Well… yes and no. From a medical standpoint, it’s true. While an eleventh-hour flu vaccine given to you or your child after influenza has already hit your community won’t protect you as well as if you had received it months ago, it will still give you a measure of protection. How much protection simply depends on the interval between when you got the vaccine and when you personally are finally exposed to the flu. That’s fairly impossible to predict without knowing a lot of other variables. So yes, if you can get a vaccine this late in the season, it is still totally worth doing so. While we are finally experiencing intense flu activity here in Oregon, we haven’t been inundated with it the way the East Coast has, and if you are careful about your exposures and your handwashing, your flu vaccine still has a good chance that it can protect you before flu crosses your path (unless you are a health care worker or a teacher, in which case you have almost certainly been exposed already multiple times).

But there’s a big ‘if’ in that statement. IF you can get a vaccine, it will still help.

Why the ‘if’? Well, it’s January, and many medical offices have either used up their stock of vaccine — and are unable/unlikely to get more — or will soon be running out. As I write this, we still have some vaccine but we aren’t sure how long it will last or how much more we will be able to get. Eventually we too will run out. We might be able to get more, we might not; if we do keep ordering more, we also run the risk that the flu shot frenzy will die down before our supplies run out. That leaves us with unused vaccine, and that’s an expensive proposition.

This article from the FDA is a nice explanation of the science and technology that’s involved in making the flu vaccine every year. I think it’s all rather exciting: the idea of the world’s infectious disease experts getting out their Magic Eight-Balls and making trips to Hong Kong to try to predict which strains will strike us sets my nerdy little heart thumping. I’d love to be a fly on the wall for that. But what the FDA summary doesn’t mention, and what most news stories about flu vaccine leave out, is the rest of the guesswork that’s involved.

How many people will queue up to get the flu vaccine? And when? Will the public flock obediently to their doctors’ offices in early fall, the way we always urge them to? Or, lulled into a sense of false security by a couple of mild flu seasons, will they keep putting it off? If they don’t bother to get the vaccine one year and there isn’t widespread disease, will they be even less likely to bare their arms for a poke the following season?

And when the news media starts showing footage of overwhelmed emergency departments in the big cities, will the public suddenly feel motivated to get vaccinated?

These aren’t questions that can be answered easily by the use of science… at least, not by the kind of science that involves going to the Far East and getting samples from pigs and chickens. Now we’re dealing not with virology and epidemiology, but sociology — human nature — and economics. Human beings, in their own way, are more maddeningly unpredictable than viruses any day.

So after the big brains at the CDC and elsewhere have consulted the stars, tossed the bones, and sacrificed the chickens to study the entrails (okay, not really… after they have Done Their Research) and told the world which strains should be included, then the manufacturers of the vaccine have to make their best predictions of vaccine demand for the coming season. What a lot of people don’t realize is that in this country, the flu vaccine — and routine childhood vaccines — aren’t made by the government, but by for-profit businesses. They want to keep their production of the vaccine high enough to meet the demand, so as not to miss out on sales of vaccine, but they don’t want to overshoot and end up with a lot of unused product. Since the flu vaccine is different every year, leftovers from this season aren’t something that the manufacturers can just keep on ice for next year.

The same process happens on a smaller scale in your doctor’s office. Every year, months in advance, we place our orders. Usually we base the numbers on how much vaccine we were able to give out the previous season. It’s especially complicated for pediatric offices, because there are different vaccine doses for the youngest children versus the older kids. In offices like ours that see both commercially insured kids as well as clients on the Oregon Health Plan, we have to order both from the commercial suppliers and the federal Vaccines for Children program. And then there’s the option of FluMist, the intranasal live vaccine, as well. Somehow, in a process that I don’t even begin to understand, our nursing staff makes their best guess and places the initial orders.

Vaccine usually arrives in late August, and as soon as we have vaccine in all of the necessary categories we put out the call and start vaccinating like crazy. I’m proud of our patients: every year you seem to come in earlier and every year we are able to vaccinate more children (and their parents, when desired) against the flu. It’s wonderful. But it could be better, and this year illustrates exactly why.

Remember the H1N1 influenza epidemic of the 2009-2010 season? That was the year when the novel strain of flu hit first in April 2009, then went underground for a few months only to re-emerge in the fall with a fury that most of us in the healthcare world had never seen before. Usually February is the busiest month of the year for us, but October 2009 broke all previous records for us for the sheer number of patients seen. (Because of what may possible have been the best vacation timing of my career, I ended up spending the very worst week of the season on a working cattle ranch in eastern Idaho; after up to ten hours a day in the saddle for a week a nice flu epidemic back home didn’t sound so bad.) Vaccine production was thrown for a loop and we had two different vaccines to worry about, in addition to all the other variables. First we got the seasonal vaccine the experts had already recommended, then the H1N1-specific vaccine. Or maybe it was the other way around; it’s all a blur now.

Patients packed EDs and office waiting rooms. Lines for the vaccine wrapped around the block. Many offices, including ours, removed toys and books from the waiting rooms and exam rooms to help stop the spread of the flu. Schools closed entirely in some places due to the disease burden. Masks were handed out at the front desk when appropriate. Everyone wanted both the vaccine and antiviral medications if they did get sick. It was, in short, a feeding frenzy, a perfect storm.

We survived, and saw increased interest in the flu vaccine the following year. Everyone remembered H1N1 and most wanted their children to be vaccinated. We had a mild flu season that year, the 2010-2011 season. And the following year, we had another mild season. Memories of the fall of 2009 began to fade.

This year, the country as a whole is having a bad year. Flu is more widespread and more severe and more people are dying from it. The result? Those who didn’t get themselves and their families vaccinated in the fall are now desperately seeking the vaccine. Some are finding it; some aren’t. It’s just so late in the vaccination season.

It might help to think of flu vaccine supplies as being a little bit like breastfeeding. If you’ve breastfed an infant, you know that as the infant feeds for longer periods and more frequently the amount of milk produced increases. It’s supply and demand: baby demands and mama supplies. Baby has a growth spurt and wants to eat every hour? Mama’s milk-producing glands start working extra shifts and paying overtime to get the milk out. It’s the same way with flu vaccine: If we vaccinate like crazy in the early fall and blow through all the doses we’ve ordered by, say, late October, we can order more, no problem. We’ll be able to get more because it’s early in the season and the manufacturers still have stock. If that’s happening everywhere and the manufacturers start to run out, they’ll make more because they know they can still sell it if it’s early in the season. It’s a feedback loop, with more demand creating more supply.

But when demand is lackluster in the fall and then suddenly peaks in January, everyone is caught with their pants down (and not in the sense of waiting expectantly for a shot in the gluteus maximus). Medical offices are reluctant to order more, because no one wants to be stuck with a fridge full of unusable and expensive vaccine. And they might not be able to get more even if they decide to take that risk, as the manufacturers may have called it quits for the season so that they don’t end up with a warehouse of leftovers. This is like the baby who has had a poor appetite for weeks and then suddenly starts eating like crazy; mama’s milk production isn’t going to come back overnight (thankfully, breastfeeding is not a for-profit industry).

The take-home lesson from all of this is predictable, even if the flu virus and the vaccine supply isn’t. Get your flu vaccine every year, for you and your children. Get it early, as soon as the vaccine becomes available. Give your doctor’s office a chance to protect you before the virus hits. The more people we can vaccinate in September and October, the better we are able to get more supplies and vaccinate the folks who will inevitably procrastinate.

Consider it your civic duty.

First, thanks to some of the local nonprofit agencies in our area that serve children and youth… please remember these agencies when you are looking to make a charitable donation.

• Easter Seals Children’s Therapy Center, for providing quality PT, OT, speech, and mental health services, and for partnering with us to provide mental health care here in our clinic one day a week for the last couple of years.
• Family Building Blocks, for providing services such as education and respite care to high-risk familes.
• Liberty House, our local child abuse assessment center, for being such a valuable resource to children and families who have suffered through child physical and sexual abuse.

We’re also privileged to have some fine specialists in the area who go out of their way to help us in caring for children. Special thanks to:

• Willamette Ear, Nose and Throat, for seeing our patients for their otolaryngologic needs… including removal of objects from many noses and ears, and helping us with the scary things like peritonsillar abscesses.
• Medical Center Eye Clinic, especially Dr. East and Dr. Tibolt, for seeing a veritable flood of children for us for their eye care needs.
• The pediatric subspecialists of Doernbecher Children’s Hospital, for all of the many ways they help us
• The pediatric subspecialists of the Legacy network in Portland.
• Oak Street Surgical Associates, for seemingly endless help with abscesses, appendicitis, and so many other things!
• Willamette Urology, for providing newborn circumcisions to our clients after we stopped offering them in our office
• The surgeons of the Salem Hospital Trauma Service, for being astonishingly willing to help out with kids in the hospital.
• Salem Gastroenterology Associates, for helping us out with some of our older teens.
• Our neonatologists, especially Dr. Cohen and Dr. Sweeney, for taking care of tiny babies so that we don’t have to!
• Dr. Sudeep Taksali of Hope Orthopedics, for exemplary help this year.

And finally, our sincere thanks to the fine nurses that work with us at Salem Hospital, on the Mother-Baby unit, in the NICU, and on our new Pediatrics Unit. You guys are the best!

New Year’s Day we will have a skeleton staff to see those few kids who can’t wait until the next day. This will operate like our Sunday clinic; you’ll need to call in the morning after 8:00 am and talk to our nurse if you think your child might need an appointment. As always, there will be a doctor on call for emergencies, but please be kind to them!

This weekend we will have our usual weekend hours, and then we will be back on Wednesday, 1/2/12 with our regular weekday hours.

Have a safe and happy New Year’s, and don’t forget to bring in new insurance information to us if you have a January appointment… many employers change health plans in January.

More and more employers are reacting to the high cost of health insurance by either choosing plans that are less expensive or by requiring employees to pay a portion of the monthly premium. Very large employers may have several plans for you to choose from, but most will have one plan for all their employees. Whatever your situation, make it a priority to know as much as you can about your plan as soon as you can. For example:

• Know if you have a deductible, and what that implies. It’s not unusual to have a plan with a $500 or $1000 yearly deductible these days. These plans typically have lower monthly premiums, saving you (or your employer) on the up-front monthly cost, but you will be responsible for that first $500 or $1000 of health care costs. Not all services are treated this way; for example, in many plans, preventive care is covered regardless of whether you have met your deductible. Know how much your deductible is, what costs ‘count’ toward it, and save all of your receipts and EOBs (explanation of benefits) in case you ever need to dispute the issue with your insurance company.
• Know if your employer offers any way to help with high deductibles, such as a HSA or even reimbursing you for part of your deductible.
• Know how preventive care is treated. The Affordable Care Act mandated changes in how preventive care is covered. Insurance companies have some leeway in how fast they make these changes, but eventually, preventive visit should be exempt from copays and, for children, allowed on the schedule recommended by the AAP. When this finally takes effect on all plans in the next couple of years, older children will have yearly coverered visits (many plans now only cover them for every other year).
• Keep on top of your balance, whether it’s at our office or any other medical office. Don’t ignore statements thinking that the charge must be a mistake. Call early if there is a question or if you need to set up a payment plan. Failure to pay medical bills can result in having to find new doctors!
• Realize that the insurance plan details are an agreement between you and the insurance company. Medical offices aren’t allowed to ‘fudge’ the record so that a non-covered service is covered. We can’t lie and change that cough/cold visit to a checkup after that fact so that it’s exempt from your deductible, or charge you less than the standard fee because of a high deductible. We cannot lower our medical standards and treat an illness over the phone in order to avoid generating a charge for you. We CAN help you navigate the insurance jungle, and even give you tips on dealing with your health plan, and we can set up generous payment plans.
• Realize that if your child is seen at our office (or in the hospital) by one of us, there will be a charge for that visit and any subsequent visits. This sounds obvious, but often parents ask us to ‘work in’ a sibling for an acute illness, and then are surprised when there is a charge. We charge for all face-to-face provider services, whether or not there was a scheduled appointment. The same goes for hospital visits: the hospital rules require us to see our patients every day that they are in the hospital, and there is a charge generated for each day. This is different from surgeons, for example; they are usually paid a lump sum for a specific procedure (for example, a tonsillectomy) and the follow-up visits are considered to be a part of that service and so usually don’t generate a charge unless they occur outside of a specific window of time.

Whew, that’s a lot! Again, know your plan, and plan ahead if you have a large deductible and anticipate accessing significant amounts of medical care early in the year. Call our billing department for help understanding your bill and to set up secure monthly credit-card payment plans if needed.

Thanks for allowing us to have this brief time closed to celebrate with family and friends. As always, there will be a physician on call for your emergency needs, but please respect their holiday time as well.

This is all my own opinion and your mileage may vary…

1. Don’t allow your children and adolescents to be overworked in the context of school. Know how much homework they have and step in if it seems to be an unreasonable amount. They won’t learn more or faster by being exhausted.
2. Do encourage them to pursue classes and interests that they will find personally fulfilling.
3. Don’t encourage them to choose classes and interests for the sole purpose of making their college applications and their resumes look good. You can’t fake real enthusiasm and real interest; college interviewers and those who read the application essays can tell the difference.
4. Don’t let them over-specialize too soon in their education. If your teen is college-bound, focus on educational building blocks such as writing, languages, math, science, and the humanities. They’ve got plenty of time later to learn medical terminology or basic accounting skills.
5. Do make room for art and/or music if your young person has interests in those areas. Their lives will be enriched by the experience and they’ll cope better with professional stress if they have some interests outside of their profession… and maybe someday you’ll have the pleasure of seeing them teach your grandchildren how to do watercolors or how to hold a guitar.
6. Don’t let the pleasures of childhood come to a close too quickly. Encourage a certain amount of nonsense and childish play for as long as you can, especially when imagination is involved.
7. Don’t let them delay adulthood for too long. Encourage a gradual move toward independence in decisions and responsibility, or they won’t be able to cope with either when they leave home for the first time.
8. Don’t protect your young person from all failure. Instead, learn how to frame it as a learning experience; prepare them for the fact that they will encounter failure at some point. Help them to problem-solve in advance so that they know how they will cope when they run up against a problem that’s too big for them.

In the end, help your children come to understand that their degree of happiness as an adult will not ultimately rest on how much money they make, how big their house is, or how much power they wield… but on the number, strength, and longevity of human relationships that they form in their lifetimes. Give them the example of a loving family, help them to make friendships a priority, and make sure they know that you’ll always be proud of them as long as they follow their hearts and stay true to themselves.

In our service area, the 211 line comes to us courtesy of United Way of the Mid-Willamette Valley.

Questions? Call 211! More information also available here.

GastroKids Resource Page

Once they are ‘up and running’, they will be available to be PCPs for your children. Please consider one of them, or one of our other mid-levels, as a PCP for your child if you would like longer visits, better appointment availability, and a little more time with your child’s health care provider. Some children with complex health care needs should have a physician as their PCP; if your child has special health care needs then just ask us if they are appropriate for PA/PNP care on a routine basis.