Natal Teeth, Bicuspid Aortic Valve, Waiting Rooms – PediaCast 132


  • Back To School: Stress, Asthma, Backpacks, Teeth
  • Baby Born With Teeth
  • Bicuspid Aortic Valve
  • Waiting Room Times



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Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from BirdHouse Studios, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone and welcome to PediaCast. It is Episode 132 for Monday, August 18th, 2008.& We're going to talk about "Babies Born with Teeth". Yes, it does happen from time to time.

"Bicuspid Aortic Valve"& –& it's a big medical term but we'll break it down and take exactly what it is. Also "Waiting Rooms: How Long Should You Have to Wait for the Doctor?" We're going to talk about that as well.

It has been a really, really busy couple of weeks since the last we met together. We sold our house, which is pretty good in this market. It took about three weeks unlisted for about three weeks and then we had our offer, some negotiating for a few days. We reached an agreement, so that we are one step closer to our move to Florida.


Now the bad news is that the house that we were really interested in, in Florida, actually went into contract. I laugh now. I couldn't laugh for a few days. It went into contract, two days before our house went into contract so we weren't able to get that one.

But we do have a contract on a lot. We're going to build a house so we're very excited about that. And we'll talk about that more in future shows. The only problem with building now we've got to move twice because we have to rent a house while our house is being built. Yeah, you go hear me complain about that, too.

So there's been all this house stuff going on, still working on getting my Florida medical license. I'll tell you what. The bureaucratic red tape, and now, actually, the holdup is the FBI, [Laughter] my background check.


Apparently, my fingerprints were smudged and we have to do it again so that's going to take a few more weeks because the government is not quick about anything, of course.

That's it, though. That's the only thing I'm waiting on for that. So hopefully it won't take too long. There has been this whole find a house, sell your house — all that — it's just craziness, and so that's why.

It's been a couple since we've had a PediaCast now. Plus, you throw in the Olympics and Michael Phelps winning all these gold medals. I think we've watched every race that he's been in. That's been exciting.

I love the Olympics. I really do and so that's also been a holdup I'm getting these shows out. So I apologize for that [Laughter] as well.

All right. We got a big show for you today. Of course, thanks to our sponsor, and we're going to talk about –& actually in the news department –& we're going to talk a lot about back to school since that's coming up.

How a back-to-school relates to stress, for both kids and parents.


Asthma — what do you do about back to school there?

Backpacks and getting your child's teeth ready for back-to-school.

Speaking of teeth, we're going to talk about babies born with teeth and I mentioned bicuspid aortic valve and waiting room time. That's all coming up a little bit later on in the show.

All right.

Don't forget that the information presented in PediaCast is for is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is, as always, subject to the PediaCast Terms of Use Agreement and you can that over at

Also, if there is a topic that you would like us to discuss, all you have to do is go to, click on the Contact link. You can also email


If you do that, make sure you let us know where you're from because the Contact page at the website has that automatically, where you have to put in where you're from. But if you email, you might forget to do that.

And it's always interesting to find out exactly where our listeners are located. And then your third option is to call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

And our next show, I promise, we're going to catch up on Skype line comments but that maybe a couple more weeks, depending on how this whole "move" thing goes. So we'll see.

All right. And with all those things that I just mentioned in mine, we will be back with News Parents Can Use, with our special back-to-school segment of news, right after this.



Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at

August can be a stressful time for teens and twins as they prepare to face another school year and with it, news, social and academic pressures. The Partnership for a Drug-free America recently released a survey, showing the number one reason for kids turning to drugs and alcohol is school-related pressure.

Of the 6,500 teens surveyed, 73% said that coping with school stress is a main reason why they turned to drugs. In an accompanying study of parents, just 7% of moms and dads thought teens might use drugs to deal with stress.


Hmm, 73% of teens said they would think about it and 7% of parents thought their teens –& only 7% thought their teens might actually do it. That's a big disconnect. There is a real disconnect between what teens are thinking and feeling and what parents believe about their teens, when it comes to attitudes about drug use.

Many parents know their kids face pressures unheard of when they were teens. along with schedules as demanding as most adults. But they may be surprised that instead of blowing off steam by playing soccer, gossiping at the mall or playing video games, some teens do see drugs and alcohol as a way to grapple with tough classes.

As parents make their to-do lists for back to school, far more important than buying new clothes and notebooks is making time to talk. Having what may be a sensitive or even uncomfortable discussion with your child about handling stress in a healthy way and letting them know you care about them too much to see them in danger.


Your kids may roll their eyes but they will hear you. Frequent discussions with kids about the risks of drugs and alcohol go a long way. Research shows kids who learn a lot about these risks from a parent or other caring adult are up to 50% less likely to use drugs and alcohol.

Now if you're not sure how to start this conversation, you can visit for advice and tips on talking about tough subjects with your teens. Back-to-school is an important transition time but it's not the only time you should talk to your kids about drugs and alcohol.

How many times have you told them not to drink milk out of the carton or leave laundry on the floor? Keep the conversation going all-year and remind your kids every day that you trust, love and support them. And of course, we'll have a link to in the Show Notes at

Nearly 11% of children heading back to school this fall have asthma. Annually, school-aged children with asthma missed just about 13 million days in the classroom making asthma-related illness — one of the most reasons kids are absent from school.


To minimize asthma's grip, parents must first be aware that per government regulation, manufacturers are phasing out production of a common type of albuterol inhaler, often called a CFC inhaler.

By December 31st, 2008, CFC inhalers will not be available to the consumer public and will be replaced by an HFA inhaler. The FDA found that HFA inhalers are safe and just as effective as their CFC counterparts.

One significant difference is that HFA inhalers do not contain ozone-depleting chemicals found in the older units.

"Some kinds might find their new inhaler has a slightly different taste or feel," says Dr. Norman Edelman, chief medical officer of the American Lung Association. "Also be aware that your pharmacy won't be able to simply substitute the new HFA inhaler for your existing one."

Your child's doctor would need to write a new prescription. It's also important for parents to confer with their child's physician to ensure each of their asthma prescriptions are current and children with asthma should be seen in the doctor's office at least once a year and more frequently if their disease is moderate or severe.


The American Lung Association offers parents a seven-step checklist to ensure a safe and healthy school year for children's suffering from asthma.

Number one: Schedule those asthma checkups. Even if your child's asthma is well managed, scheduling a check up with your doctor is critical to ensure your child's asthma continues to be effectively controlled. This is also an opportunity to evaluate medications and physical activity restrictions.

Number two: Confirm medicines are up-to-date and fill those prescriptions. If your child uses an inhaler, ensure you have a current prescription for a new HFA-type unit. Check your medicine cabinet to ensure your child's asthma prescriptions has sufficient refills available and that they have not expired.

Three: Know About Prescription Assistance Services. No one should have to do without their asthma medications because of financial need.


Two organizations are available to help. The Partnership for Prescription Assistance can be reached by calling 1-888-4PPA-NOW. And Rx Outreach also provides needed help.

You can get more information from their website at And as always, we'll have all that information in the Show Notes at

Number four: Asthma Action Plan. All students with asthma should have a written Asthma Action Plan that details personal information about the child's asthma symptoms, medications, any physical activity limitations, and provides specific instructions about what to do if an asthma attack does not improve with prescribed medication.

Five: Visit Your Child's School Nurse and Teachers. All teachers, coaches and school nurses and the principal's office should have access to a current copy of your child's Asthma Action Plan. Discuss with your child's teachers specific triggers and typical symptoms so they can be prepared to effectively assist your child should an asthma attack occur during the school day.


Number s — : Advocate for Your Child. It's important to learn if your child's school allows students to carry and independently administer their asthma medication. Some schools require students to carry a note from their doctor. Learn what steps need to be taken to have your child carry and use their inhaler if recommended by their doctor.

And finally, Know Your School's Asthma Emergency Plan. Ensure that your child's school knows how to contact you in case of an emergency. It's also important for parents to know the school's past history and dealing with asthma episodes. Parents should confirm that school staff including coaches and bus drivers, have been trained and responding to asthma emergencies.

From inhalers to backpacks, many children and teenagers carry backpacks during the school year for school books and other supplies. "When used correctly, backpacks are the most efficient way to carry a load and distribute the weight among some of the body's strongest muscles." That's according to Dr. Eric Wall, director of Orthopedic Surgery at Cincinnati Children's.


However, there is room for injury. In fact, the American Academy of Orthopedics and the U.S. Consumer Product Safety Commission say, more than 13,000 children are seen each year in hospital emergency rooms, urgent care centers and doctor's offices for backpack-related pain.

The Division of Orthopedic Surgery at Cincinnati Children's Hospital Medical Center recommends these simple guidelines to prevent unnecessary backpack injury to your child throughout the school year.

When choosing a backpack, look for one that is lightweight, has two wide and padded shoulder straps, a cushioned back, and waist straps. A rolling backpack is another good option if your child has to carry a heavy load. But keep in mind, school terrain is more challenging to negotiate with wheels than your average airport.

Also encourage your child to use both shoulder straps and make sure the straps are tight.

Limit your child's backpack weight to no more than 15% to 20% of his or her body weight.

Organize your child's supplies and books so that the heaviest items are closest to the center of your child's back and distribute the load evenly by using all available compartments.


Encourage your child to stop at his or her locker often to avoid carrying all of their books throughout the day.

When wearing or lifting a heavy backpack, remind your child to bend using both knees.

Also remind them not to leave their backpack on the floor where others could trip over it, and avoid swinging the pack where it may hit others.

Back and shoulder discomfort is common with heavy backpack use. If your child complains of persistent back pain, be sure to consult his or her doctor.

And finally, some back-to-school news from the dentist, Dr. Mark Helpin, acting chair of the Department of Pediatric Dentistry at Temple University says, "Back-to-school is the perfect time to schedule a dental check up."

So much of dental care is reactionary with parents taking their children to the dentist only when there's a problem. But Dr. Helpin says, "Moms and dads should schedule oral health checks just as a schedule routine well-child visits with their pediatricians."

And there's good reason for this advice. According to the Centers for Disease Control and Prevention, tooth decay is the most chronic childhood disease in the U.S. and is five time more prevalent than asthma and seven times more prevalent than hay fever.


Yet, it's a condition that is entirely preventable.

Helpin says, "The key to prevention lies with early regular visits to the dentist every s –& months, in addition to treating and preventing tooth decay. Kids and parents get valuable information about maintaining healthy teeth and gums.

The American Academy for Pediatric Dentistry recommends taking your infant to a dentist within s –& months of the first sign of a tooth and warns that without regularly scheduled dental care, poor oral health could lead to a number of larger health issues in the teenage years and beyond.

"It's important to establish relationship with the dentist, the same way you would with a pediatrician," Helpin says. "This is the idea behind the "dental home"& –& a place where an oral healthcare provider has established a relationship with the child. That doesn't mean just treating an issue; it also includes preventive treatment and nutritional counseling."

According to the American Academy for Pediatric Dentistry, the concept of a dental home enhances the dental professional's ability to assist children and their parents in the quest for optimum oral healthcare, beginning with the infant visit and continuing for years to come.


By including dental checkups in the back-to-school health screening process, Helpin says "Parents can establish a routine where dental care and education are provided, which will in turn ensure good oral health and overall health for life.

All right. That concludes our News Parents Can Use and we will be back to answer your questions right after this break.



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All right. First stop in our Listener segment is Barbie and Barbie is one of these folks who wrote in by email and didn't include where she's from. So Barbie that's OK. We're still going to answer your question.

I sometimes get accused of being condescending to my listeners, and if I ever come across that way, I apologize. You just have to realize that I'm a bit sarcastic and that just goes along with the territory.

So Barbie know, you know, no harm, no foul. Next time you write-in though, let us know where you're from.

Barbie says, "Hi, Dr. Mike. I love the show. Thank you so much for putting it on iTunes. I had a baby in February and PediaCast has helped answer so many questions. My daughter now four months old was born with two lower front teeth."

"She had difficulty latching and by day three the teeth had become loose and were bleeding and she had lost over a pound since birth. Per my pediatrician's advice, I had the teeth pulled by a pediatric dentist."

"Unfortunately neither my doctor nor dentist has seen this before. My personal dentist warned me that she might have speech difficulties and problems with the placement of her lower teeth."


"Have you had patients born with teeth or are aware of babies born with teeth? In particular, what should I look out for in regards to her teething and when to start solid foods? Thanks, Barbie."

All right. So let's define this phenomenon and they're called natal teeth and that just means teeth that are present at birth. So you think prenatal like a prenatal ultrasound means an ultrasound done before birth, so natal teeth are teeth that are present when the baby is born.

Now how common is this? The true prevalence really is unknown. Some studies show that's about 1 in 700 births, although that's probably too high. Some show that's 1 in 30,000 births. That's probably too low. So the truth is likely somewhere in the middle.

There's also conflicting differences between male and female prevalence. Some studies saying that it's more common in males and some studies saying it's more common in females.


So there's actually a lot of confusion out there on this topic and the research that is presented is conflicting. However, all the studies do agree on this. The most common location is the mandibular incisors. So this is going to be the front middle bottom teeth, which is where Barbie's baby had her teeth.

The next most common location is the maxillary incisors, which is the front middle top and then the least common are going to be the cuspid teeth and the molars.

Now another interesting consideration with this, greater than 90% of them are primary teeth, meaning that they are true baby teeth. So pull them, you're going to have another tooth come true until the adult tooth comes in.

Less than 10% of these are supernumerary or extra teeth and you can tell the difference between, whether it is a primary tooth or whether it is a supernumerary tooth with an x-ray.


So you get an x-ray of the baby's mouth and if there is a baby tooth underneath the tooth that's popped through and an adult tooth starting to form below that, then you know that it's an extra tooth as opposed to a true baby tooth.

Now why is it important? Why would you even want to know that? If it's a true baby tooth and if it's not causing a problem or posing a danger, you want to leave it in. Why? Because there won't be a subsequent baby tooth to take its place and then you'll need a spacer work to keep proper positioning of surrounding teeth so that there's room for the adult teeth to come in, if you don't want the surrounding baby teeth to slide over and fill in that space and then there's no room for the adult tooth to come in.

You either have to figure out some way to put a spacer in, between the baby teeth as they come in surrounding where the tooth is lost.


Now if it's a supernumerary or an extra tooth, you generally want them pulled to make room for all the normal baby teeth that are yet to come. Now another important consideration which I hint to that: are the natal teeth causing a problem or posing a risk?

In other words, are they interfering with latching and feeding with subsequent weight gain issues, like with the case with Barbie's baby. Is the baby cutting his or her tongue? That's possible and sometimes happen.

And then are teeth secure or are they loose? If they're loose and they fall out, it could be a choking or aspiration hazard. So you got to be careful with that, too. You don't want those coming off in an unsupervised time and the baby chokes on the tooth, or inhales it down into the trachea or down into the lung.

So there's lots of things to think about. And I think your doctor did the right thing, getting a pediatric dentist involved right from the get-go.

Now on to Barbie's more specific questions and add a few more questions, which Barbie probably had, but just forgot to ask. [Laughter]


What about teething and introducing salads? Really nothing should change here. Teething is highly variable to begin with. I mean you can see some kids getting their first teeth when they're two or three months old. That's definitely early.

You can also see some babies not getting their first teeth until after they're a year old. In general, teething begins around s –& months of age, may be four to s –& months of age, really depending on genetics and your baby's individual development pattern.

So it's really highly variable to begin with, and it will be highly variable in kids with natal teeth as well. So just because they have natal teeth does not mean that they are prone to earlier teething of the other teeth.

So natal teeth do not predict early or late bloomers — when the teeth come, they come just like in every other kid. So that's really not going to be any issue special to your child, Barbie. It's going to be, just it would with any other kid, highly variable.


With regard to food introduction, nothing changes here either. If you leave the natal teeth intact, it does not mean you should start salads sooner because there's still choking issues, still nutritional issues. So feeding advice really remains the same.

You do just breast milk or formula until they're four to s –& months of age. At four to s –& months, you start introducing cereals and stage one baby foods; between s –& and nine months of age, you start with a stage twos; 9 to 12 months of age, you start with stage threes and table foods. Just the normal feeding advice, for newborns or for babies, is going to apply for kids born with natal teeth as well.

Some other questions that come up with natal teeth that Barbie didn't ask. But I think there are also important questions. If the natal teeth are primary teeth or true baby teeth, how do they fair? There's actually bad news report on that front.

Tooth development appears to arrest after eruption so these are soft teeth with poor quality enamel and they're very prone to decay erosion and trauma.


Now still, as long as they are in securely and proven to be true baby teeth, they're not supernumerary or extra teeth, and they're not causing a problem or posing a hazard –& it's still better to leave them in rather than pulled them just because of a high likelihood of significant decay down the road.

Now once decay sets in, then what do you do? Well, that's judgment call. That has to be decided on a case-by-case basis between mom and dad and the pediatric dentist. If the decay isn't problematic, other than looking bad, you may decide to leave it well enough alone and let the teeth act as a natural spacer.

On the other hand, if the decay is painful or causing recurrent oral infections then it may be best to pull them.

Another good question is how well developed are the remaining teeth when they erupt? In most cases, they're completely normal. They stay inside the gums, develop on schedule and erupt into healthy teeth with stronger enamel and ditto for the secondary or adult teeth that follow.


And finally, what about other health problems? Do natal teeth herald any other non-dental disorders?

In most circumstances, they don't; however there is a weak association between natal teeth and some rare genetic disorders among them — Pierre Robin Syndrome. Pierre Robin, we do see some time to time but these next ones are much more or really rare.

Jadassohn-Lewandowsky syndrome, Ellis-van Creveld syndrome and Hallermann-Streiff syndrome. Now these are beyond the scope of this discussion. And there's something though that your doctor will want to keep in mind if other problems start popping up.

So to sum it up, natal teeth are rare but not unheard of. Most are real baby teeth that have popped out early on the bottom gum in the middle. If they are true baby teeth, which you can tell with an x-ray and they are secure and not causing a problem, you leave them in.


But you expect them to have decay issues no matter how well you take care of them. If they are not true baby teeth, they are supernumerary or extra teeth, or if they are loose or causing a problem, then you pull them out.

If they were true baby teeth and you pulled them out, then you're going to have to deal with a space issue and keep the surrounding teeth from crowding and interfering with the adult teeth to come.

The remainder of teeth is going to be the "normal"; teething expectations are the same, feeding schedules; all the same, nothing changes there. But there are similar syndromes, natal teeth can herald so your doctor would have to be on alert for those.

But most kids with natal teeth won't have any other problems. So I hope that helps, Barbie.

I do have a link in the Show Notes to a very well done website that discusses natal teeth and includes a fabulous reference list. And as always, we'll put a link to that site on our website at


OK. Next stop is Laura in Las Vegas. And Laura says, "Hi, Dr. Mike. I sent you an email a few weeks back about my 15-month old who's now almost 17 months, having a heart murmur. We saw the pediatric cardiologist and she diagnosed my son with a bicuspid aortic valve."

"The doctor didn't recommend any treatment, just to watch and monitor at twice yearly with echocardiography. The doctor said that as he gets older, he might need to have surgery on the valve that stops working properly, as well as avoiding heavy contact sports."

"I'm not sure if you plan on covering this topic at all but I would love to hear any information you have on this condition. As always, I enjoy your show and look forward to each new episode. It's very informative and entertaining as well. Keep up the good work. Thanks, Laura".

OK. So let's talk about "bicuspid aortic valve". First, let me take a sip of coffee. [Sipping coffee]

I'm sorry I'm not a professional broadcaster so you just have to deal with that. [Laughter] It is morning.


OK. So bicuspid aortic valve, what is it? Let's start with just the aortic valve in general. Let's just start with heart valves in general.

Valves regulate flow, right? And the cardiovascular system is basically plumbing, so let's approach this from a plumbing perspective.

Heart valves really regulate the direction of blood flow. So valves and plumbing can either regulate direction of flow or how much flow gets through. So the heart valves are really the type of valve that regulates the direction of flow. So what happens?

All it can do is squeeze. It can't tell the blood which way to go, OK? So the heart muscles squeezes in a given chamber and when it does, the valve on one end of the chamber has to close and the valve on the other end of the chamber has to open. So the blood only has one way to go. So when that heart muscle squeezes, pressure builds up in the chamber.


You have decreased chamber volume because the muscle is pushing in with constant blood volume, so you're going to get an increased in pressure. And something has to give and hopefully, what gives is going to be the correct valve, and that opens and blood flows out of the chamber and then the heart muscle relaxes and more blood flows in.

Now meanwhile, the valve that opened to let the blood out closes so that the blood that just exited the chamber can't go back in, and that's how you maintain flow in a given direction. So in plumbing terms, heart valves are check valves. That's the term used for valves that maintain flow in a given direction.

All right, so now let's get a little bit more specific. The aortic valve lies between the left ventricle and the aorta, so it regulates the direction of flow of blood from the heart to the general circulation.

Now the aortic valve is normally a tricuspid valve that means it has three leaflets or three cusps that come together when the valve closes.


So if you're looking down into the valve from the top, when it's closed, it's going to look like a pie that's been cut into three equal pieces. And when the valve opens, those pie pieces swing out from the edge of the circle, so the middle part swings out and then blood flows through.

When the heart muscle relaxes, the blood flow stops and the pie pieces swing back shut, keeping the blood in the aorta. So that's a flow back into the heart.

So we have three pie pieces or leaflets or cusps –& whatever you want to call them –& that make up the valve. This makes it easier to understand what a bicuspid aortic valve is. And I bet you can guess. It only has two cusps or two leaflets. So it's like a pie cut down in the middle into two pieces instead of three.

So what's the big deal? These cusps tend to be stiffer and don't close as well.


So a trickle of blood is able to leak back from the aorta into the left ventricle. Now as long as this leak is tiny, it's not really much of a problem. But if the leak becomes larger, the volume of blood in the left ventricle increases because now you have blood coming into the chamber from two sources –& from the left atrium and then also back from the aorta where it's not supposed to be becoming from.

So the heart has to work harder to keep that blood moving forward and of course, keeping blood moving forward is critical for oxygen delivery to the tissues.

Now also, if blood is coming back in from the aorta, so this valve is insufficient, not closing all the way and blood is leaking back down into the heart, then as that becomes more and more of a leak back, then there's less room in the ventricle for the blood coming from the left atrium or the preceding chamber.

So the greater the leak, the smaller the room for blood that's supposed to be getting in there and less room means the blood starts backing up.


And what's upstream of the left atrium? The lungs! So blood starts backing up there. An increased pressure in the lungs from this backed up blood causes fluid to leak out of the blood vessels and into the lung tissues.

So now we have fluid in the lungs, the person has major exercise and tolerance. They have chronic cough and we have a condition known as "heart failure".

Now the good news is that this leak back in from the aorta to the left ventricle is usually very mild in kids. But it does often get worse with time and that's the reason for the every s — months echocardiogram.

Echocardiogram just uses sound waves to get a picture of the heart and the flow so that you can see if there's valve insufficiency or blood that's leaking back the wrong way.

Now there's more to the story than just the leaky valve. Remember I said that the bicuspid aortic valves are often stiffer than normal aortic valves and they are so stiff that they usually make a clicking noise as they operate.


Your doctor hears this clicking or snapping noise which clues us into the problem. And blood flows more turbulently over these stiff leaflets or cusps, creating a murmuring sound, which clues us in further that something's up.

Finally, the turbulent blood flow over these different valves eventually leads to calcium deposits on the valve cusps and these further interfere with the valve closing properly and then you get even more backflow or insufficiency of the aortic valve.

And if the calcium deposits get too big, they even interfere with flow when the valve is open and this is now a condition called "aortic stenosis". And this leads to an even louder murmur and worst backing up of blood and heart failure, because blood is having a hard time getting out of the heart.

So we have lots of things going on. In most cases, these scenarios play out over many years and most often they don't create a problem until the third or fourth decade of life.


And what then? Well, mild cases may still be managed medically with drugs that decreased blood volume, diuretics such as Las –& and also drugs that help the heart contract more efficiently.

But in many cases, the valve will eventually need to be replaced, either with an artificial synthetic valve or a porcine or pig valve; otherwise permanent and life shortening damage occurs to the heart.

So how come in this condition? About 1% to 2% of the population is affected. It's twice as common in males compared to females, and there is a genetic component with the disorder clustering in some families.

There is a nice resource on the subject of heart valves. It's a book by Adam Pick. It's called the "The Patient's Guide to Heart Valve Surgery". And I'll have a link to the book's website which has some great information concerning bicuspid aortic valves in it and the type of things that go on during valve surgery. And I'll have a link to that in the Show Notes at


All right. We have one more listener question to cover. This is an interesting one. It's really non-medical and I put a lot of thought into the answer of this one. It took me quite a while to come up with a little presentation on it.

It's probably going to be a little controversial. So who wrote in? It was Dr. Eric from Fort Myers, Florida.

Dr. Eric says, "Dr. Mike, I discovered your podcast about three months ago and I've been a faithful listener ever since. As a fellow pediatrician, I find it extremely valuable and I often steal your answers to questions to give to my own patients."

"My question for you is less medically oriented and more logistics oriented. How long are your patients average wait times in the office?"

"I've been in practice about four years so I'm still new at this. And I always feel guilty about patients waiting to see. Our practice tries to make scheduled patients waiting no more than 30 to 45 minutes to see the doctor while same-day sick visits can expect to wait for an hour or longer on extremely busy winter days."


"I tried to give patients my full attention and often spend longer than strictly necessary to ensure that all of their questions are answered fully, and all issues are covered. That's naturally means I get behind during the day but I feel like my patients appreciate the extra attention they get from me at each visit." I'm sure they do.

"I thought your listeners might appreciate hearing what pediatrician's expectations are for wait times and what they should expect for good care. I look forward to your answers. Sincerely, Dr. Eric."

It's a great question. It really is. And I think that given the system that we have today, that the wait times that you present are very typical and as I compare them to my own practice and other pediatricians I know, so 30 minutes is definitely common and sometime as long as an hour or more during the busy season.

The secret from a patient-parent standpoint is to schedule first of the morning or first after the lunch break appointments because the backup hasn't occurred yet.


So that's really the best time now. Some of you know, especially if you're long time listeners, I have some glaucoma issues with my eyes. I've had eye surgery in the past. So I have to see my eye doctor every three- to four-month basis.

I always try to schedule the appointments first of the morning or first to the afternoon because if you do a late morning or late afternoon appointment, you're going to be waiting a lot longer because of this backup that occurs.

Now, naturally the question becomes –& why schedule so many patients? I mean why not just count on spending more time in the room and putting fewer spots in the schedule so that you don't get backed up?

And there are many reasons for this, but the elephant in the room, I mean, probably the biggest reason of all is that as much as you are or I might not want to talk about it, medicine in America is a business.


And not only it is a business but in the primary care world it is a business prone to high overhead and slim profit margins, and the only way to keep your head above water from a doctor's point of view and from a doctor's expertise on business practices is to increase production.

I mean we can't really increase rates because insurance won't pay us what we charge. They pay what they pay, whether we like it or not. And in most cases, we can't bill the patient directly outside of their guidelines.

We have a contract that says "we'll accept the co-pay" and we'll accept what the insurance gives us and that's it. And if we refuse that insurance company's contract, they say "fine". We'll send our clients to another practice who will sign our contract.

So it's crazy really. I mean what other business is prone to that third-party control when it comes to what they can charge for their product? So the number of spots in a schedule is often not based on how many patients we'd like to see but how many patients we have to see in order to pay the bills.


Another issue of course is doctor availability. If you don't the space in your schedule, people go elsewhere but that only works so long. At some point in many communities, there's nowhere left to go.

Everyone is busy and because there is a shortage of primary care doctors in the urgent cares and the emergency departments fill up. And that too is a scene played out in many places. The doctor's schedules are full because there's nowhere else for people to go.

So if you combine the financial need to see X number of patients to pay your employees and your rent and your immunizations, the stock that you have to buy, with the community's need for us to see X number of patients, and you combine those things with the compassionate doctor who's interested in your family and interested in educating you and interested in not rushing through, things like in assembly line, you end up with long waiting room times.

And there's really no other way around it, given our current system. And this is really the controversy comes in.


But I don't think it's really going to change until people stop feeling health care as a "right" and start looking at it as a "commodity".

For too long, health insurance has made people feel like they were getting something for free. And soon you feel like you have the right to have free health care even though from most of our country's history, health insurance plans didn't even exist. It's really a twentieth-century phenomenon.

Back in the 1800s, health care wasn't as good as it is today, but they paid for health care just as you paid now for oil changes and cable TV and groceries. You have to pay for health care as well. And back then it was no different for doctors but now people have this idea that "I'm paying for something"& –& well, how many backup?

Before maybe the last 5 to 10 years, probably more than last five years, people didn't really pay that much for their insurance.


They expected their employers to pay it. There wasn't really a huge deduction off your paycheck. Co-pays might have been $5, $10 at the most and prescriptions were a lot cheaper.

But now, there is more of a "burden" shifting to the consumers. So then now, we have higher deductibles, much higher co-pays and the consumer wants more and more quality and more convenience because if I have to pay out a pocket, I don't want to wait an hour for the doctor.

If see it coming out of my paycheck, when I go to the doctor's office, I have a $30, $40, $50 co-pay, I don't want to sit there for an hour because now I look at it as a commodity rather than a right. And I want the best place who's going to look at me as a customer and treat me well and make sure I don't have to wait this long.

So when you look at health care as a "right" that you get for free, I'll wait an hour because it's free.


And I don't really have a choice. But it is my right and I'm going to be here as long as it takes. But when health care becomes a commodity, when people see themselves paying for a service, they want something more.

They want quality. They want timeliness. They want a good service. They want to be respected and they deserve those things. Unfortunately, doctors can't give better service in many cases as long as we are constrained by the insurance system.

And doctors tend to be ignorant on good business practice, which include cutting overhead and widening profit margins. All we know how to do is add volume to match our increasing expenses.

Medical students see primary care doctors struggling financially and they say, "I don't want to be any part of that." So they decide to pursue medical specialties and subspecialties which pay much, much better to see far fewer patients, which means that fewer medical students become primary care doctors which just exacerbates the problem and something has to give.


And it is beginning to give.

More and more doctors are getting out of business for themselves and becoming employees in a corporation run by people more savvy in business practices. In fact, that's what I'm doing.

I'm going to practice now where I'm a partner and we have to manage the business aspect of it, which is becoming much more difficult to do, with slimmer profit margins and higher expenses and overhead.

Large corporations are stepping in to staff emergency rooms and radiology departments, with doctors who are on a payroll. And some companies are even opening up their own healthcare center at car plans. For instance Toyota is starting to do this. Many of their factories have their own health center, which is run by a company that employs doctors, just staff physicians, who are on the payroll.

Some doctors are actually stepping out of the insurance came all together and there's an increasing number of concierge-style doctors who have very small panels of patients.


They don't take insurance. They charge higher fees but they provide outstanding personalized care. Is that only for the very rich? Maybe. It depends on what you're willing to spend for good service.

I mean, a family of five easily drops a $100 to $150 on a nice dinner out. Is it worth a $100 t0 $150 out of pocket to see a doctor who gets you in at a time that's convenient for you, who doesn't make you wait but is waiting there to see you, who spends as much time as you need, whether it'd be 10 minutes or 30 minutes is that worth a $100 t0 $150 outside of the insurance game?

On the other hand, if you're going to settle for $20 co-pay medicine, you're going to get what you pay for. And at the present time, that's long waiting room times and a doctor who often seems hurried.

That's the system we have now but it is changing slowly. And in many ways I think it's improving and getting better.


It is taking money coming out of the patient's pocket so that then they start to demand better service because they see the money leaving their pocket, whereas when it's just coming out of the paycheck and your company is paying for most of it, then you don't care so much.

So these improvements though can only go far –& can only go so far as long as insurance companies are the ones calling the shots and as long as patients look at health care as a "right" rather than a commodity.

OK. So he talking about the business aspect of medicine because everyone wants to think that their doctor is just being there because they want to help you. But the truth is, as a doctor, I have a mortgage to pay, I have two kids to put through college. I have all the expenses that you have, plus medical school loans that are as much as another mortgage.

And so, we have to look at those things, too. And when insurance companies aren't paying much, we have to book, put lots of spots on the schedule so that we can pay the bills.


All right. We're going to go and take another break and we'll be back to wrap up the show, right after this.


All right. Thanks go out to Nationwide Children's Hospital for providing the bandwidth for our program. We really appreciate them. They've been our sponsor now for almost a year as our bandwidth sponsor.

So we really, really thank Nationwide Children's Hospital in Columbus, Ohio for helping us out with that.


Also thanks to for being our episode sponsor today. Thanks to Dr. Eric for writing in. Really appreciate that. And I'm going to be a fellow colleague in Florida as soon as the FBI does my background check, which I don't think is a problem other than smudge to fingerprints.

Also thanks go out to Vlad over at for helping us out with the artwork at the website and on the feed.

Medical News Today for helping us out with our News segment. Our Listener segment I just want to thank all of you, guys. Thanks go out to Barbie and Dr. Eric. And we also had Laura in Las Vegas, writing about bicuspid aortic valves.

So thanks to all of you for contributing to the show. I know there many, many, many, many more of you who have contributed and requested topics and such that we have not gone to and I apologize for that.

We try to get to as many as we can and we'll be able to get to it a lot more once this whole move thing goes through.


So once we're settled in Florida and I'm hammering away at the new job and there's a lot less hours with the new job than the job I have now, so there's going to be lots of more time to work on the show. So I'm excited about that.

So thanks to everyone for participating and of course, thanks to my family for putting up with me [Laughter] in doing this, although it's been less of distraction from family life since this move thing is going on because I'm very involved in that, obviously, and not working on the show as much.

OK. My family does some blogging. My wife does the PediaScribe blog which you can find at So will get you there, too.

A couple of posts that I'm highlighting, one is called "Katie Through the Years" and the other is "Nick Through the Years".

Karen found this site called Yearbook Yourself and we'll have a link to it in the Show Notes. But Yearbook Yourself, you basically take a picture of yourself or your kids or your loved ones or whoever you want.


And you put them, you upload them, and then this site generates what you would look like as a yearbook picture in the 1950s, the 1960s, the 1970s, the '80s, the '90s –& that kind of thing.

And it's really funny, amazingly accurate. [Laughter] You have to check out what my daughter and son would have looked like had they been kids in a public school. And we home school so we don’t really have a year book. [Laughter] That'll be interesting thing.

We should come up with a home school yearbook. That would be cool. So anyway, Katie and Nick, you want to see what they look through the years in your book pictures. We have it for you at

Now my daughter, Katie, she does a blog called BaggaChips — all that in BaggaChips — and feature on this one is, normally, we want –& I want you to be healthy and I tried to be healthy, although I could do better job. I'm sure.


But anyway, at the Ohio State Fair, one of the traditions of our family is to share a deep-fried twinkie. Now I tell you. As disgusting as that may sound, it's actually really good.

And so Katie did the blog post on deep-fried twinkies and we'll have a link to that in the Show Notes at

All right. Reminders. Don't forget that PediaCast shop is open. We have t-shirts and we also have bags, tote bags, that sort of thing with the PediaCast logo on it.

iTunes Reviews are very helpful. If you haven't done that yet, please stop by iTunes and put a review and we'd really appreciate it. We also have a poster page at the website where you can download PDF files and print them out as posters to hang up on bulletin boards.

And we also have a Listener Survey, a new shorter one. If you're one of those people who are a long time listener and you filled out one of the old survey forms that took forever and you thought "Why in the world are they asking me all these questions?"


The new one is much shorter and we'd really it appreciate it if you would stop by there. All these things are in the side bar at the website at

All right. It's probably going to be another couple of weeks before I get another show out because we're right in the time now where we're wrapping things up. We're going to be closing on our house in a few weeks and making the move to Florida, so I'm not sure when the next show is going to be.

But suffice it to say, it probably won't be until sometime in September. But bear with me because once October hits and things settle down, there's going to be lot more shows, although I will point this out.

The estimated time of our new house being done is going to be like late January, February, most likely, maybe as late as early March. And until the news is built, I'm probably not going to have as nice of a studio as I have now because we're going to be living in a rental.


It's much smaller. I'm actually getting rid of the desk that currently I use for my –& the wood to stand my microphone. So probably, once we move to Florida –& but before the new house is built, I'm going to be using a headset.

And I think the quality of the audio and production of the show is going to take a little bit of a hit so just to prepare you for that. But as soon as the new house is built, we're going to have a new studio, which is going to be awesome because I can design it from the ground up.

I'm really, really, really excited about this. It is going to be an awesome studio. And the audio capabilities of this house that we're putting into it are going to be incredible. So I'm really excited about that. But it's going to take some time so you just have to bear with me and understand. [Laughter] I appreciate that.

All right, enough of the "jibber-jabber".

Don't forget we are going to get to the Skype line calls, too.


So if you have called in to the Skype line and asked a question that way and it seems like it's been forever, the next show will be Skype line calls. But again, I don't know when that's going to be.

Until that time, whenever it is, this is Dr. Mike saying, stay safe, stay healthy and stay involved with your kids.

So long everybody!


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