Tomorrow morning Monkey has an appointment to be evaluated by the sort of doctor who specializes in medicating children for things like ADD/ADHD. We don’t actually KNOW if he’s ADHD, at this point, you understand. We think he might be, and the sensible thing would be to have him tested for it, so naturally, we plan to do that.
Of course, the doctor who does the testing can’t see him until November. And really, what’s the rush? It’s only my son’s mental health, and perhaps his first grade experience. Clearly I am one of THOSE MOTHERS for being concerned in the first place. (I find it interesting that if I allowed his explosive behavior to continue unchecked, I’d be a horrible parent, but if I want answers and treatment, I am a horrible and possibly LAZY parent. This parenting thing? Is A LOT MORE CRAPPY than is generally advertised.)
Anyway, it’s not that I don’t trust this doctor we’re going to see, but I just thought I’d check in with the kids’ ped, first. I’m not sure what I was thinking. Possibly that it would be best to be cautious and/or thorough. Silly me!
Well, I called the pediatrician’s office last week and asked for a call back from the doctor. I might have had better luck calling and asking them for a thousand dollars. The woman on the phone was clearly affronted. She wanted details so that she could decide if I was worthy of actually getting a call back. When I explained why I was phoning, she cut me off.
“Oh, you want to schedule a physical,” she said. “Well, I can schedule that for you in November.”
“Um, no. I want to TALK TO MY CHILD’S DOCTOR to determine IF he needs to be seen before this other appointment.”
*crickets chirping*
This clearly wasn’t on her list of situations to handle. How dare I want to consult with the pediatrician. Either I was calling to demand an appointment or she had no idea what to do with me. The asking fifteen times to just get a call from the doctor wasn’t enough information for her to go on that I just wanted to talk to the doctor, I guess.
Anyway, I was told not to expect a call until Monday. I explained (again) that the appointment in question was ON Monday; could one of the other doctors call me, instead? Or a nurse? Well, she just didn’t know. She’d try to find someone for me.
[It was at this point that I seriously contemplated hanging up and calling back and hoping for a different secretary. At which time I would insist that Monkey was quite ill—but not TOO ill, because then they’d send us to the ER—and get an appointment for THAT AFTERNOON.]
The good news is that I actually got a call back from the pediatrician on Saturday. Saturday! That was impressive. The bad news is that I alternated between wanting to strangle her and feeling like a dismissed moron, myself, while speaking to her.
I explained what we were doing—who we’re seeing, what the general gameplan is, and a quick rundown on what’s been happening with Monkey. Then I launched into my concerns.
Could there be something wonky with his thyroid? No, she assured me. There’s no point in testing that, because if he had a thyroid problem, it would be affecting his growth. We’d see it. (Funny, all I see is a kid who is the SMALLEST IN HIS CLASS, but clearly he’s growing JUST FINE. Silly me.)
Could he be hypoglycemic? No, all kids get cranky when they’re hungry (with “you are an overreacting, annoying mother” implied). Right. All kids get cranky when they’re hungry. Heck, I myself get cranky when I’m hungry. However, I don’t ever throw chairs because of it. Isn’t it worth investigating? No, no need.
Could he be having more food allergy issues? No, if he isn’t sporting a million allergy symptoms, that’s not it. If he was head-to-toe with hives, maybe we could consider that a contributing factor. (Right, no one has EVER had subtler symptoms with allergies, particularly food allergies.)
Could he be sensitive to salicylates or food dyes? Well, you know, any kid at a birthday party who eats a lot of cake and ice cream is going to get a little nutty. (This was where I thought maybe I should just give up. Cake? Ice cream? Birthday party?? Who’s talking about any of these things? Not me. I can’t ask about food dyes without her thinking my kid just got a little spazzy at Chuck E. Cheese one day?)
So, basically, Monkey’s pediatrician is totally fine with this other doctor prescribing my son stimulants or other mood-altering substances without doing any sort of check-up, first. Though I am free to call her after the other appointment if I have any other questions.
Really, the only other question I have is “Could you please send his file over to his new doctor?” But the sad reality of how ALL of these practices work now is that switching probably won’t help. They’ve all been taught how to provide the “basic standard of care” that translates to “as little care as possible.” Hmph.
On the other hand, it’s good that we can’t get in to see the testing doctor for a few months… because it’s going to take that long to get his referral processed.
In the meantime, I guess I can just tell Monkey to stop eating sugar and getting nutty. You, kid—shaddup and eat some green beans. Probably that’d fix everything. Hooray!
This sounds weird, but have you had his hearing checked? Just finished reading a book by Leonard Sachs, MD. titled “Why Gender Matters” – boys at this age have a hearing deficit that girls don’t, placed in the back of a class they can’t hear thus can’t focus. Act out because they are bored and after a month or so, start coming home with notices to be evaluated. A teacher friend of mine suggested I read it. I am offering Assive for sure, but I applaud you for being cautious. Good luck for a positive outcome
Seriously, doctors. They just don’t get it sometimes. I’ve had my own share of bad experiences with them. Too many to list here. Just one question . . . Why does it take so long for pediatricians to recognize a problem that you as a parent recognize as soon as it develops? Just a little pet peeve of mine. And Medical Assistants/Secretaries . . . worthless. Completely worthless. Monkeys could answer phones better.
If you lived in Phoenix, I could recommend an INCREDIBLE pediatrician to you. She always called you the same day if you requested a call. She never got impatient or made assumptions when I was discussing a concern. She was an older woman, so she has learned from experience that parents know when something is up with their kids, so I never got any dismissive answers when I would bring something up. In fact, she would immediately order up all the appropriate tests in order to rule out serious problems. She had just the perfect amount of caution, instinctively doing just the right amount of tests without going overboard and turning a parent into an emotional mess. She was actually my pediatrician when I was a baby, and I was very happy to bring my kids to her when I started my family. She has huge displays of pictures of almost every single child she has helped since she started her practice (I found my own little smiling baby face from 1975 during one visit for my son) and she treated my kids like they were her own grandchildren! For those readers who might live in the Phoenix/Glendale/Peoria, Arizona area who might be interested, her name is Dr. Bandusavee Rhumba. She has a bit of an accent that makes her a little difficult to understand, but I have regretted losing her ever since we moved away from Arizona! Good doctors are hard to find!
I can hardly wait. You see, I work for one of the largest health insurers in the nation and they have decided that as of Jan 1, we all go on either HMO or “health savings plan” (which translates to “screw you if you get sick.” No more PPO for us. The EMPLOYEES of the health plan. No, we cannot pay more to be in the PPO. We are stuck with the HMO.
Last time I was stuck with their HMO, it took me six months to get approved for surgery on my herniated disk – six months in which I worked standing up the whole time because sitting down was too painful…grrrrr.
I feel for you.
My doctor’s not like that, so I know some doctors aren’t like that. It’s worth looking for one who’s not like that.
I work with kids in foster care, and if there’s anything they have in common it’s parents who aren’t proactive about their kids behavior issues. So even though there’s a big brick wall in front of you the simple fact that you are looking into it speaks volumes…
That is absolutely horrific. My knee-jerk reaction tends to be “thank God health care is so much better here in Canada,” but obviously from the other comments you’ve gotten there are people in the US who are getting decent care for their children too. You and your kids deserve better, and I hope you find it!
Arrrrgh, I hate the idea that Monkey might have to be on ADHD meds, although some respond to them very well. Also, I’ve had my doctor tell me that what the medical profession knows about food allergies can be written on the head of a pin.
May you have better information today.
The sad fact is the US educational system is not child friendly. Newsweek just did a great story about first grade and how stressful it is. My mom was a kindergarten teacher for almost 20 years and she said that many children who are placed on ADHD and ADD drugs don’t need them. She said these children often aren’t mature enough, even if they are intelligent enough, to handle being in a structured situation for long periods of time and if left alone, would outgrow their behavioral problems (with parental guidance). It’s a crappy trade-off: kids who do well in school but who are drugged. I’m sorry you’re going through this.
gah. our (former) ped told me that extreme rages, daily diarrhea, and lack of growth for 2 years was “normal”. We weazled a referral to a naturopath, who did the celiac testing, and have a much happier (if still not neurotypical) child.
our current ped is our current doctor BECAUSE they do things completely differently. They listen to us and suggest mainstream and alternative answers.
I hope you can find good answers for Monkey.
oh honey, sometimes it sounds like we live a parallel life! Don’t you just want to strangle those secretaries? I feel for you, honest I do.
I know I don’t have to tell you to research all the medications on line, and read up on thyroid disorders, ADHD, food allergies, and sugar intolerance because I’m sure you will. You’ll know so much by the time you actually get in to see the doctor that you can just tell HIM what the problem is, and which prescription to have ready.
Then send him a bill.
I’m so sorry, Mir. I know how awful a doc can make you feel about REAL concerns! We have a great doc, but he can still make the top of my “crap” list on occasion. Poor Monkey. You’re a great mom–concerned and active–you’ll get this all straightened out.
I have much better luck getting to a doctor when I call and ask for a nurse. Apparently nurses are not protected people like the doctors are, and then when you get one, they will immediately turn you over to the doctor. Sort of like a screening process and I have found the way to sneak myself through. That being said, I totally understand your frustration with doctors because my son has been puking nightly for almost a year now, and no one can seem to figure out what is wrong. He’s not just “nervous”. That wouldn’t wake him from a sound sleep to violently puke his guts out. It also wouldn’t cause the bloody diarrhea (too much info, sorry!) I swear I wish sometimes that I had gone to medical school just so I would be able to actually help people and also figure out what is wrong with my own kids. And if I had gone to medical school, I would totally help you out with your son too. Good luck!
Mir:
I sympathize with all of your post. I hope you proceed cautiously. The one thing I can never understand is why it takes 2 months to get an appointment with any doctor. Are they really that busy? Maybe they have too many patients? Would someone please explain this to me???
LOOK FOR A NEW DOCTOR! I wish ya lived where I do – I have a great one. You may have to talk to every mom in your kid’s classes to get a good one – you may have totrack down moms at the playground — DO IT. A doctor SHOULD NOT be dismissing your concerns as a parent.
Why does it take so long to get an appointment? Around here, doctors hours are Monday-Wednesday 9am-4pm, closed from 12noon-1pm. Perhaps if they actually had office hours for 40 hours a week, they could see more patients in a timely manner.
I hate doctors. and HMOs.
I didn’t mean to imply there aren’t great docs out there. I’ve just never had the pleasure personally.
Like someone said before, it seems like we are living parallel lives.
I don’t understand why it is that I seem to be the one diagnosing a child, and then telling the doctor what is wrong. And when it comes to my son and his strange behavior and skin rashes, they just throw their hands up and say, “He seems fine. Maybe he needs more sleep?” I just want to scream! I wish that I had pediatricians who looked at the whole – all of the symptoms and behaviors – and then tried to go from there and find out the problem. Instead, I’ve got nothing… and I’m trying to diagnose and find out which specialists to go to for help. because there has to be someone out there who can help, right? Meanwhile, the poor kids are expected to cope…
Oh, I feel your pain.
Grrr… That’s just so frustrating. The thing that kills me about that level of bureaucracy in healthcare is that it is SO MUCH LESS EXPENSIVE to prevent and diagnose correctly than it is to brush patients off until their problems can’t be ignored. Good luck– I hope you find a better doctor.
Grrr… That’s just so frustrating. The thing that kills me about that level of bureaucracy in healthcare is that it is SO MUCH LESS EXPENSIVE to prevent and diagnose correctly than it is to brush patients off until their problems can’t be ignored. Good luck– I hope you find a better doctor.
I feel for you with this doctor thing…I’ve had very limited success in finding doctors who can think beyond the standard, canned answers. It’s so frustrating. That’s why I was thrilled with the pedi GI doctor we were referred to last summer when my daughter was having major health problems. Not only was he polite and competent and seemed to know what he was doing, he *listened to me and my concerns* and even *took them into account when planning her treatment*!!! What a NOVEL idea that was…to think the PARENT might acutally KNOW something. Sheesh. (Now, his office staff? That’s another story…seriously, I think they all must be required to take “Speaking in a Condescending Manner 101” and “Advanced Patonization.” Honestly. :P)
i dont know what your plan covers, but i would strongly suggest seeing a naturopath… they work wonders… and help with behaviour issues as well. plus they don’t try to stuff your kids with meds.
Tread lightly on the AD/AHD thing. My daughter’s teacher told me that she needed drugs, turns out she needed a new teacher. I had a very inquisitive child who was bored. Some of the guidelines my “wonderful” pediatrician asked me to watch were things like, can she sit for long periods and watch a television program, can she play board games, (yes, she did throw pieces if she did not win)can she sit and listen while I was reading to her. Things like that. Once I determined that she could do all those things, no meds. Today I must report that she is a very “busy” young woman who holds down 2 jobs and is functioning quite well. You are great to be on top of this though. I’m sure you will do your homework and thus end up doing what’s right for your little Monkey. Hang in there Mir, there are some great Docs out there. I’m sure you will find yours.
One semester in college my asthma got out of control and the idiot doctor who saw me thought maybe I should start therapy, because there was obviously no medical basis for my breathing difficulties. You know, other than the virus I’d been sick with for 2 weeks.
I’ve been fighting to get good care for ages, and the absolute best thing you can do is ask questions, be proactive, and don’t be afraid to switch doctors. There are still good ones out there. Of course, now that I’ve found a few, I’m terrified of ever moving away.
What about the way they are teaching him? Maybe he does not like how they present the material, etc. I wonder if a different teacher would have the same opinion of Mr Monkey…good luck either way!
To chime in on one of your points. You might want to check on what kind of testing the doctor plans on doing. I would highly recommend (from experience) that you get a doctor that is going to conduct some quantitative tests, not just use one of the behavior inventories. Good luck.
Mir,
I am going through something similar with my little one — he’s 3. His behavior is affecting his pre-school experience but at home, it’s not much of an issue. I have observed him at school and I’m shocked at the difference in personality. Early intervention has ‘rejected’ us twice from services and now that he’s turning 3 we qualified for the city’s social service evaluation team. They met with him and think it might be ‘sensory integration disorder’. I’ve research it and many of the behaviors and ‘symptoms’ are on target. Maybe you can check it out for Monkey…
More assvice: Th doctor’s dismissing you? CALL HER ON IT. My doctor was doing the same re: my headaches, and another doc also dismissed my concerns about Dylan’s heart. I called BOTH of their asses on it and they smartened right up. No need to be nasty, just simply say, “I feel as though you are dismissing my concerns and I would like you to focus on these concerns instead.” You pay for good health care – as do we (through our taxes, mind you, but still), you deserve nothing but the best for your kids and only you can be their best advocate. Essentially you pay those doctor’s salaries.
I hope that wasn’t out of line – but it works for me, and I hope whatever happens, you get the best care possible.
Karen
xo
I agree with the naturopath suggestions. After years of teaching SDC, I can tell you there are some kids you respond really well to meds but others who become zombies. This is an important year for him academically, so playing with medications to get the right dosage or cocktail could waste a lot of time. I had three students who went off meds and changed their diet to accomodate their needs. It worked like a charm for two, not so much for the third.
Let me give you some advice. If it comes to a point where you are setting up a 504 or IEP, know that you are in the drivers seat here. There are a lot of options that are available and schools will NOT tell you about. Simple things like snack breaks or a modified schedule. I was actually threatened with a revoked tenure for telling a parent they had a right to refuse the IEP. Gee, I wonder why I left education…
Finally, listen to your heart. You are the parent. You know Monkey better than the doctor and the teacher. You may have to become one of “those” moms (in the mind of others anyway) but if it means he gets what is right for him, it’s worth it.
May I suggest a move to a smaller, rural community? I know it may sound like I’m asking a lot, but consider this… The run around everyone in urban settings gets from their family doctor. *insert dirty words of your choice here*
Doctors forget they work for us. They a lot us 15 minutes of their time, don’t listen, and charge us up the *see above*
Stick to your guns Mir, you’re a great mom, your doctor is a typical modern day quake, in a typical modern day medical mill. They say there is a shortage of nurses (I”m not arguing this fact) but there is a shortage of caring, not over worked physicians too.
HMO’s have led us down a massivily destructive path.
I sooooo feel your pain! My son’s problems include the food dyes (behvioral) reactions, but they can’t do allergy tests for it. His principle refused to believe that having 4 different meds with red 40 during one illness would make him freak out and throw a chair at the classroom tv. On the plus side, after that incident they did hook me up with a good behavioral doc. One thing we learned was that our school system works with social workers that can help in some cases. Made me nervous as hell to be involved with a social worker. However, she had dedicated appointments at different docs that made it so we didn’t have to wait for an appointment more than a week. Maybe yours has something similar that would work for the testing doc.
Keep in mind that your instincts are going to be more on target than anything the annoying pediatrician says.
Good luck pretty, pretty Mir! And good luck to Monkey!!
Mir,
I used to live in Massachusetts and had the most fabulous, kind, empathetic and responsive pediatrician known to man. So much so that I considered (very seriously) keeping him as my kids’ primary care physician now that we live in Washington state and just scheduling their yearly physicals for when we go back east every year. Feel free to email me if you’d like his name.
Monkey and Chickadee are blessed to have you for a mother! Remember no matter what, you KNOW your children. Trust your gut and don’t let a doctor talk you into something that feels wrong for your child.
I would advocate for pushing the doctor on the blood work. A handful of tests would put your mind at ease, being able to say “well it’s not X or Y or Z, so what have we got left?” I am a firm believer that eliminating possibilities is making progress towards a diagnosis.
Kids with growth hormone defeciencies (god I can’t spell) have a flatter than normal growth curve (IIRC). So even if Monkey is small, as long as he’s ON a curve and following it, he’s fine that way. I’ve got a kiddo with major growth issues so I’ve become an arm-chair expert in that area :-P It is okay for him to be the smallest in his class as long as he is growing at the right rate.
Hypoglycemia and allergies, you can play around with the foods you give him and see what kind of results you get. Eliminate dairy for a few weeks, or gluten, or whatever. Does the behaviour improve? Make sure he’s got something with a protien component for his lunch and snacks, does his behaviour improve? Stay away from juices, pop, cookies and other sugars for a couple of weeks. (they can make you crash HARD, I am hypoglycemic).
So some of these things, you can “test” yourself to see if it helps Monkey. Even if it isn’t the actual source of the problem, if it helps, USE it. You have the power to effect change.
Sheesh, why is there a Chuck E. Cheese-y, ice-cream-serving birthday party masquerading as an elementary school?
The good news from that phone call is that, should you feel the need to throw chairs across the room next time you’re at that doctor’s office, they’ll understand. As long as you’re hungry.
Hmph. HMO’s suck. And Dr’s who buy into the HMO mentality suck.
A local psychiatrist will NOT schedule any ADD/ADHD evaluations unless the child goes thru a thorough physical first, including bloodwork for allergies, hormone imbalances, etc. I wish all Dr’s were so open-minded.
Good luck. May you and Monkey find some answers.
And meantime, there’s still ice cream.
Hi Mir – I have a brother who is 17 years younger than I am, and when he started school, the teachers kept telling my mother that he was definitely an ADHD candidate. My mother did not think so… she got this book called “Raising Your Spirited Child”, which seemed to be the answer to a lot of her problems. I found a review of the book for you: http://parenting.ivillage.com/gs/gsbehavior/0,,45pv,00.html
Hope it helps.
Poor Mir and Monkey. I wish I could send you my GP and my (wince) Chiro (who’s more like a whole body health care physician – and, who saved my LIFE) on a silver platter.
So sorry. So very very sorry.
I gather there are a few non-sock-and-sandal-together wearing Chiros who actually treat the “whole person”, so to speak; I found mine by sheer accident, and I love her. I wish I could find you her clone near you because that is the kind of doc that makes people WEEP WITH JOY. (See exhibit A, the husband who HATES Chiropracrors but now would enthusiastically trust his very life and well being to our Chiro of 1 year.)
I also wish I could send you the perks of the Cdn health care system, which pretty much include seeing any damn doctor you want to for any reason, and having (some) GPs that are so good that you need to see a specialist fewer times anyway.
Sending good health vibes your way. And calmness vibes and coffee.
Also, my bro had a horrible time adjusting to Kindergarten. Tried two schools and he was a stressed out, unhappy kid. The 3rd time was the charm. Maybe he’d do well in Montessori or something?
Just blathering. I think you’re doing great. You are awesome and you’ll figure it out. And, I love you.
Good luck! Diagnosis can be a long haul. If you have doubts, get a second opinion — whether it be teacher or doctor. Keep all of the symptoms in mind, not just those that might be relevant. Small size and slow growth can be symtoms of conditions that affect behavior, too (sleep apnea, for example). You are awesome and pretty and you will do right by Monkey!
I remember taking my son to the doctor as a part of the required testing from his school to see if he needed special consideration with his schoolwork. It turned out that he had a very mild form of dysgraphia, but what killed me is when the doc walked into the exam room, picked up my son’t file, literally flipped through it in about 30 seconds, looked up at me and announced that he was not going to medicate my child just because I was too lazy to discipline him. Oh yeah.
I wasn’t there for medication, I was there for him to make sure there wasn’t any medical reason for my son’t difficulties. What a jackass.
So I shot fireballs at him from my eyes and he melted into a puddle of jackass goo.
I’ve been in this spot. We had testing done on our oldest son, by a pediatric neurologist. He did some really great tests and we ended up with a diagnosis of no ADD or ADHD and a prescription to go see a pediatric educational/behavioral therapist…who was like gold. Our son saw her for 8 months, she gave him practical strategies which he still uses, years later. She also gave him a battery of educational, psychological and personality tests, and diagnosed him with a mild information processing disability.
So, I highly recommend a GOOD ped. neuro.
Also? I’ve had really crappy encounters with pediatricians but we have a wonderful, caring compassionate family physician who treats the whole family. Very convenient when strep runs rampant and he just writes off a sheaf of prescriptions for us to call in when we need them. He’s also very accessible and extremely knowledgeable. Ask around and see if you can find a good family doctor.
This ADHD journey is tough…so much of it is confusing and contradictory. Hang in there. Something will come clear in the months ahead.
Oh this is such a sensitive issue. I had a cousin that was ADHD. My aunt used medication for awhile, but she ended up taking him off of it and used charts, discipline, and a lot of struggle. Strangley, at about the age of 12, when she remarried and they moved to a smaller, more attentive school district, a lot of his problems disappeared. I don’t know if it was the school attention, or not being labled a ‘problem child’, or his age, or what, but from then on his grades shot up and he was a great kid.
I also have a nephew that’s about 7. He’s been diagnosed ADHD since he was 4 or 5, and he’s on medication. I can’t tell you how hard it is to look at him, and see his pupils at pin points, and watch him sit around high.
I can understand the frustration and anxiety and mania of having kids. Mine were more than I could handle from time to time. Emotional outbursts and meltdowns were frequent occurances. And now my son is 11. Over the last year and a half, I have seen so much change in him. I had many people ask if I’d had him tested. I never did. No matter what I was not going to medicate my son through his childhood.
But I understand it’s about personal choice. It’s what’s going to work out best for the child and the family. Keep asking questions and pushing for the best care for Monkey. You’re doing a fantastic job. Don’t take the cold shoulder and the ‘Oh you silly woman’ brush off from those egotistical doctors (he he, my dad was one of those egotistical doctors).
One place I’ve found helpful is :http://www.help4adhd.org/en/treatment Finding out just what the criteria are, what the popular rating scales are, and the like can give you good information. Of course, it can also make you frustrated when others don’t have this information!
Keep pushing!
Mir, when Lil Daughter nearly died from hypert hyroid that went misdiagnosed for three years she wasn’t having growth problems. And one of the resons it was missed is because it’s so rare in a child that young. Most of her early symptoms were behavioral. It’s a quick stick for blood to get the test done, it’s inexpensive and if you rule it out you will know. I’d say get a second opinion (new pediatrician). You are in our prayers. I know how scary and frustrating this is.
Juat back from vacation so I’m weighing in late on this (and haven’t read more recent posts, maybe you’ve already followed up). Speaking as a nurse and a mother, I would have done exactly what you did. All I would have done differently is not let them blow me off. Yes, you will TOTALLY get loud sighs, you will feel stupid and overrreactive (especially if, God forbid, everything comes back normal), but saying a few (hundred) times, “It would really make me feel better to know beforehand that his thyroid is ok” (IMO, the ped may have been talking out of her ass – they rarely seem to have the child’s chart in front of them when they make call backs like that. Unless she seemed to have specific knowledge of Monkey’s growth history, she was probably making assumptions). There are always the few key words that will always get a reaction, and a few ways to ask doctors so that a) they think it was their idea to get the test and b)they can’t disagree with the request without seeming as though they are putting themselves at risk by ignoring it. Does that make sense at all? Lastly, yes, you may be labeled the overreactive mother as often as they see you but who cares? I would rather err in that direction than be the one they label “disconnected”.
Lastly, let me tell you this, and it takes more balls than I generally have unless I feel very strongly about something – if you make a specific request (especially in writing) about a specific concern stated strongly – they will without a doubt honor it if for no other reason than to cover their own behinds. Gotta get those MDs on the defense ;-)