which allowed the lobbyists to dictate the new standards.  And at what cost?

While I agree we have to start somewhere with educating the public and attempting to change the dietary habits of children before the suffer the health effects of obesity, including early onset Type 2 diabetes, hypertension, and high cholesterol, I don’t see this actually being effective.  Substituting whole wheat for white flour in pizza and spaghetti, while it looks like a wonderful idea on paper, may instead be thrown away in favor of other offering either by the school, or an entrepreneurial student.  And while I am in full support of the potential economic lesson this might lead to, it most likely will do little to help.  Nationwide standards have not helped to improve our education system, and without getting input from local officials and parents, I doubt that this will be much different.

Had change been truly desired in the school lunch program, input would have come from the parents, teachers, physicians, dietitians rather than the food industry who would have seen their potential profits cut.  The making of a pizza a vegetable merely because of its tomato paste (which is incorrect, since most use sauce which has a lesser concentration of tomatoes and tastes better) shows just what kind of answers we get from Washington.

When did my career become a secret?

A couple of days ago I noticed something. When people ask me where I work, I don’t usually introduce myself as a doctor.  It was one thing, when buying a car, that I would off-handedly say, “I work at the hospital.”  You are always told adding Dr to your name adds zeros to every purchase, buying a car, building a clinic, buying a house.  Anyway, in purchasing, you just don’t do it.

However, this time it was different.  I was eating dinner with my children at the Olive Garden, when the waiter asked what I did for a living.

I was wearing scrubs, so the question was initially, “So did you work all day.”

“Yes.”

“So what do you do?”

It was not the waiters fault, he was perfectly hospitable, taking care that our table had drinks and attention that anyone would appreciate.  We talked about the iPad 2, since I happened to have both children’s and mine with me.  And if I thought it would be a good deal to buy one, and if we liked ours.  All perfectly pleasant.  It was only when he came over during a discussion with my oldest, as to why I could not donate blood at his school’s blood drive the next day.  (Previous years, I have, but this year it was on a Wednesday, and most Wednesdays I barely have time for lunch much less time to drive 30 minutes to his school, donate blood, and return to work)  So I pulled up my schedule on the iPad, and showed him how full it was.  Still not overly impressed, he said, what about after work?  At that point, I promised him, if by some miracle of miracles, I were to finish by 4 pm, I would donate blood.  However, since I have yet to get out of the office by 530pm on a Wednesday in about 8 months, well it probably was not going to happen.  And this is when the above conversation happened.

I don’t know why I stuttered.  I am not really ashamed of what I do.  Obviously I would not be blogging about it online if I were.  But stutter I did, as I admitted that I was a physician.  Admitted, is this what the once noble profession I dreamed of being as a child came too?  Or maybe it was that I was caught off guard, since it was an early dinner due to having to leave work early in the afternoon to take my youngest to speech, and then kill time between therapy and a skate party.  And maybe that I was worried I would have to explain.

I spend a lot of my day explaining things.  Why I don’t take call, why I don’t go to the hospital regularly, why I have no desire to work in the ER, why I leave early on Tuesday and don’t see patients on Thursday.  And maybe that was the reason.  However, he did not ask for explanations, he actually was reassuring that my career was not equivalent to that of a drug dealer, even though some days, I think that is what I have become, at least in the eyes of some patients.

Maybe I spend too much time online, reading the terrible things people say about doctors, how they make too much money, they rush in and out of rooms too fast, they take too much time to get to their room, that they just don’t care.

I heard a joke once in training that the person who yells out first “Is there a doctor here?” is probably a physician themselves.  And sometimes, I wonder if that is true.  The days, weeks, months, years of fighting public perception as a money hungry individual willing to throw their patient under the bus for a dollar on one side, and the fighting for the dollars rightfully earned trying to provide the patient care that they deserve may have worn us down.  The time spent fighting against liability claims and fear of lawsuits despite no wrong doing, maybe those have worn us down as a profession.  The stories of physicians who have stopped to help someone on the side of the road and despite no wrong doing receiving a lawsuit for a bad outcome.  Maybe that is why we no longer stand up and say I am a doctor.  Or maybe, I just I don’t want to be chased through the grocery store to look at a mole.

And in my case, where my husband and I made the choice where he would take my call, so that one of us could be at home at night with our children, maybe I just didn’t want to explain one more time, why I don’t go to the hospital.  It is not that I can’t, it was that I put my kids before my career.  It is the years spent justifying why I don’t do shifts in the ER like my husband.  It is the time spent alone, at night, wondering if I made the right choice.  Did I do what was best for my patient?  Did I make a difference for the better?  Or what am I missing on that patient?

For the most part, I love my job.  I like that I am in most of my patients’ lives.  In many instances, after they get a recommendation from a specialist, they come back and ask me what I think they should do.  Or if they could have a second opinion, not necessarily that they disagree with the first, but that it is a major decision and they would like to have another perspective.  I don’t make as much in my clinic, as my husband makes doing his shifts in the ER.  I see the reports as to doctors not choosing primary care residencies, and I understand.  The money is not as good, and most of us graduate with a large amount of debt.  And you have to spend a large amount of time fighting, fighting insurance companies, fighting for payments, and watching the general population equate your training with that of a midlevel.  Even though you have twice as much training, 4 times as much debt, and way more liability.  And then at the end of the day, you notice the pile of paperwork- not visit notes, but other paperwork.  Prior authorizations, home health messages, home health certifications/re-certifications, various forms for patients regarding why they cannot work, disability questionnaires, and random notes that the patient wanted you to write for them yesterday.  Add to that orders that the specialist decides that they want done, but don’t want to obtain the prior authorization themselves, despite having the pertinent data needed to get the test approved, and yet they don’t send it to you.  So I understand why students are not choosing a career in primary care.

And maybe it is just a combination of all of those reasons that I don’t introduce myself as doctor out in public.  At maybe, just maybe that is why I stutter when asked what I do for a living.

Testing oneself

This morning, I am focusing on getting myself ready to test for my black belt in Tae Kwon Do.  It has been a long time coming.  Do I have to do it?  Well that is a loaded question- Yes and No.  No I don’t have to do it.  There is no one forcing me to do so.  If I don’t test, nothing bad will happen to me, I won’t lose my house, my family, my job.  But in some ways I do have to test

Here is why- and part of the reason it has been a long time coming.  I started Tae Kwon Do about 3 and a half years ago- give or take six months, sometimes things in my memory get mixed together regarding time.  Any way I moved normally from white to orange, yellow, camo, green, purple, blue, brown, red and red black recommend.  No big deal.  For me, my husband tore his ACL shortly before testing for red and red-black but that cannot be my excuse.  Well I decided not to test on my first chance, was it a mistake?  I don’t know, I didn’t know what the next 6 to 12 months lay ahead.  I just wanted a little more than two months to prepare, so I made the choice.

However, summer came along, things got busy with the kids, and finances got back at work.  In other words, life got in the way.  I had a son with a broken leg- who still tested, a husband limping around refusing to admit he did anything to his knee, and only after someone else made him an appointment did he finally see a surgeon.  Was told that he not only needed surgery, it should be sooner than later, so he chose about 3 months from then.  (Doctors are terrible patients, though in his defense schedules are made 3 months in advance, so there is that)  Ok, so with balancing life, I got busy.  Missed testing opportunity number 2.  And most of the six months between opportunity one and two.

So January comes, hubby has surgery.  So I have to take care of him, his patients, my patients, hospital, kids, … for about 2 weeks.  Then I am back to normal, my patients and kids.  Maybe valid excuses, but excuses, none the less.  And then there is an explosion on the business end.  (Not an actual explosion, but one of patients due to physician leaving town.)  So my thoughts of maybe this testing turn to …well, maybe not, maybe next time, I am just not ready yet.  May comes and goes.

Now we are 6 months later.  Life is still going.  Life will continue to go.  Work is good, though turned over an entire office, gave my first lecture at a national convention, two kids science fair projects, wiped the tears of my oldest when he missed breaking the board at the last test.  And up until last weekend, I was still on maybe and I will try.  However, Sunday night I realized that I have to test.  Time will continue to pass, and there will always be excuses.  And how can I expect my kids to put forth the effort and try, if I don’t get back in the game. And my oldest told me he believes in me and that it is only important that I do my best.

So today, I will go and give it my all.  Because if I don’t test, I am more afraid that I never will.  And that is what life is about testing oneself, improving oneself.  I just have to have faith that I know it, and give it all that I have got.  Wish me luck

Do we overmedicate?

I saw a child the other day, a patient.  He was brought in for routine medication, one he didn’t want and didn’t feel he needed.  His parents weren’t sure either but the school was demanding it.  This actually is not too terribly uncommon.

The diagnosis of ADHD has become so used and diagnosed, it makes me question whether all the diagnosis are valid.  I try to do the right thing, I make sure all my newly diagnosed patients are formally tested, but over the last 6 months to a year, I have found that all of the tests are coming back positive.  That makes me question, am I only sending those that I already know have ADHD, or is something else going on?  In fact, some that I sent more for developmental delay came back positive as ADHD.  This was not the case two years ago, and I was using the same people to do the test.

Is the problem becoming overly epidemic or all some of the tools becoming misused to put more children on stimulants so rather than having to engage the children in their work they are merely medicated so that their job is easier.  What if the decreased concentration has more to do with the children being bored because of lack of stimulation, than to do with true ADHD?  I can calm any child down with Ritalin/Adderall and other stimulants, but to what cost?  And now the American Psychiatric Association is discussing with their DSM -10 changing the lower age limit down to 4.  How many of you had a calm 4 year old?

I have grave concerns for this trend.  I thought it was improving briefly and there are definitely times when medication is needed to help the child succeed in school and life, and even some adults sometimes need it.  But are we trading in our children’s health and well being for well ordered classrooms?

One of parents greatest complaints is that sometimes their children seem like zombies on their medication.  That child is overmedicated, but when we decrease the dosage a little, there seems to be complaints from the school.  I don’t know about you, but I went into a local school about 2 years ago, and was horrified by what I saw.  In the time before classes began there were more children on the wall in time out than there were sitting at the tables in the cafeteria.  This was before classes had started. And I saw one teacher send another student that way for merely asking another student for a pencil.  So my question is, whether the ADHD epidemic is true, or is it manufactured from our one size fits all education system.  Are we forgetting that 5 year olds need to be stimulated?  Maybe we need to sit down and look a little closer at where the problem is coming from.

As for me, I am stuck between a rock and a hard place.  What do I do for that child?  Is medicine the best choice?  Maybe, maybe not.  But him getting kicked out of school definitely isn’t.  So I write the prescription, and we discuss things to help him function better in school, and I will see him again, in the next room, or tomorrow.  Unfortunately in some cases, I don’t have the answers, only the questions.

Busy days ahead…

Here it is the end of October- and I find myself, well not overwhelmed, but close.  Flu season has yet to begin, and yesterday, I saw 36 people.  Now some of it is caused by the fact that next week I am going to be in Orlando at the AOA convention for both CME and to give a speech.  A bit nerve racking really, that people would want to listen to something that I would have to say.  I am not a born speaker, and I have not discovered any great treatment for diabetes, hypertension or cancer.  Instead I just happened to with my husband receive the first electronic medical record incentive in the country.  Funny thing is that a year ago when we started the process to apply for the bonus, we didn’t actually believe that the Centers for Medicare and Medicaid services would actually follow through with their proposal.

So now next week, instead of seeing patients, I am speaking, obtaining CME hours, networking, connecting/reconnecting with friends and colleagues, going to Mickey’s Not So Scary Halloween, and who knows what else.  However, that talk remains in the back of my mind.  It has been there for about 5 months.  Since I first agreed to do it.  I have made two or three power point presentations, not happy with any of them- the basic knowledge is there, but I have a tremendous fear of being that boring monotone professor that no one wants to listen to.  That is probably why I can’t sleep, well tonight anyway.  But it is almost morning now- so I don’t plan on trying until after my day is done tonight.

It is funny how for the past several months, it has been there.  But it wasn’t until the first of this month that the talk hit me.  It was this month.  They want us to help to inspire other doctors, that the check is real.  And how we went about obtaining it.  Which I can tell, I was there.  I have the big check in my office to prove it.  But it seems funny all the same.  So the next two days at work will fly by.  Trying to get all of the routine appointments in before we leave town.  And then Saturday, the drive to DFW and the flight to Orlando.

Funny how public speaking can make some of us frightened out of our wits.  I am sure that they won’t tar and feather us- or at least I hope they won’t.  Though if they do- at least it is Halloween and I can pretend that it is my Halloween costume.  I could be a huge bird.  Sorry my attempt at bad humor.

It is however, important that I do this, mostly for my children.  So they can see the importance of presenting yourself calm and confident.  They need to see that despite fears, we can present a public appearance of knowledge and no how.  Maybe it will help them the following week at their science fair.  Maybe they will see everything that they can be, or what they can do if they have the desire to do so.  And maybe, I can give hope to other physicians who have no idea if they can even achieve what the government has decided is meaningful use.  Though I don’t know if they will all get a YouTube video of themselves produced by CMS

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