I’m a physician so I’ve testified as both a fact witness and as an expert witness. My husband is an attorney need I say more? We’ve had foster children, adopted some children through foster care.

I think that this and that in reality some healthcare systems are just horrible to their physicians and at some point when you’re working overtime, literally getting assaulted, literally risking your life, something has to give. I may work in one of the few decent health systems so I’m not personally worried for myself but as a mom, wife, daughter, and sister the physician loss in the US concerns me for the healthcare for my family, and our nation.

In the past JCAHO could grant Medicare certification but Medicaid was more complex in some states. That changed in 2010 with MIPPA. CMS is now the Medicare authority. Medicaid is still regulated largely at the state level and several states do not recognize JCAHO for state facility licensure.

My husband actually did the bulk of Thanksgiving this year. I worked a physician overnight shift in the ED 11/22 into 11/23. It was a really busy night and pretty much everyone truly needed to actually be in an ED (or ICU). Somehow everyone survived. I left the hospital and went to run a Turkey Trot with our daughters. I came home, showered, and went to sleep. DH did pretty much all of Thanksgiving Dinner except some of the pies I made ahead of time. Also when I got up and felt human again I pulled together a quick spinach lasagna to go along with the rest of the meal (a tribute to my Italian heritage and a kindness to one of my vegetarian colleagues who was joining us). He also supervised the kids (including DD2 and DD5) while I was sleeping. I’m sure he delegated some but I’m still pretty thankful to have him.

I'm sorry for whatever else is difficult and complicated in your life. I think I would impose consequences for taking/destroying her sister's things. In our family, while we encourage sharing and helping, we do respect our children's right to have choose not to share some possessions and in some contexts and situations to choose not to help. Generally they do choose to share with and help their siblings. For example, when our current DD17 and our eldest daughter were both living at home they did share clothes some [as possible---our eldest is quite tall so some things were just not shareable] without any issues. Fast forward four years and now they are college freshman/first year medical student attending the same institution and sharing clothes again at least somewhat which is kind of sweet.

We have adopted through foster care and we had guardianship of my husband's godson (his late father was one of DH's best friends) while he aged out of foster care in our home. Having said that, I truly see myself as a mother of ten. Although I have different connections to and special relationships with all of my children I see that as the reality that they are all unique and special individuals. Each of them bring something different, yet very beautiful, to the fabric of our tightly woven family. Half of our children are my biological offspring, 60% of our children are my husband's biological offspring, but they have all grown into our hearts in a way that has certainly changed us, and our collective family, for the better.

We have a large walk in pantry off of the kitchen. Our chest freezer is in there. We also have a smaller chest freezer in our root cellar.

I agree that you can be grandparents without taking custody. Our DD13 and DD9 have a strong relationship with their biological MGF who has really become a part of our extended family [ie he was recently here to celebrate our biological daughter's second birthday with the rest of the family]. This grandfather actually briefly raised DD13 when she was four right after her parents' death and then in quick succession after the death of his wife and her grandmother. He had a MI and many complications and as there really wasn't any other family to care for her she went into emergency foster care and then when her infant sister was released from the NICU they both went into a foster adopt home. By the time their grandfather was out of the hospital and physical rehab the girls had just turned five and one and the foster parents were working towards adoption. Those foster parents were not interested in him having contact with the girls as they believed it would be confusing and he says that hurt him but he was led to believe they were happy in their new home so he felt he should try to respect their new parents. For various reasons the foster adopt placement was not a good fit for DD13 and the adoption never happened because the court would not separate the girls adoptions. We started taking DD13 as a respite child when she was seven and then ended up with her after the foster parents abandoned her at our house. They took DD9 with them when they fled the state. When they were apprehended a few months later DD9 (who was four at the time and traumatized) was placed with us as well. Ultimately we have managed to adopt both girls and allow them to re-establish a relationship with their biological MGF.

To verify board certification check with the relevant board. In your case, this would be the American Board of Psychiatry & Neurology. If the physician happens to be a DO then they may be boarded through the Osteopathic board (although many DOs are allopathically boarded or also allopathically boarded). In 2020 all GME will be fully merged everyone finishing residency then and beyond should be allopathically eligible.

1.) I have never looked at reviews. Verify no disciplinary action and current board certification if it is an unfamiliar physician sure. I personally also make sure that my child will be seen by a physician at least for part of the visit. [so I am ok with physicians who do use NP/PA as physician extenders but still examine all patients and sign off on the plan but not physicians who supervise only retrospectively.] 2.)If I had personal safety concerns with the area then I would avoid for that reason. Otherwise, no, my eldest daughter's unsung hero of a pediatrician worked in an FQHC and was amazing. 3.)Child/Adolescent is a subspecialty fellowship off of Psychiatry. With a teen I think if you have CAP availability you can/probably should start there but if you don't have CAP availability and have general psychiatry comfortable with teens that could be a good option. In your case I would call the office and ask if they would be comfortable. I personally wouldn't put much stock in online reviews but if you have had good success picking physicians via review sites then maybe that is a good approach to continue.

With all of the push for independent practice from NPs (and even PAs sadly) I don't think this is a safe assumption. Regardless unless the physician is also seeing the patient on the same day then the supervision is retrospective and will be more on the order of identifying mistakes after the fact rather than ensuring quality care is delivered in real time. Additionally if the supervising/collaborating physician never sees the patient at all but just looks at the NP/PA documentation then it may look like acceptable care but in reality the diagnosis may be completely incorrect and critical exam findings may be overlooked.

Tapentadol works on the Mu opiate receptors so addiction issues are certainly a concern and a reality for some. I think the DEA was doing the right thing when they classified it as a schedule 2 drug.

Oral ketorolac does exist and actually has been shown to have similar/superior in some studies efficacy to hydrocodone/acetaminophen.

Statistically where I practice this is the case but the issue is a bit more complicated and multifaceted than that. A lot of communities now are also seeing heroin contaminated with fentanyl, and carfentanil which are increasing the overdose and death rate.

I can agree with a lot of your post. Unfortunately, I do not think Suboxone is the answer so many believe it will be. I do not favor increasing suboxone caps or allowing non physician members of the healthcare team to prescribe.

I had one cesarean section and four vaginal births. Three were VBACs. I didn't take narcotics after any of my births. I think that was probably a bit atypical in the initial twenty four hours after my cesarean and I won't say I wasn't in pain but it was manageable albeit not completely eliminated with non narcotic options. Interestingly after the birth of our final daughter a little under two years ago the nurse I had in post partum was aghast that the only thing my OB had written for pain was ibuprofen. She made a big deal of paging and "advocating" for me to get something (while ignoring my attempts to explain my OB probably knew I didn't want anything else and if I was in sufficient pain to need something else then I was probably having some horrible complication and needed re-evaluation much more than narcotics). I don't disagree that physicians need to take responsibility for what/when they prescribe. However, I think there are some regulatory and reimbursement scenarios that penalize physicians who do prescribe responsibly. I don't offer that as an excuse because I firmly believe that when you are sacrificing your clinical judgment for external forces and pressures then it is time to stop practicing. I stand by that and I know I am fortunate to work for a medical director and healthcare system that respects my profession and my professional judgment. Not all physicians are so fortunate and some of that is part of our physician shortage. Then of course there is last week's tragedy in Indiana. At this point the opioid epidemic is shifting back into heroin partly because it truly has less street value than prescription opiates. [based on my statistics as a toxicologist not personal experience.] Controlled substance restrictions are also making prescription opiates harder to procure which contributes to the shift.

We have never belonged to HSLDA because some (ok, probably most, or even all) of their views, values, and political agendas contradict our Christian faith and approach to raising our children. Beyond that, my attorney husband believes that they have committed legal malpractice in a few cases in a few states he is admitted to the bar.

In my experience as a physician, unfortunately it seems that nutritional restoration, medical monitoring, and management of medical complications due to suboptimal nutrition are very overlooked aspects of eating disorder treatment. I would definitely schedule an appointment with your primary care physician.

So far our kids have lived: -in our guesthouse while commuting to a state university about 40 minutes away. -in a townhouse he owned [he went into the military at 17 and then came home to work his way through a BS while working]. -in a freshman dorm as her school doesn't have separate dorms for athletes. Current DD17 will also be living in an on campus dorm when she heads off this fall.

Prayers are sent.

I'm trying to avoid quoting so bear with me if the response seems very disjointed. *Please pursue professional evaluations. Too often I see foster families buy into the all they need is love and good parenting mantra. While I agree that all children need these things children with trauma need specific treatment and if there is superimposed or secondary mental illness that needs to be treated as well. If you want to advocate for these children then push for the evaluation and necessary services. If necessary present for a crisis evaluation to your local ED or mental health community center. *The superficially charming mommy shopping behavior with raging at home is a red flag for RAD but there is a lot of overlap with other diagnoses like PTSD/CTSD, depression, TBI (sometimes meeting ASD diagnostic criteria), and ASD as well. I think the best option is to keep an open mind about all diagnoses. The evaluating child psychiatrist should not rush to a diagnosis either and often a second opinion is very appropriate and helpful. *If PTSD is a consideration then I think treating that should be the top priority. TF-CBT with a certified and skilled clinician is an evidenced based approach that can be used (and studies have included) children as young as three. If you have specific questions about this feel free to message me. *If you're getting angry then please look into what options there are for support for you. Are there additional parenting classes that could give you some new skills? Are the kids eligible for some respite? Is this just a bad fit placement and would it be best for the caseworker to seek a better fit? *Gently, and I really believe that you're doing the best you can, I don't think any child needs our anger. Yes, I can imagine if you are angry/loud/scary enough they may capitulate in fear [unfortunately, that may just entrench the PTSD/CTSD and make things worse in the long run]. Good Luck!

Our cars are generally clean. Everything (except emergency supplies and a spare diaper bag which live in the cargo holds) comes out of the car when we get home. We vacuum as needed in between having the cars periodically detailed.

Sending positive thoughts and if you need another perspective feel free to message.

As an EM physician, I have seen some bad burns/injuries from consumer fireworks gone wrong so I don't have a problem with states that outlaw them. The majority of states where we own homes only allow sparklers and I think this is generally a good compromise although I have also seen some misadventures with these and they are not something we personally will have at least while we still have small children at home. Our communities do have organized fireworks displays on certain holidays and I think that can be nice (and since it is at one discrete pre-planned time it is much more possible for pet owners, veterans, parents etc to plan ahead). Where our main home is we can actually get a quite nice view of the display from our side lawn/patio/pool but really don't hear much. For our family, viewing July 4th fireworks from the pool is a great option.

While we certainly have tried to show and model the importance of supporting your children financially and emotionally we do not agree that sole earner scenarios are always the responsibility of the male half of the couple.