Resilience

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I have this baby at home. He’s super cute, as babies tend to be. Fairly uncoordinated, as babies tend to be.

Not surprisingly, falls are a regular occurrence in this house. Maybe there was an unfair wrinkle in the rug, or an unattended Duplo sitting in just the right spot, or an imagined breeze. But whoever it is that’s to blame, the results are the same: you’re walking along, bothering no one – no one! – and all of a sudden you’re on the ground, and you hurt. Much high-decibel sadness immediately follows.

But do you stop walking?

Well, maybe for a few minutes. Hell, your head still hurts. Like, a lot. And who knows exactly WHY this terrible thing happened? It’s scary putting one foot in front of the other when something that seemed so routine ended in tears just a few moments ago.

But no. After a quick comfort snuggle, you get back up and keep toddling across the floor, with renewed zeal fueling your quest to plunge your hands into that ficus planter soil, maybe even tasting its earthy deliciousness one more time before the tall people catch you.

I think I know how he feels.

A year and 24 hours ago, we were bundling up the kids for a crowded T ride into the city, heading for a friend’s apartment on the marathon route to enjoy some fantastic company and a beautiful spring day, and to cheer on a bunch of runners we’d never met. They’d write their names on their jerseys in Sharpie, so we could call them out by name: “Go Sarah/Bill/Melissa! You’re doing great! Wooooooo!” (Our older kid is particularly good at this last part.)

And then a year and 12 hours ago, everything felt, somehow, fundamentally different. The fear of an unknown future following a major terrifying event can seem immobilizing. Even though we knew, deep down, the marathon would continue next year, and the year after that, and the year after that – because you can’t defeat the world’s oldest annual marathon that easily, PLEASE - would we go? As a random spectator, would it feel easier, safer, just to stay home and enjoy the day off from work?

But a lot can happen in a year.

This weekend, our marathon route friend was over for our baby’s first birthday party. She looks at me. So what are you guys doing for the marathon? I pause to think for a moment. Then, with a smile: Nothing…yet. She, also with a smile: Want to come over to our place? We can grill, the kids can hang out…

That sounds awesome. We’re in.

Human beings are pretty f-ing resilient creatures. It’s fundamental to our success as a species. When we stumble, when we feel pain, or fear, obviously we tend to react, at least immediately, with avoidance. Clear evolutionary advantage here: you don’t want the entire family sauntering back out of the cave when just moments ago Grandpa was eaten by the lion that’s still standing outside.

But once you have some time to take stock, reassess the level of risk, make your process a little safer if need be, we tend to get right back to it - whatever “it” might be - even more focused and determined than we were before. We can be capable of some pretty great things, and it’s our stubborn resilience in the face of adversity makes these great things possible.

I mean. It’s not like that ficus soil is going to eat itself.

Dear too-many colleges: here’s why you’re next in line for a Title IX suit

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Another week, another famous institution of higher learning in the news for mismanaging cases of sexual assault on campus.

This time, it was Harvard. The most common response, from what I can tell, seems to be summarized thusly: “Oh myyyyy - even at Hahvahd?” (eyebrows raised in surprise, mouth forming a delicate “o” of prim concern).

The morning the story broke in the local news, I happened to be having lunch with these two guys who work in administration at a nearby college. Guy #1 says to me, “So, have you heard about Harvard? And the sexual assault case?” Why yes, yes I have. Guy #1 continues, in a voice of genuine concern: “So, what can we do to keep people from drinking so much?”

Guy #2 murmurs in agreement, eyebrows knitted with empathy.

LADIES AND GENTLEMEN. EXHIBIT A. This, right here, is the crux of why colleges keep finding themselves in trouble when it comes to dealing with sexual assault.

I know, I KNOW. It’s not like Guys #1 and #2 are alone in their thinking here. Just read the comments section of any article on the college-sexual-assault topic for a primer on the latest and greatest in victim-blaming. The idea that intoxication negates one’s ability to provide consent seems to be a logical stretch for quite of few of the world’s armchair analysts.

But here’s the thing. I don’t really care if some random dude with a laptop disagrees with whether rape is rape when alcohol is involved. I mean, I don’t like it, but one guy with an opinion just doesn’t matter all that much. The extent of his power ends once his opinion’s been expressed.

However. If you’ve made a career for yourself in college administration or college health, and you continue to think that the epidemic of sexual assault on college campuses is really about excessive drinking and morning-after regret, don’t act shocked when your school is next to hit the news with a Title IX suit and a bunch of unflattering media attention of your own.

Yes, you could be the next Harvard. Or Dartmouth. Or Mizzou. Because sexual assault is happening on college campuses EVERYWHERE. It has, without question, happened on your campus. And if this common-yet-ultimately-wrong-minded perspective frames how you choose to respond to a sexual assault survivor’s case once it’s been brought to your attention, there’s a good chance that survivor will feel justifiably wronged. And, if they’re feeling brave enough, they just might decide to take this dissatisfaction with you and your colleagues public. Very, very public.

Don’t misunderstand me. I’m not denying that there’s a problem with binge drinking on college campuses that we need to address. But it needs to be addressed as an issue that’s separate and distinct from that of sexual assault. After all, just because it might be easier to mug someone who’s walking home late at night after they’ve had few drinks with friends, it’s not like the mugging itself isn’t still a crime.

I mean, someone who’s been attacked and robbed isn’t told by the authorities that their mugger didn’t REALLY commit a crime, because, y’know, you WERE pretty wasted, after all, and maybe sorta kinda asking for it by walking down the street in the middle of the night. I mean, who’s to say you didn’t HAND that aggressive stranger your money when he asked nicely? Who knows? He said, she said. You know what? Let’s just chalk this one up to youthful indiscretion and a lesson learned.

Hell no. Safety bulletins are sent out, city and campus police start patrolling overtime, and no one rests until the assailant’s been caught.

Intoxication may make a predator’s job easier. But it doesn’t make them NOT a predator.

In a perfect world, everyone would GET THIS, and this tortured public debate over what-is-or-isn’t-rape would cease to exist. I’m not naive enough to think that sexual assault wouldn’t still happen – because some people are terrible human beings – but society would deal with it the way it does any other violent crime. Meaning a) those who choose to commit a crime are consistently removed from the community for the safety of others, and b) the threat of criminal charges and incarceration might make some of the would-be assailants of the world think twice before committing assault. Both of which would result in less sexual assault. And I’m pretty sure we can all agree that less sexual assault = GOOD.

Those of us who work on college campuses need to be held to a different standard than Random Laptop Guy. You can’t hold regressive and harmful views on a topic as important - and yes, public – as sexual assault, with those views shaping your institutional response to individual reports of rape, and NOT expect that it might come back to bite you someday.

Unless, of course, you’d been hoping to end up on the front page of the Globe someday. In which case, vaya con Dios, my friends.

The end of (quote-unquote) supervision?

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You may already be familiar with how truly, madly, deeply annoying I find the term “supervision”.

I mean, not in its appropriate context, obviously. My daughter, despite being quite precocious for a kindergartener, still requires supervision while using grown-up scissors. My son, who seems to think he’s capable of essentially any physical feat imaginable, needs pretty much constant supervision, since he’s nearly always wrong. Not at all developmentally inappropriate for a toddler, but still. If we want him to survive childhood, supervision is definitely required.

Clearly, supervision has its place. But some problems arise when we start using the word to describe a mandated relationship between a physician and a nurse practitioner. Not the least of which is the fact that I tend to take issue with the intentional misuse of language. It’s kind of a pet peeve.

I wrote something about why exactly I find the word “supervision” so annoying a few months back. (Go ahead, I won’t judge you for clicking.) Afterwards, an NP from another state read it and said something along the lines of “Huh. Supervision? Is that still a thing in some places?”

Yeesh. Why yes. Yes, it is still a thing. In some places. Apparently.

Thing is, I never dreamed that moving to an uber-progressive state would mean I would still be subject to outdated laws that don’t make any logical sense. Maybe that whole no-buying-alcohol-on-Sunday-mornings thing should have tipped me off?

Don’t get me wrong. It’s not like you’d have any idea there were any restrictions on my practice on a daily basis. I go to work and see my patients, order my labs, write my prescriptions, write my notes. Pretty mundane, actually.

Except for this one annoying thing where all my prescriptions have a second name on them: the name of my “supervising physician”.

And even though my “supervising physician” is pretty great, this bugs her as much as it bugs me. And I totally get it. I’d probably be super annoyed too if there were a bunch of prescriptions out there with my name on them that I had nothing to do with writing. Risk exposure much?

Ah well. I’d just assumed it was something I needed to get used to. Just like I got used to the sight of seeing tarps thrown over the beer section at the supermarket whenever I happen to find myself grocery shopping on a Sunday morning. (Actually… nope, still haven’t gotten used to that either.)

But then I finally opened one of the emails that the Massachusetts Coalition of NPs has been sending me to find out WAIT, WHAT? There’s an actual, real-life bill at the State House RIGHT NOW that could fix this?

True story! It’s called HB2009/SB1079, or “An Act Improving the Quality of Health Care and Reducing Costs”. And it’s pretty great. (Even if it could really use a new name.)

I’ve heard that some of the arguments that legislators are hearing against the unfortunately-named bill sound like this:

  • “NPs and CRNAs are not educated enough.”
  • “Patients will be harmed because they don’t know what they don’t know.”
  • “They need continued oversight in order to be safe for patients.”

Here’s the thing, people-who-either-said-these-things-or-wish-they-did. I hate to break it to you, but that ship has left the dock. The train has left the station. The car has left the carport. NPs are already seeing patients and making diagnostic decisions and prescribing stuff – lots of stuff! – on their own, every single day. Whether you like it or not. It’s already happening! You’re too late!

And that’s why I have such a hard time understanding why physicians would be AGAINST removing the supervision language from the books. If my name is going to be attached to someone’s actions, I want to be sure I had something to do with it. But “supervising” MDs? They get all the risk that comes with clinical decision making and prescribing, with none of the power to actually make those decisions. How does this sound like a good deal?

Well, maybe if your income was affected by how many NPs you “supervise”, it would sound like a great deal. As long as that whole risk-under-your-name thing doesn’t bother you too much.

…But wait a sec. If you’re confident enough in the abilities of the NPs you “supervise” to feel comfortable with this level of risk, one might surmise that maybe you don’t actually, deep down, think NPs are all that unsafe after all… which would suggest that all these protests about “safety” may be just a teensy bit disingenuous, no?

In conclusion: this bill rocks, and its time has come. So if you live in Massachusetts and agree with my pointed use of quotation marks around the word “supervision”, please – figure out who your rep is and call, or email, or carrier-pigeon over your thoughts on the matter.

Thank you. That is all.

Quantifying awesomeness

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So, I’ll admit that I tend to think of myself as being a pretty awesome NP. Kind of a rock star.

But I recognize that I might be slightly biased.

My mom, my husband, my kids are all similarly convinced that I, generally speaking, rock when it comes to being an NP.

And they’re, most definitely, totally and completely biased as well. (And more than a little unqualified to judge.)

Isn’t that human nature, though? To think of ourselves as being pretty damn good at what we do? Probably true for everyone, but maybe even moreso for clinicians?

I mean, this job can be hard. REALLY hard. Crazy schedules, crazy patients, crazy admins, crazy insurance companies. If we don’t think we’re particularly great at it, that we’re bringing something special and unique and AWESOME to the table – and I mean even more than that other guy over there – what’s the point?

But we all know that all clinicians are not equally awesome.

Every clinic everywhere has “good” providers and “bad” providers and “okay” providers. It’s not written down anywhere, but when a friend asks a friend who knows some things about who they should ask to see, certain names come up, over and over again, while others are conspicuously omitted.

I’ve been thinking about this topic recently because of a conversation I had with a certain administrative type from a certain clinic this week. While we were chatting about unexciting clinic business, he let slip that roughly half of the patient complaints the clinic receives are consistently about one particular clinician. He then brushed them aside because he thinks of this clinician as being stingy with prescribing antibiotics, so therefore the fact that 50% of the clinic’s complaints are about 1/10 of the clinical staff may not the best measure of the quality of this guy’s work. Besides, he sees A LOT of patients. Very, very quickly. No drama. Admins love a high volume:drama ratio.

Hmm.

Zoom out.

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There’s currently this great experiment underway to figure out how to measure which clinicians are particularly good at what they do, and to reward those who are the MOST AWESOME in an effort to inspire everyone to be even MORE AWESOME than they may already be.

On one level, this makes perfect sense. Why NOT pay more money for better care? Why not reward high quality? Isn’t that how the rest of the world works?

But measuring quality in health care isn’t the same as counting how many widgets an assembly worker makes, or how many five-star Yelp reviews you get.

Briefly, a probably-incomplete rundown of what seem to be most common approaches to quality measurement in healthcare:

a) Volume. How many patient visits can you squeeze into X minutes? Easy to measure – the greater the number, the greater the reward. In a fee-for-service environment, the reason for this relationship is obvious: more visits = more cash. But even outside the FFS world, this idea – that part of what makes one clinician better than another is how on-time they run, or how soon a patient can get an appointment – is a pervasive one. And who knows, maybe it should be. Access matters, right?

b) Patient satisfaction. How happy was your patient with the perceived quality of the care provided? If health care was just like any other consumer-oriented business, this would make 100% perfect sense.

BUT. Studies show that patients may not always be the best judges of the actual quality of the care they just received. Scores go up when providers hand out more antibiotics and more narcotics. Scores go up when providers order more expensive tests and procedures. Satisfaction matters, but so does averting a post-functioning-antibiotic future, avoiding the unintentional promotion of opioid addiction, and keeping medical costs from bankrupting the nation.

c) Adherence to clinical guidelines. How many patients got a flu shot this year? How about a Pap smear, or a mammogram? Hard to see what could be wrong here. Lots of people who know lots of things spent lots of time creating those guidelines. Flu shots are good. Early detection and treatment of cancer is good.

But what about shared decision making? Does judging clinicians based on their adherence to guidelines, above all else, result in strong-arming patients into taking medications, or having tests performed, or whatever it might be that they don’t want, or can’t afford, or may not even be considered appropriate care in 5 years? (cough mammograms cough)

Having a conversation with the patient and discussing guidelines, and the evidence behind the guidelines, in a shared and mutually understandable language is always a good thing. But is it possible that overreliance on adherence to guidelines as a marker of quality misses something?

d) Measuring outcomes. How many of your patients’ LDLs, blood pressures, and A1Cs are within normal limits? This, also, seems reasonable. Considering that part of our job (most of our job?) is to try to make these things better, it makes sense that we be judged on how well we do.

But we also all know that controlling chronic illness is harder in some populations than others. Access to care matters. Wealth matters. Community norms and expectations matter. Does rewarding clinicians who can show better outcomes unwittingly drive them away from caring for more at-risk populations?

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Back to this unpopular-with-the-patients clinician. Sure, he’s decent at avoiding prescribing antibiotics for colds. But I also happen to know he’s not great with the interpersonal skills. He also doesn’t bother to spend much time explaining what he’s thinking and why – to anyone, really, about anything, let alone his diagnostic and care plans with his patients. So you can consider me completely unsurprised to learn that he receives a far-greater-than-average number of “He did nothing!” complaints than the average clinician.

Not for nothing, but I’m also known for being stingy about prescribing antibiotics. And yet I consider it a point of pride that even my most pre-visit-antibiotic-committed patients leave their visit agreeing with me that their nasal congestion is viral.

I don’t actually have any answers here. I feel like each of these quality measurements dances around an aspect of care that matters, but also somehow misses the bigger point. It feels like there’s got to be a way to measure and reward the intangibles.

Any ideas?

Blame the EMR

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Another day, another article blaming EMRs (electronic medical records) for the sorry state of medical documentation today.

The latest, “We are in the age of copy and paste medicine”, blames EMRs for the fact that medical providers are producing useless, inaccurate clinical notes because it’s easier to copy and paste a previous note’s history/review of systems/exam/whatever into your current note than it is to actually write a new note.

I can’t deny that EMRs make it EASIER to create useless notes. But the EMRs aren’t the ones creating these notes.

Clinicians are.

It’s time to stop blaming EMRs for our crappy documentation, and do something about it.

What can we do about it? We can START WRITING BETTER NOTES.

Sure, maybe this means it takes another couple minutes to finish your note. Do I find note-writing to be one of the most onerous tasks of my day? UH, YEAH. It’s a pain, it’s tedious, it sucks. But it’s part of my job.

I owe it to the patient, who took the time to come in and share their story with me, to write that story down somewhere. I owe it to my colleagues, who might see that same patient when she comes back in a week, to write down what I saw the first time around. I owe it to my future self, who might see the patient for a follow-up visit in 6 months, to write down my current and prospective plans for managing that patient’s care.

Back when computer illiteracy was a thing, and a decent percentage of health care providers were still technology novices, there was an argument to be made about how EMRs made life oh-so-hard. I’ve actually lived this: My first job as an NP was with an office where the implementation of an EMR, and the (questionable) decision to adopt temporary-but-actually-permanent schedule reductions for our more slow-to-adopt providers, resulted in the financial ruin and closure of an otherwise thriving primary care practice. That. Sucked.

But today? When the majority of Americans own a smartphone? When nearly 3/4 of Americans have a broadband connection at home? The argument that COMPUTERS ARE HAAAARD doesn’t really hold water.

So yeah. Copy-and-paste notes are terrible. Illegible template-based notes are terrible. Agree, agree, agree.

But we’re not powerless here. Like any form of technology, the EMR is just a tool. It’s up to us to decide how we’re going to use it.

You don’t like your colleagues’ templated, copy-and-paste notes? Tell them. Maybe they don’t realize how bad they are. Maybe being called out will inspire them to start creating less useless notes.

You don’t like your own templated, copy-and-paste notes? Don’t write them. Every EMR I’ve worked with has a free-text function.

The first step in recovery is admitting you have a problem.

The sooner we all admit that we share at least as much blame in producing lousy notes as the EMR developers do, the sooner we can start fixing the problem.

The luxury of time

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I have had a lovely week.

Really. I mean that. I’m not just talking about the perfectly-grilled steak I had for dinner last night, or the fact that I’ve been lucky enough to find Girl Scouts selling cookies at my subway stop, even though those were definitely highlights.

No, this week was something special. This week, I was able to be the health care provider I always want to be, the kind I always aspire to be, the kind I hope I’ll be able to be on any given day. With every patient.

Except I typically have at least 3 patients waiting and OH WAIT another double-booked emergency visit between me and this shining ideal. But not this week!

Why? Because as a grown-up woman, I’ve found myself once again completely, swooningly in love with that unique college tradition known as Spring Break. While most of my patients spend the week in exotic locales, enjoying all-inclusive cocktails and remembering what it feels like to experience above-freezing temperatures (MUST BE NICE), I get to stay behind inside the endless polar vortex, holding down the clinic-fort and taking care of the students who are opting out of paradise in order to spend their week sleeping in and catching up on House of Cards.

But that’s okay. My week may not have involved jell-o shots, but it did involve something even more delicious: time.

The clinical schedule was relatively light, but steady. Functionally, this meant that I was able to spend about twice as much time with each patient as usual.

Functionally, this meant that when I thought this one patient and I had reached a decision point, only for the patient to stop and ask to explore, from the beginning, a completely different possible option, I didn’t internally groan and look at the clock.

Functionally, this meant that when another patient continued to send me wordless signals that she was still worried that Something Serious might be going on beyond being unlucky enough to catch a third cold this winter, I dug a little deeper and asked, and listened, and talked until the signals indicated relief.

Functionally, this meant that when a different patient decided to “oh, by the way” me as our visit was ending with a completely unrelated, and much more complicated, symptom of concern, I asked her to tell me more with a warm smile. And I meant it.

It made me fantasize about an alternative reality: one where I’m empowered to spend as much time with each patient as the patient needs – as much time as we both might need – to feel confident that I’ve done everything I can do on that day, in that moment. Fewer patients might be seen. Which means the clinic might need to hire more providers. Which, I’m quite certain, won’t be happening any time soon.

Spring Break can’t last forever. The party has to end sometime.

But the memories last forever.

When “good” isn’t good enough

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Dear parents-of-college-students: before you decline your kid’s college health insurance plan because you have “good insurance”, please check to make sure that “good” will be good enough.

Recently, a patient came to see me with a history of recurrent ovarian cysts. She presented her story like it was old news, since this has been happening to her since she was 14 – or in other words, since well before she left the comfort of her parents’ home for the big wide world of college.

Her issue is that three or four times a year, she experiences what she describes as several weeks of progressively intense unilateral lower abdominal pain, culminating in severe pain (which she assumes is from a cyst rupturing) that eventually resolves on its own, with the help of lots of pain meds and missed class. 

Generally speaking, she manages things on her own, but yesterday, the pain was worse than usual. Her prescription NSAID wasn’t cutting it. She’d missed a midterm. I had a few questions: who does she normally see for this? When was the last time she’d had a pelvic ultrasound or any other imaging? Was there a plan to change her birth control pill, which she was ostensibly taking to keep things like this from happening? Was it time to dig a little deeper, to see if maybe something else was going on?

Well. It turns out that she hasn’t seen a health care provider (besides our college clinic) in years. Why? Because she grew up in New York. Her parents continue to live, and work, in New York. Their insurance allows her to be seen by providers in New York, and to have labs, and imaging, and procedures, and pretty much anything medically-related she might ever need, in New York. I’m sure it’s very “good” insurance – in New York.

If she actually lived in New York, well, that would be just fine, wouldn’t it?

BUT SHE DOESN’T.

I know, I know. Parents have a hard time thinking of their grown-up kids as no longer living with them. Sure, they’re away at school, but that’s just temporary. Their permanent address is still here with us, at home, right?

Hold up. If your college kid wants to keep listing your house as their permanent address while they’re bouncing around between dorms, sublets, and friends’ couches, living the typically transient life of an undergrad, that’s all well and good (after all, those parking tickets have to be sent somewhere).

But they need to have medical coverage in the place where their physical body actually spends the most time. If you live in California, but your daughter goes to school in Arizona, the place she needs coverage is Arizona.

You might be thinking something like this:

“I’m not worried. We just schedule her routine care while she’s home on break.”

Great, but what if she needs care that’s non-routine? What if something happens in the middle of the semester that might not meet criteria for being rushed to the ER, but really warrants being evaluated by a gastroenterologist, or a cardiologist, or whatever-ologist this week or the next, rather than months from now when she happens to have a few days off from school?

And what about that time – that not-too-distant time – when she stops coming home every summer or spring break? When she gets an internship, or a part-time job, or decides to take classes over the summer? How do you expect her to be able to get even routine, preventative health care if her insurance doesn’t allow her to have Pap tests performed in the state where she lives 95% of the time?

“Well, our insurance is pretty good. I’m sure she’ll be covered.”

Really? You might be surprised. One way that insurance companies trim costs is to limit where you can access care, so even if you’ve been pleased as punch with your plan’s low co-pays, and local provider network, and coverage for fun stuff like acupuncture, you can’t assume it covers anything beyond emergency care once you – or your dependents – leave the state.

Back to my patient from New York. Our options were limited to this: ER or no ER, since emergency care is all that her plan covers here in the state of Not-New-York. Beyond bringing her to an ER, my hands were tied – I couldn’t run labs; I couldn’t order an ultrasound.

Even though she was in pain, she didn’t want to miss yet another midterm. So against medical advice, she refused to allow us to transport her to the ER down the road, and instead returned to her dorm room, clutching her lower right side, with strict instructions to call the campus police to bring her to the hospital if things got worse overnight.

Had I been these parents, had this been my daughter, I would NOT be okay with this state of affairs. I would insist that we find a plan somewhere, somehow, that allows my daughter to access medical care where she actually lives. And I would insist a whole lot harder if she had a chronic or recurrent medical condition.

If, despite my best efforts, I couldn’t find a plan for our entire family with decent in-state and out-of-state coverage, I’d look really, really closely at the plan offered by my daughter’s college before checking the little “waive school insurance” box hidden somewhere within all that orientation paperwork.

So. My humble request to the college parents of America is this: if you’re planning on waiving out of the health plan they’re offering through your kid’s school, please, please, PLEASE read the fine print, or pick up the phone and sit through the terrible hold music until you get a human being to talk to, and find out whether your plan covers medical care – specialists, labs, imaging, etc. – in the state your child is about to move to.

Those insurance premiums aren’t cheap. So make sure they’ll pay for the care your family actually needs.