Parents can tell if an ear infection is getting better

Posted December 5, 2016 by Dr. Roy
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The Pediatric Insider

© 2016 Roy Benaroch, MD

Good things come in small packages. A short, sweet letter to the editor in the November, 2016 edition of JAMA Pediatrics confirms that parents can tell whether their children are getting over an ear infection, with no doctor exam required.

The letter, from four Finnish physicians, is about a page long. It summarizes a small part of their data from a much larger study on the treatment of ear infections. In the letter, they’re only looking at 160 children, age 6 months to 3 years, who were initially treated for an ear infection without any antibiotics. Current guidelines from the US and many other countries do support treating less-severe ear infections with pain relievers only, waiting on antibiotics. But these guidelines suggest that if children with ear infections aren’t given antibiotics, they need to be followed closely and re-examined to make sure they’re really getting better. These authors asked, is that really necessary?

The 160 children were all reexamined for this study, and parents were also asked questions about whether they thought their children were improving, getting worse, or staying about the same. It turns out that among the children whose parents thought were getting better, only a very small number had worsening ear exams (less than 3%). Compare that with children thought to be getting worse – about 30% had worsening findings on their ear exams. Keep in mind that these were all children who did not receive any antibiotics. Presumably, if they had, even fewer of them would have gotten worse.

Parents, not surprisingly, were pretty good at judging whether their children were getting better. So good that based on these numbers, a repeat exam to make sure ear infections were clearing was probably unnecessary!

Caveats: I’d be a little more cautious with children at risk for prolonged ear infections or  persistent fluid behind the ears. Children with a history of difficult-to-treat ear infections should get a repeat exam, as should kids with hearing problems or developmental language delays—it’s crucial that those children get over their infections completely. But for the majority of children with ordinary ear infections that seem to be getting better, it may be reasonable to wait until their next check up to look at those ears again. Most of the time, parents’ judgment is just as good as a repeat ear exam.

Finalnd!

 

Beware crappy telephone medicine

Posted November 28, 2016 by Dr. Roy
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The Pediatric Insider

© 2016 Roy Benaroch, MD

Someday we may miss the quaint idea of going to see your own doctor for your medical concerns.

I realize taking your children to see their doc is a pain. So is taking your car in to the mechanic, or waiting for the cable guy, or going out for groceries. There are other things you’d rather be doing with your time. Can a quick phone call substitute for a doctor visit?

Apparently at least one huge insurance company thinks so. My own family’s health insurance comes from Aetna Healthcare (the letters of which can be rearranged to spell “At Heartache Lane”.) They’re really pushing me to try out “Teladoc” (which, ironically, can be rearranged to spell “late doc” or “eat clod” or “led taco.”) One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?”, it says, in big friendly letters. Holly, presumably the child’s mom, is quoted “One night my child was running a high fever. I called Teladoc & the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER.”

24/7 doctors! What could go wrong?!

What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history, and symptoms, it would have been appropriate to either: (1) stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor; or (2) if there was chance of a genuinely serious medical issue, to go get evaluated right away. The child could have had meningitis, pneumonia, or a viral infection, or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever means “call in a prescription”? That’s completely, utterly wrong.

So why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?

I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis and prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.

Though there are zero pediatric studies, I found one good study in adults,  reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses, and many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record.

I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just 2 copies of telemedine records in the last few years, and they’re frankly embarrassing. One was about an 8 year old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s what’s called the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone. The other telemedicine record I have was nearly identical, a 15 month old also diagnosed with strep , amoxicillin called in. More Krap Kare for Kids.)

There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be a great way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms.

But current available technology (like this Teladoc service) doesn’t allow a clinician to really examine a patient, look in their ears, or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick – and that, really, is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy. But it’s no substitute for genuine medical care.

Acute Flaccid Myelitis: A reassuring primer for parents

Posted November 14, 2016 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2016 Roy Benaroch, MD

Nina wrote in: “Hi Dr. Roy. There has been a lot of discussion in the media lately around acute flaccid myelitis (AFM). This I am sure as it is for many parents is terrifying, especially when you are a card carrying vaccination parent (which doesn’t matter in this case from what I understand)! Any insight you can provide here would be so much appreciated.”

AFM has been in the news a lot lately, typically with breathless click-bait headlines.  The Washington Post, never stingy with words, came up with “A mysterious polio-like illness that paralyzes people may be surging this year.”  Huffpo’s headline was more direct: “A mysterious neurological condition is paralyzing children” The antivaccine sites (to which I will not provide links), predictably, blame it on vaccines, because they blame everything on vaccines. Which is ironic, because we’ve been able to prevent almost all historical cases of this condition with vaccination. It’s a funny world, sometimes.

Anyway: there’s no need to panic. While there’s more to learn about AFM, it’s not as mysterious as these headlines would lead you to believe – and it’s really rare.

 

What’s AFM, anyway?

AFM (Acute Flaccid Myelitis) is a disease of the nervous system. Inflammation causes damage to one section of the spinal cord, leading to weakness of one or more extremities. Sometimes, the weakness affects muscles in the head or neck. There’s typically no changes in sensation like numbness or tingling. The brain is not affected, so there aren’t symptoms like fuzzy thinking, seizures, or coma.

The words in the name AFM describe its key features: it’s Acute, meaning it starts suddenly; it’s Flaccid, meaning muscles are weak or floppy; and it’s a Myelitis, meaning there’s inflammation of the spinal cord.

 

What causes it?

Historically, almost all cases were caused by polio. 60 years ago, poliovirus infected about 60,000 children per year – thousands of whom became paralyzed. Polio has been entirely eradicated in the US and in most of the rest of the world. But until it’s 100% gone, we need to stay vigilant and keep vaccinating. We know that interruptions in vaccine programs have led to the return of polio to areas of Africa and Asia – and polio could come back here, too.

Though polio itself is not causing any of these AFM cases in the United States now, poliovirus has cousins – other viruses in the enterovirus family. One that seems to be associated with many cases of AFM is a relatively new enterovirus, called D68. Other new or “newish” viruses can cause AFM, too, like West Nile Virus. And some cases seem to be associated with other well-known or common viruses, like adenovirus.

 

That sounds kind of weaselly. How can one disease be caused by different viruses? And what’s with the “seems to” and “associated with” stuff? I just want a straight answer!

Medicine is messy sometimes, and often there are multiple causes for similar conditions. The common cold can be causes by dozens of different viruses (rhinovirus, coronavirus, human metapneumovirus, and many others), and pneumonia can be causes by a whole slew of viruses, bacteria, or even fungal infections. It would be simpler if we said that there was one cause of AFM, but it wouldn’t be true.

And those “seems to” kinds of phrases – that’s what happens when we’re accurate. Some cases of AFM will occur in children who have a definite viral diagnosis, but sometimes the tests are done too late to know for sure what the cause was. That doesn’t mean we’re completely in the dark, or that this is a huge mystery illness.

 

Who is catching this? How serious is it?

Children, mostly. So far in 2016, 89 people have been reported with AFM nationwide, mostly in the western states, and most cases have occurred in kids (average age, about 7.)

The best long term data we have on the outcome of AFM are from a case series from 2014. Though there we no deaths, many of the children did not have a return to normal muscle functioning. Supportive care has helped prevent complications, but so far no specific therapy has seemed to help these children recover.

 

What should parents do?

Don’t panic. Take a break from media and Facebook, and spend some time playing with your kids instead of reading about the Next Big Danger.

Though AFM remains rare, there are ways to prevent at least some cases. Make sure your child is fully vaccinated (that eliminates not only the risk of polio, but greatly reduces the risk of many other neurologic illnesses, including meningitis and encephalitis associated with influenza, mumps, and other causes). Try to avoid mosquito bites (which rarely can spread West Nile Virus and other causes of encephalitis). Wash hands, use hand sanitizer, try not to be around sick people, keep your children home when they’re sick, and get into the habit of not touching your face with your fingers. I know, that stuff sounds simple, but those are the best ways to keep your children healthy.

More about AFM from the CDC

keep calm

Codeine is not for children

Posted October 31, 2016 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Codeine is a terrible choice for treating children’s pain and cough, and we ought to just stop using it. It’s like an old yogurt container, way at the back of your fridge — sure, it was once tasty, and then for a while you held on to it for sentimental reasons. “Remember that yogurt?” you’d say to your spouse. But it’s well past time to throw that stinky stuff away.

For a long time, codeine was thought to be safer than other opiate-based pain medications. It’s a naturally occurring form of morphine with good oral bioavailability (that means you can swallow it in pill or liquid form.) But codeine, the molecule itself, has no biologic activity or drug effect on its own. It has to be converted, in the liver, to an active “metabolite” to have any effect on your body. And that’s the problem: the “activation” step. It turns out that different people have a huge variability in how quickly they activate codeine, which can lead to all kinds of problems.

Some people are “fast metabolizers” — meaning they very rapidly activate codeine. If you’re one of these people, the effects and side effects of codeine will be much higher than expected. There have been about 64 cases of severe respiratory depression reported in children taking “normal” doses of codeine, and many of these children died.

On the other hand, some people are “slow metabolizers”. They can take a dose of codeine, and their liver just sits there, twiddling its liver thumbs. Nothing happens. There’s no therapeutic effect of even very high codeine doses in these people, because their bodies don’t activate the drug.

A slew of international smart-guys has already begun to limit the use of codeine, especially in children. The US FDA slapped a black box warning against its use in post-op children, the Europeans issued a report suggesting that we stop using codeine entirely in children less than 12, and Health Canada even joined the fun, calling codeine “a big hoser of a mistake, eh?”

So, if not codeine, what else can we safely use to treat serious pain in children? Oxycodone (found in Percocet and other products), should have much less variability, though there will still be some added risk to fast metabolizers. The best option, really, might be to go back to using straight-up morphine, but there aren’t great studies looking at its absorption in children.

Non-opiate pain medicines work well, too — in many cases, as well as opiates, if used correctly. These medications, including acetaminophen and ibuprofen, can very effectively relieve even serious, post-op pain, if they’re given in advance and on schedule. Even if they can’t relieve pain completely, they can be used to reduce the doses of opiates needed. There are also IV preparations of acetaminophen and some NSAIDs.

We also need to be very careful about the kind of pain we’re treating. Acute serious pain, from surgery or a broken bone, can and should be safely treated with a combination approach that often includes opiates in the short run. But chronic or recurrent pain (including backaches and migraines) should not be treated with opiates. In the long run, these medicines actually increase the body’s sensitivity to pain, potentially leading to a cycle of dependence and addiction.

Sometimes, codeine is also used as a cough suppressant. The same risks for high- or low- metabolizers are there, and in fact there are no studies showing that codeine is even effective for cough in children. You’ve got all the risk for potentially zero benefit.

Codeine is an old medicine that’s way past its prime. We’ve got better drugs to choose from. If your doc offers a codeine prescription for your child, it’s time to say “no.”

Mmm codeine

The why and the how of stinky feet

Posted October 24, 2016 by Dr. Roy
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The Pediatric Insider

© 2016 Roy Benaroch, MD

Ever nibble on a baby’s toes? I sure have. It’s one of the perks of being a parent – and a pediatrician. Nom nom nom, nibble them, count them, baby toes are about as adorable as anything can be. So why do feet sometimes turn on us? The 10 cute piggies and sweet little feets, in a few years, sometimes become, well, foul and nasty.

Teenager: “Do I need to take my sneakers off for my sports physical?”

Me: “No no no no no no no!!”

Honestly, most feet don’t smell too bad. Sweat barely smells at all. But the combination of sweat, warmth, trapped air, and what we’ll call “cellular debris” (ie, bits of foot skin) create, at least in some people, a tasty salad for the overgrowth of stink-producing bacteria. These include Bacillus subtilis, Kytococcus sedentarius, and brevibacteria, which is also responsible for the smell of Limburger cheese. There’s some cocktail party trivia for you! The bacteria eat up the foot debris, releasing “evil stink molecules” of  organic acids and sulfur compounds. And it’s those compounds, the stuff made by hungry microorganisms, that create what Frank Zappa famously called Stinkfoot. The science name for this – more cocktail party trivia! — is “bromhidrosis.”

So what can kids do about the stinkfoot? Try to keep them (the feet) clean. Wash them, every day, with soap and water and a washcloth. Letting soapy water kind of dribble across feet in the shower doesn’t count. Use a washcloth or pouf or whatever, and don’t forget in between the toes. Afterwards, dry ‘em, and stay barefoot for a while. Bacteria love moist and dark and enclosed. Open, dry, cool air will help.

The choice of footwear matters. Natural fibers allow more air circulation, and plastic things are the worst. All-cotton socks are a good, too, though there are also sports-sweat-wicking socks that may work even better. Whatever socks and shoes you wear, once they’re wet with sweat, take them off and put on another pair. You might need 2 or 3 pairs to wear on different days, to make sure they completely dry out between wearings.

Sneakers can be run through a washing machine every few weeks, or at least their insoles. There are odor-neutralizing sprays, some of which have disinfectants, which can help too. Spray the shoes or spray your feet, whatever it says on the label. Powders can be used to trap sweat, but you need to clean up the gunky powder rather than let it accumulate and turn to concrete.

For ultra-stinkfoot that doesn’t improve with simple measures, a trip to a doc may be needed. Sometimes there’s a yeast or bacterial infection that can be treated. We can also use medicines or other things to decrease sweating (that’s not a quick-fix, though—clean foot hygiene will still be necessary.) As a last resort, I suppose you could try this. But remember, whatever you do, you can’t run away from your own feet.

Frank

 

How much media use is too much? The AAP weighs in

Posted October 21, 2016 by Dr. Roy
Categories: In the news

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Today, the American Academy of Pediatrics released two new policy statements outlining their official recommendations for media use in children and adolescents. Media, here, means television, video games, tablets, apps – pretty much anything with a screen. We know this kind of entertainment has become a huge part of our lives. How much is too much, and how do we ensure that media is being used wisely and safely? The policy and accompanying technical report rely on hundreds of solid references, providing the best answers based on the best science we know about how children learn and interact with the world of media.

Younger children, less than 2, need exploration and social interactions to learn best. They cannot learn from traditional “media”, at least not on their own. Some learning via electronics can begin by age 15 months, but only via caretakers participating with their children and reteaching the content in an interactive way. By 2 years, we know children can learn word skills by live video-chatting with a responsive adult, or by using apps that reward the child for choosing the right answers.

Preschoolers, aged 3 to 5, can boost their literacy and cognitive skills by watching well-designed TV programs (like Sesame Street.) However, higher-order thinking skills like task persistence, impulse control, and flexible thinking are still best learned during truly social, interactive play – and that’s just not something media can provide.

There are some specific medical concerns raised by media use in young children. Heavy media use increases the risk of obesity, by filling time with sedentary activity and exposing children to unhealthful food advertising. And increased media use directly corresponds to less sleep for children (this is especially true for evening exposures, before bedtime, which interfere with sleep onset, sleep quality, and sleep duration.)

Excessive media use in early childhood is also associated with cognitive, language, and social delays. Some of these associations depend on exactly what’s being watched — switching from violent to pro-social content has been shown to improve preschool behavior, especially in boys. There’s also concern that excessive media use by parents can interfere with other family activities, and may model and reinforce media excess in their children.

With all of this in mind, the AAP has made these specific recommendations for young children and media use:

  • Under 18 months, discourage all media use (other than video chatting with family. Facetime and Skype are OK.)
  • From 2-5 years, limit all media, combined, to a total of less than 1 hour per day of high quality shows. These should be shared together between parents and children.
  • No screens at all during meals and for 1 hour before bedtime.
  • Parents should keep bedrooms, mealtimes, and parent-child playtime screen free.

The AAP had a second policy statement about media use in school aged children and adolescents. There’s good evidence for some benefits of media use at this age, including exposures to new ideas and information, and opportunities for community engagement and collaboration. Social media can help children access support networks, which may be especially valuable for kids with ongoing illnesses or disabilities. Media can provide good opportunities to learn about healthy behaviors, like smoking cessation and balanced nutrition.

But: there’s a down side, too. There are risks for obesity and sleep problems with excessive or untimely media use. Children who overuse online media are at risk problematic, addiction-like media usage, sometimes characterized by a decreased interest in real-life relationships, unsuccessful attempts to cut back, and withdrawal symptoms.

Many teens use media at the same time they’re engaged in other tasks, like homework. They may think they’re learning, but good objective data shows that no one can truly multitask like that. And, of course, though media can deliver positive, healthful information, parents need to be wary of some of the misinformation that’s out there. Information about nutrition, vaccines, and exercise is often misleading or flat-out wrong. Kids can easily find material actually promoting risky health behaviors like eating disorders, sexual promiscuity, and self-mutilation.

There are also significant risks from cyberbullying, sexting, and online solicitation – issues that are especially problematic because the perpetrators may be anonymous. The internet has created some horrifying opportunities for the exploitation of children.

Bottom line, here’s what the AAP recommends for these school aged children and adolescents:

  • Families are encouraged to create their own Media Use Plan. This addresses how media is accessed, both how much and what kind. Consistent limits and a clear and explicit understanding of expectations is crucial. Families should work on these plans together.
  • Children should not sleep with their devices in their bedrooms (parents shouldn’t either.)
  • Media shouldn’t be used during schoolwork, family meals, or other family-designated “media free times.”
  • Parents should engage in selecting and co-viewing media with their kids.
  • There needs to be ongoing discussions of online citizenship and safety.

The AAP’s new policy doesn’t include a specific amount or number of hours of media time is recommended for children and teens. But media use should be limited, so there’s time for exercise, adequate sleep, and other activities. How much media is too much? For teens, when it prevents them from participating in other activities they ought to be doing. Media has become a huge part of all of our lives, but there needs to be time for other things, too.

My hero

Obamacare: Is it working or not?

Posted October 17, 2016 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

‘Tis a season, fraught and shrill. Volume has replaced thoughtful discourse. I realize many of us have long-ago made up our minds about the Affordable Care Act – and if you already know whether it’s good or it’s bad, this really isn’t the post for you. But if you’re one of the people in the eerie, quiet middle, curious for some context and facts, here’s one doc’s take on the status of what’s typically called “Obamacare.”

 

What are the problems?

There are two big ones, the way I see it. First, the whole program is not sustainable with the current model. When the ACA kicked in, the whole idea was to provide uninsured people with a way to purchase insurance plans, similar to the ones offered by employers. This looked like a big bumper crop of new customers for insurance companies, who initially lined up with all sorts of plans at affordable rates. The costs for consumers, at first, looked especially appealing, because government subsidies made premiums pretty cheap. At first.

But: insurance companies ended up taking a bath on those ACA insurance products. The people who signed up for them turned out to need more health care – to spend more money – than expected. The “young invincibles” who don’t need much health care spending aren’t signing up for these plans, despite having to pay a penalty. (The penalty is still cheaper than the premiums, and they can always sign up later if they develop a health problem. They’re young and invincible, but they’re not stupid.) Insurance companies have had to raise their rates, this year by an average of 10%, and in some areas as much as 55%. Many have exited this part of the insurance market entirely. It’s estimated that when enrollment starts in November, about 20% of people looking for individual plans in the ACA insurance exchanges will have only one plan from which to “choose.” And, of course, areas with fewer plans are seeing the highest rate increases.

Insurance companies would like to hold down rates, but so far their solutions have been both unsuccessful and unpalatable. Smaller “in-network” groups of physicians, hospitals, imaging centers, and labs do reduce costs. But inevitably that means clients – I mean, patients – have to wait longer for services, or travel farther, or navigate endless administrative roadblocks. Another idea to contain insco costs: increased deductibles and copays, which share more of the health care costs with patients.

Which brings us to the second Big Problem: many people are finding that their ACA-compliant plan is costing them, big time, to actually use. Just having health insurance doesn’t guarantee access to affordable health care if you’ve got huge deductibles and out-of-pocket expenses.

 

Have any parts of Obamacare worked?

Yes. The ACA has brought insurance to about 20 million Americans who lacked it, including about 9 million via expansion of state Medicaid programs to low-income families (that number could be much higher, if some states hadn’t refused to participate.) The uninsured rate has fallen from about 16% to 9%. Though deductibles can be high on some plans, people with insurance are at least protected against truly catastrophic costs from a serious hospitalization or chronic illness, like cancer or a heart attack.

Though premiums on the exchanges are rising, they’re actually about $600 a year below what was projected for 2016. And, overall, the rise in national health care costs has been reduced to record-lows, in part from ACA-required hospital cost-control and quality improvement mandates. Overall, federal government spending on health care in 2015 was $2.6 trillion less than it was expected to be – and that’s even with the 20 million more covered people in the system.

 

You’re full of sh*t. Obamacare is (the greatest thing ever)/(a complete disaster for everyone) <–ß you choose!

Yeah, well, see, I was hoping to weed out the partisans with that flowery introductory paragraph. People on either side of this issue seem to have a hard time seeing this from the other point of view. The very idea that “the other side” may have something worth saying and listening to doesn’t seem to jibe with the world of Facebook, Twitter, and the current election cycle. Democracy can be hard, but (I think) it’s the best system out there. Let’s give it a try!

 

OK, Hippie, we’ll try it your way. What do you suggest?

More young people need to sign up. This can be encouraged by increasing subsidies and/or increasing the penalty for non-insurance. Though forbidding insurance from excluding pre-existing conditions is a common-sense provision that needs to be retained, the rules can be tightened. People shouldn’t be allowed to take advantage of this by dropping insurance when they’re well and restarting it only when they get sick.

More flexibility will allow more competition, so people have a choice and premiums can be kept in check. Insurance companies should be allowed to offer products in any state, and regulations requiring certain kinds of coverage for all plans can be relaxed. People should be allowed to choose the kind of coverage they’re willing to pay for.

There are other good suggestions to improve the Affordable Care Act, but it will take a bipartisan congress of adults actually listening to each other to get it done. Their focus needs to be on making quality health care accessible, rather than protecting the profits of the insurance industry.

 

You’ve made some good points! Will you be our next Surgeon General?

I’ll consider it, but I certainly wouldn’t accept that nomination if <REDACTED> wins.

Balance is possible