The Bad Guys in Healthcare Aren’t Who You Think They Are — Doctor Enough

I’m going to take a stand on something that really gets my blood boiling… health insurance companies. People want to blame physicians for bad outcomes (I’m looking at you NRA supporters that are claiming we, as physicians, need to fix our own lane first). They want to blame hospitals for long wait times, they want […]

via The Bad Guys in Healthcare Aren’t Who You Think They Are — Doctor Enough

Paid Maternity Leave

I had just written a response to a partner’s email regarding outpatient coverage and the focus of work-life balance.  I think it’s a great initiative that she is tackling while brainstorming what could help the group with flexibility as well as some normalcy while raising a family.
This made me think of changes to antiquated practices we currently have in our work environment… primarily, paid maternity leave as well as paid sick leave.  Many of my male colleagues can continue to work and can take as little or much leave as they would like for family bonding or vacation time to spend with their newborns.  This is their option.  Unfortunately, the women physicians in our group are not afforded that same luxury.  There is a 6 week medical leave of absence with a vaginal delivery or an 8 week leave of absence with a C/S as proposed by the OBs.  During this time, we are not paid.  State disability is a joke bc it’s not even enough to cover a mortgage payment.  Look at other large companies, there’s often paid leave or sick leave available to the employees.  Therefore, women who choose to have kids while working as a physician in our group are penalized, especially if they are the breadwinner.
Not only that, even while off on medical leave, we are required to pay into the trust and pay ridiculously high premiums to cover the wide age gap of partners in our practice.  I would be happy to look elsewhere for my medical coverage, but I simply cannot come off our medical insurance plan.
Therefore, I propose there be a fund set aside to create a pool or trust for persons creating families (just as we do for our more distinguished and elderly physician population with our health insurance plans and exorbitant premiums) who will have families and work in our group.
Here are some examples in the news of what is and has been in the pipelines….
Here are examples of companies getting it right:
Please consider updating some or all of the policies for paid maternity leave.  I am open to your thoughts and considerations.

 

Poll on Maternity Leave

What it’s like to be a female anesthesiologist…

Breastfeeding

I’ve heard that breastfeeding is tough.  The 1st month can be outright brutal.  Why does such a natural process give so many new mothers problems?  So, I’m researching and looking into this.

Exclusive pumping for a newborn

WHO: Optimal timing for exclusive breastfeeding

Exclusively pumping and nipple pain

Sample pumping schedules

FAQ: Medela Pump Advanced in Style

Medela: Cleaning and Sanitizing

Willow Pump

Important Links:

aap_guide_storing_fresh_breast_milk

I’ve been thinking lately (I’m 37 weeks, 6 days)… can I get a head start on breastfeeding to induce labor?

breastfed-baby


UPDATE: February 26, 2018 post-partum

Breastfeeding is hard.  The first week after Arden was born was a really rough one — lack of sleep, whole new routine/schedule, physical pain, soreness, learning new parenting skills, etc.  It took a while for my milk to come in… almost a week for me.  Once it did, it wasn’t much.  So my pediatrician recommended that we start supplementing with formula as Arden had lost 10% of her birth weight.  This made me so sad as I was committed and ready to exclusively breast feed.  But, my body was not ready.  So, I continued breastfeeding her every 3 hours (we set alarms to make sure I was on time) while also supplementing her with 2 oz. of Enfamil Premium Newborn.  I started going to a breastfeeding support group which is so wonderful because it connects mothers with other mothers and helps us all troubleshoot our breastfeeding challenges.  It’s interesting to hear other moms speak of their troubles because everyone seems to have different questions at various points in their baby’s life.  After doing a week of formula supplementation, I went back to the pediatrician and Arden not only met her birth weight but also gained some as well.  This made me feel better as a mom because she was getting the nutrition she needed despite my best efforts at breastfeeding.  But, I wasn’t giving up on the boob.  The more I searched the internet and asked at our breastfeeding support group, the more I learned and started brainstorming to see if I could get my body to produce more breastmilk.

Week 1:

Breastfeeding 10 minutes on each breast every 3 hours (starting from the initial feed, not at the end of the feed).  Nipples were extremely sore.  Arden had a great latch and would suckle vigorously.  I even considered a nipple shield for pain.  I used breastmilk and lanolin around the nipple after each feed.  This was the most painful week.

Week 2:

I started experimenting with pumping as there was one day where my nipples were too sore to allow Arden to breastfeed.  I still went every 3 hours on the breast pump (Medela In-Style Advanced). After 1 day of pumping, I revisited trying to breastfeed her and my nipples felt better.  I read somewhere that I should try and pump at the halfway point of my breastfeeding times.  So, I would pump 1.5 hours after I started breastfeeding.  This helped increase my milk supply.  I went from doing 0.5 oz per breast to 1oz per breast.  I think this more closely mimics a cluster feed and helps the body adapt to feed a hungry baby.  Halfway through week 2, Arden started doing 15 minutes at each breast.  I would often see milk in and around her mouth, so I know she was getting some breast milk.  The biggest trouble was getting her to stay awake at the breast.  Burping her and changing her diaper helped wake her up for the 2nd breast.  Towards the end of the week, Arden started only taking one breast at each feed.  She would pass out at the breast and even when we tried burping her and changing her diaper, she was satisfied enough that she did not want the second breast.  This was a new behavior and I’m not sure what to do.  So, I would pump the second breast…and then start her on that pumped breast at the next feed.

Helpful links:

Week 3:

The start of this week, Arden is feeding every 1.5 hours.  Is this a growth spurt?  She’s still getting 2oz (sometimes 3 oz) of supplemental formula.  This article from KellyMom was a wealth of info for me.

One of the days, Arden fed 12 times in a day.  My nipples were incredibly sore from the constant feeding.  I called three different local board certified lactation consultants to help — currently scheduling when that will be.

Also, I found out the Medela phone app has a video call to board certified LCs — I’m excited to try this out.  It’s for a fee (not hefty), but they’re available 24/7.

When the breastfeeding baby falls asleep before they’re full

Week 4: Dialing it in this week!

45 min – 1 hour
1) Undress Arden down to diaper to feed and feed every 3 hours or sooner if she cues.
2) Use Breastfriend pillow to get her to nipple height.  Turn her tummy to tummy.  Firm up nipple.  Touch top lip, wait for wide open mouth and bring her to you quickly. (RAM = rapid arm movement).
3) Stimulate breast (5 o’clock position) for squirt to wake her at breast.  Feed effectively for goal 15 minutes (ok 10-15 min) on one breast.
4) Burp her in front position.  Change her diaper.  Then offer second breast for 10-15 minutes (goal 15 minutes).
5) Handoff to help when available —> Supplement with previously pumped breast milk first, then formula to meet goal of 2.75oz (full feed goal).
6) Pump while help in supplementing her.  Do 15 minutes of pumping both breasts simultaneously directly after breastfeeding (or after supplementing if no help available).  Every 5 minutes: increase the suction as tolerated and hand massage both breasts simultaneously and lean over for another letdown.  Don’t need to hit the letdown button on Medela pump if just came off breastfeeding bc Arden already stimulated the letdown.
7) Save what is pumped from breasts for supplemental feed the next time at feeding.
8) Journal all feeds, supplement, wet diapers, stools, spit ups, behavior, etc.
Key Points:
  1. Feed baby
  2. Establish milk supply
    1. Double pump
      1. Never uncomfortable
      2. High suction
    2. Galactogogues
      1. Fenugreek: 3 capsules, 3x/day = 9 capsules/day
      2. Milk tea: 2-3x/day
      3. Oatmeal
      4. Multigrains
      5. Lactation cookies
  3. Breastfeeding going well
DOB: 2/11/2018 —> 7.3 lb
D/C: 2/13/2018 —> ?
1st Peds: 2/14/2018 —> 6.10 lb (10% drop)
2nd peds: 2/20/2018 —> 7.1 lb
LC help: 3/6/2018 —> 8.6 naked, 0.6 pampers diaper, 9.2 with fresh diaper
Both breasts for feed —> 0.7 oz
Goal full feed —> 2.75 oz per feed

Week 5

Things are going better with the combo breastfeeding, pumping, and supplementing.  Arden seemed like she had a growth spurt a couple of days ago that left her almost inconsolable and crying and fussy for most of the 2 days.  Her intake has gone up (and that’s self-guided by her).  The pump output has increased (but I’m still popping the galactogogue pills and cookies/drinks).  The tatas are sore, but not like week 1 or 2 sore.  I’m slowly becoming okay with the reality that she may be a formula baby.  But, I want to give her the best I can.  The other change that happened this week is that I rented a hospital grade breast pump for a month –> Medela Symphony.  I like it…. it is definitely bigger than my small portable Medela In Style Advanced and I think the Symphony has better suction capability.  Perhaps that is really helping to increase my supply and the other pills/cookies/drinks are just placebos!
More breastfeeding info:

Week 6

For the first time, my letdown has ejected milk from the other boob while Arden is feeding on the opposite boob.  I got the NatureBond Manual breast pump to place on the “free” boob while Arden is nursing and it collected 0.8 oz of liquid gold!  This is a new thing for me and I’m so stoked to be able to collect every single drop!

Looking back at what I have taken consistently to get to an increase in milk supply:

And we’re already thinking of traveling with Arden soon!!

EatingRichly: Traveling and Pumping

Week 7

I’m decreasing the pumping after breastfeeding to just 2-3x/day.  On days where I pump only and don’t breastfeed, I’m getting roughly 3oz total.  How do women create freezer stashes?  I don’t get it.  I’m poppin’ pills like a druggie, putting Arden to my breast at least 8x/day, pumping after feeds at least 2-3x/day (now I’ve spaced them out instead of pumping directly after a feed…I now pump about an hour after a feed — to resemble a cluster feed).  I could do a better job of hydrating.  I’m watching my nutrition.  I’ve started to workout.  Then when I look at the real facts… I had a prolactinoma… that was resected… and it may have affected my milk production from a hormone standpoint.  Even if all the working parts are there in my breasts, I have come to the realization that it’s ok if I’m not fully able to give my baby 100% of what she needs from nursing.  I’m happy if I’m still able to transfer at least some of my milk and antibodies and goodness to her…. as well as help her develop and gain weight with the addition of formula supplement.

Here’s what we started with:
Earth’s Best Organic Infant Powder Formula with Iron, Omega-3 DHA & Omega-6 ARA 23.2 Ounce (Packaging May Vary)

After what seemed like some gas and more pasty stools… we moved to this one and she’s really loved it and I think it’s helped with her gas.
Baby’s Only Organic LactoRelief with DHA & ARA Toddler Formula

Various things that she has preferred without issue of nipple confusion:
Comotomo – Baby Bottles – Baby Feeding – Green – 4 Pack – Two 5 Ounce Bottles and Two 8 Ounce Bottles

NUK Breeze 2 Piece Orthodontic Pacifier, Girl, 0-6 Months

Week 8

Things are going well. I’ve come to terms that I just don’t have enough milk. My letdown is fine. There’s fullness in the breasts if I go more than 5 hours for a feed. SO, I scheduled an appointment with an endocrinologist to follow up on my prolactinoma to see if that’s it. Either way, I’m enjoying breastfeeding with what I can supply and then having my husband or family pitch in to bottle feed. She just went through a growth spurt and was eating and fussing a ton.

Through all of my breastfeeding challenges, here are my thoughts/reviews on what has and hasn’t worked for me:

  • Medela Personal In-Style Advanced (PISA) — This is a great pump for me and it was covered by my insurance. When I got out of the hospital after delivery, this is what I used to help boost my milk supply. Granted, I was super sore the first two weeks, but I think that was because I was breastfeeding and then pumping right after. Plus, I don’t think it’s that uncommon to have sore nipples when first learning to breast feed and/or pump.Medela Pump in Style Advanced Breast Pump with On the Go Tote
  • Medela Symphony — I would highly recommend using this pump first for the first month bc it has such a gentle cycle of letdown/expression. Rent one from the hospital if they have availability. I think it’s a tad gentler and smoother than the Medela PISA.
  • Spectra S1 — I heard a lot about these pumps, but don’t have any experience. I would potentially try and get insurance coverage with this if we have another kiddo. There were so many rave reviews from people.Spectra Baby USA – S1 Plus Premier Rechargeable Electric Breast Pump, Double/Single, Hospital Grade
  • Lansinoh Smartpump — I purchased this as a second pump so I could use it in the morning as I’m getting ready for work. I have to get up pretty early for work 5:30a or 6:00a so this allows pumping as well as makeup/getting dressed. I like that it has different suction/expression tempos in addition to the intensities. Plus, there’s a Bluetooth tracker that counts your pump time when you turn on/off the pump (I always forget to hit STOP on my phone to end a pump session). Lansinoh did such a great job with a complete package: 2 sets different size flanges, 4 bottles, 2 nipples, pumping bag samples, carrying bag, instructions, etc. And it’s a super small footprint! Lansinoh Smartpump Double Electric Breast Pump, Connects to Lansinoh Baby App via Bluetooth, Breast Pump Bra Compatible, Hygienic Closed System, Adjustable Suction & Pumping Levels for Mom’s Comfort
  • Nenesupply flanges — I purchased several of these for my Medela PISA bc I wasn’t sure if I would be able to wash my parts between pumps. Turns out, I learned you can just use one set and refrigerate between pumps so you don’t have to wash bt sessions. Wish I knew that before! Nenesupply Pump Parts for Medela Pump In Style Breastpump PISA 2 Large 24mm Breastshield 4 Valve 8 Membrane 2 Tubing Not Original Medela Pump Parts Not Original Medela Breastshield
  • Maymom flanges — same reason I got these flanges. Both manufacturers work nicely and you can’t go wrong. What I don’t like as much about the Medela fitting flanges is the little suction piece with that fragile plastic flap. It’s a pain in the ass to clean and find.
  • Philips Avent manual breast pump — I purchased this in the event I was stuck in a long case and couldn’t get relief to go pump. Perhaps I’m not as comfortable with it as my double electric pumps, but I don’t feel that it empties me out as much as the electric pumps. I’m sure hand tiredness attributes to that as I can go 20minutes on an electric pump no problem….but after 10 minutes on one breast, my hand gets tired. But, I do think it’s a very comfortable manual pump to be used in a pinch or bind.Maymom Breast Pump Kit for Medela Pumps; 2 Large One-piece 27mm breastshields, 4 Valves, 6 Membranes, 2 Pump-in-Style Tubing; Simple Wishes Bra Compatible; Medela QuickClean, Micro Steam Bag Safe
  • Willow Pump — I had such high hopes for this pump. I wanted it to work to not be tethered to a pump with cords and such. However, when I tried this pump, it hurt. It was heavy in my bra and I felt like it pulled my breasts down. The suction is HIGH even at the lowest setting — even my more seasoned/withered nipples couldn’t weather the pull of the Willow. I’m going to give it another go as I used the 24mm flange that comes with it… and I ordered the 27mm ones and haven’t tried those yet. For reference, I started with the 24mm flanges on Medela…. then moved to a 27mm which I think is more comfortable.
  • Pumping pal flanges — a bunch of reviews raved about these flanges. I wish they worked better for me. No difference that I could tell in output of milk or comfort on the breast. Pumpin’ Pal Breast Pump Flanges (Set Regular, S,M,L pairs)
  • Medela breast milk freezer pack bottles– these are great to pump into. Plus, since I don’t have enough of a stash to freeze, it’s great to put these bottles directly into the fridge. I use the standard Dr. Brown nipples or generic nipples on these for a feed.Breast Milk Freezer Pack, 2.7 oz (80ml) Bottles (Pack of 12)
  • Freemie Collection Cups — these cups are the most amazing thing! It’s like the portability of the Willow pump (minus long tubing) with the lightweight profile of the flanges. I love these so much! Plus, I don’t have to mess with the trouble of a hands-free pumping bra (the holes on the bra rub my nipples and makes me wince a bit with pain). If I were to do it all over again, I’d order two sets of these and say “to hell with the flanges.”Freemie Collection Cups The Only Hands Free and Concealable Breast Pump Milk Collection System, Clear, 25/28 mm Funnels
  • NatureBond Silicone Manual Breast pump — this is a great asset to catch the milk letdown from the opposite breast that you’re nursing. You’ll be amazed at how much collects in this device.

If I were to do it all over again I’d get:

  1. Medela Symphony rental for the first month or two after leaving the hospital.
  2. I like both my Medela PISA as well as my Lansinoh. Both are highly portable and perfect for returning to work. KEEP IN MIND that the Freemie collection cups work with the PISA and not the Lansinoh (as of this writing on April 10, 2018). For a second go, I would get the Spectra S1 just to try it bc I hear the suction is so gentle.
  3. Freemie Collection Cups — I’d get two sets.
  4. Medela breast milk freezer pack bottles
  5. NatureBond Silicone Manual Breast pump

Week 18

I’ve been back at work for a month.  Breastfeeding/pumping has been a challenge.   My job is a bit difficult in terms of getting a set schedule to breastpump at work.  See my schedule below for what I’ve been trying to do:

6:00a breast pump

Try and get a 1-2 pump sessions at work when possible

6:00p breast feed

9:00p breast pump

I can definitely see my supply going down, but I’m trying my best with what I can.  Arden has been thriving on what I’ve been able to give her supplemented with formula (see 4 month update here).

 

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The healthcare debate

Here it is.  I didn’t want to opine, but it’s here and I can’t get away from the topic.  I see it at work.  I watch it at home.  It comes up in discussions…  so in order to make it stop, I’m going to give you an idea of what I see and what I think about Obamacare and whatever else is out there.

April 2015

Public Integrity: Insurers backed Obamacare, then undermined it.  Now they’re profiting from it.

February 2016

Talking Points Memo: The real reason insurance companies are complaining about Obamacare

August 2016

CNN: Will Obamacare survive as insurers pull out?

October 2016

Salon: Making a killing under Obamacare: The ACA get blamed for rising premiums, while insurance companies are reaping massive profits

November 2016

Portland Press Herald: Maine Voices — The problem isn’t Obamacare; it’s the insurance companies

December 2016

NYT: Health insurers list demands if affordable care act is killed

The Huffington Post: The Obamacare paradox — The real reason health insurance companies don’t like the ACA

January 2017

Market Watch: I’m a former health insurance CEO and this is what Obamacare repeal will do.

Great Z’s: Liberals are out of touch

March 2017

LA Times: Here’s the secret payoff to health insurance CEOs buried in the GOP Obamacare repeal bill

Common Dreams: Why big insurance adores the American Healthcare Act

What I see:

When Obamacare was initiated, I recall seeing a patient who had broken her foot while hiking locally.  She had a surgeon who was covered under Obamacare, as well as an anesthesiologist.  However, the hospital chose not to accept Obamacare and she had to pay out of pocket for her overnight stay.

It seems that we’re seeing more and more insurance companies pulling out of the system because it doesn’t seem to be profitable for them.  Insurance companies are a business; they’re not looking after the wellbeing of the patient.  Physicians, nurses, caretakers, the care team look after the wellbeing of the patient.

How many people do you know are satisfied with their insurance coverage?

I’m covered by Anthem on a PPO plan with about 240 physicians.  My insurance rate is lousy for the coverage I receive — a high deductible plan.  I’m young and healthy and take responsibility for my health — why am I paying $620/mo for barely there medical coverage as a physician?  Well, the answer is that our company makeup is a majority of older partners who skew the coverage toward a higher premium — basically a mini-Obamacare environment.  I’m subsidizing their health coverage… and someday, hopefully I will still be healthy bc I’m responsible for my health (keypoint right there folks) and doing everything I can now to give my body the best fighting chance to survive into “old” age.

My question: 

Anyone think to make insurance companies accountable with transparency re: ACA?  Start there.  Does anyone else think it’s odd that the people who are helping shape the bill don’t actually participate in the care/exchanges like the public?  All the while, government and insurance companies dictate coverage and force physicians into tougher situations to deliver care.  Is this what you (the public) want?  When was the last time you saw the fine print of the bills being passed?  Don’t just follow the masses, look for the details and truth for yourself.

</off soapbox>

What government officials have for insurance: