tag:blogger.com,1999:blog-7950271042943860402024-03-13T23:14:14.159-07:00The Ethical PediatricianDr. Wolffe Nadoolman's blog about the practice of medicine, medical ethics, and the delivery of healthcare. Particular interests are in the ethics of primary-care medicine, the ethics of ethics applications and study, and the business ethics of medical practice.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.comBlogger23125tag:blogger.com,1999:blog-795027104294386040.post-28157349728873237262012-01-22T23:52:00.000-08:002012-01-22T23:52:00.675-08:00A Patient with Natural Supplements 3<p>In the last couple of posts, I recounted having to spend about 2 hours looking up all of the ingredients of all of the supplements a patient of mine was taking, at the prescription of her chiropractor.</p> <p>This post is about my anger.</p> <p>Why aren’t supplement ingredients on the label of the product?</p> <p>How come most prescription products come with a sheet of paper the size of a tablecloth, folded 1024 times so it ends up the size of a stamp, completely covered with tiny print that is required bylaw to mention every rare adverse event that happened to subjects during a clinical trial?  Because it’s required.</p> <p>If the product is effective as a drug, and is used as a drug, why aren’t there clinical trials?  </p> <p>Why do I need to spend 2 hours looking this stuff up?</p> <p>Why didn’t the other guy review with the patient all the potential side effects, the risks of interactions, the risks of hypotension and collapse, of bleeding spontaneously, of increased menstrual cramps, flushing, lactating, breast pain, odd body odor, stomach pain, gas pain, diarrhea, allergic reactions, rashes, itches?</p> <p>Why is it that I have to reassure myself that the undocumented sourcing of slaughterhouse discards of adrenal and thymus glands and testicles from many animals of several species won’t require disclosure of the risk of Bovine Spongiform Encephalopathy—Mad Cow Disease?</p> <p>Why should I have to worry about the products claiming to be better and natural sources of vitamins because they are derived from algae?  The fact that algae are being proposed to de-contaminate toxic heavy-metal superfund sites, because they so selectively accumulate this kind of poison, shouldn’t be a problem for people taking algae every day, right?  </p> <p>If I prescribe a medication, and there’s a problem interaction with one of the supplements, who will rush to help the patient?  Who will answer the phone on the weekend, or at night?  Who will spend the time to figure it out?  Who will be blamed?</p> <p>And it did, indeed, occur to me after hours of research into these products and their ingredients, that I looked up what was on the label.  There is no regulation requiring that what is on the label is exactly what is in the pill, or if it’s fresh, or if it’s not contaminated, infected, or accurate.  </p> <p>Are you really, really sure you want your kids taking this stuff?  Is it really better than whatever you consider a drug?  Did the person at the health food store tell you about all the side effects and interactions?  Did that nice woman in your mom’s group?</p> Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-54558439644954682862012-01-15T23:12:00.000-08:002012-01-15T23:12:00.084-08:00A Patient with Natural Supplements 2<p><a href="http://lh3.ggpht.com/-kybFrXL78Ks/TwFZDcdQ9nI/AAAAAAAAA9M/39Q912Tm3_c/s1600-h/marigold1%25255B5%25255D.jpg"><img style="background-image: none; border-right-width: 0px; padding-left: 0px; padding-right: 0px; display: inline; float: left; border-top-width: 0px; border-bottom-width: 0px; border-left-width: 0px; padding-top: 0px" title="marigold1" border="0" alt="marigold1" align="left" src="http://lh6.ggpht.com/-XtUb9YTEJok/TwFZF_HZL8I/AAAAAAAAA9U/l5WleDvQROI/marigold1_thumb%25255B3%25255D.jpg?imgmax=800" width="177" height="175" /></a>When I first reported the prevalence of Calendula in natural products recommended for skin conditions, I pointed out that calendula was a derivative of marigold flowers.  Marigold is a sibling to ragweed, the most common allergen in North America.  So it seemed particularly shocking to me that the natural products industry has somehow targeted all those kids with eczema to get this product that will often make their skin much worse, even if they avoid the emergency room for the asthma attack.</p> <p>I noticed that my patient had some nasal allergies.  I didn’t make anything of it—I have some of these too.  But I spent a couple of hours making sure that the medication I was prescribing didn’t have some kind of interaction with the 8 nutritional supplements recommended by her chiropractor.  I wasn’t too concerned about the vitamins, whether they came from algae or a Swiss pharmaceutical company.  Deep down on the list of one of the products—mostly vitamins and minerals in this one—was a quick mention in the ‘other ingredients’ section:  barley grass.  I wondered if it could be triggering her grass allergies in the middle of winter.</p> <p>And there was another product with Globe Artichoke as an ingredient.  It’s in the same flower family as marigolds and ragweed.</p> <p>Yet another product contained Milk Thistle.  It’s in the same plant family as, sure enough, marigolds and ragweed and artichoke.</p> <p>But it probably didn’t help that buried in the long list of ingredients in another product was dandelion. Lots of people are allergic to that, too. She wasn’t taking antibiotics, so I wasn’t worried about the dandelion lowering the levels of antibiotics in her blood. </p> <p>She was taking a product I often recommend:  Fenugreek.  It’s a common spice in Indian recipes, but that’s not the way I prescribe it.  I use it with new mothers struggling to develop their milk supply.  Not with all, and not with whatever dose they want.  I write down for them exactly how many milligrams, how many times a day, what they should expect, and what side effects they should look out for.  Just like any medication I prescribe.  </p> <p>Because I was very experienced with the use and dosage of this product, I don’t expect—though that doesn’t mean it’s not possible—that this teenage girl will start leaking in an embarrassing way during 2nd-period geometry.  Should I warn her that it can increase uterine cramping?  </p> <p>I found out that many of the product ingredients interfere with blood clotting.  Some have effects on blood pressure.</p> <p>I’m happy to admit that somebody with high blood pressure might do quite well on Reishi Mushroom.  Maybe better than on conventional drugs.  But it’s still a drug.  Some studies show that it decreases platelet activity.  That’s generally a good thing in heart-disease patients.  And anything that lowers your blood pressure increases the risk of fainting, sometimes not at the most convenient moment.  </p> <p>What is so annoying is the obvious elephant in this room.  It’s a supplement when I try to supplement my diet with some extra fruit and vegetables.  But these are drugs.</p> <p>The natural medicine folks want to have it both ways.  If the plant products actually work medically, they are better because they work ‘naturally.’  But if they work medically, and do all the things claimed—like serious changes to bleeding, blood pressure, or the immune system—why aren’t they drugs?  If they don’t work medically, why are they recommended?  </p> Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-67404467691765589932012-01-09T22:09:00.000-08:002012-01-09T22:09:00.776-08:00A Patient with Natural Supplements 1<p>Late last week, I met a new patient.  A delightful teenager, she was interesting and engaging.  She was insightful and open, and I agreed with part of the diagnosis she came in with.  I would be prescribing some medication for her.</p> <p>I asked some typical new-prescription questions.  Was she taking any medications?  Did she have any allergies?  No, and no.</p> <p>It was the first time I met her, so I asked about her stuffy nose that she kept rubbing.  Well, she did have <em>those</em> kind of allergies.  As we went through some of her medical issues, she revealed some typical teenage-girl symptoms.  I asked if she has tried to do anything about these, does she take ibuprofen, and so on.  She said that her mom took her to the chiropractor, and she takes some supplements that were recommended.</p> <p>Which supplement?  She didn’t know.  She said it was 8.  </p> <p>“Eight ingredients?” I asked.</p> <p>“No,” she said.  “Eight separate bottles.”</p> <p>“What do they do?”</p> <p>“I don’t know,” she said, earnestly.  At my request, a parent emailed me the list.</p> <p>Don’t expect a complete horror story—this isn’t one.  Most of the products were basically vitamins.  Calcium from seashells, and B-vitamins from Blue-green algae.  There were a couple of surprises, and some insight from my research.</p> <p>Funny thing about algae:  it concentrates what is in the water it lives in.  So it is a concentrated form of protein and vitamins.  But it is often found with high levels of <a href="http://www.youtube.com/watch?v=arpZ3fCwDEw&ob=av3n" target="_blank">heavy metal</a>s.  And sometimes it gets contaminated with microorganisms you probably don’t want.</p> <p>There were a number of products with names that didn’t give a clue about what they were for.  So I looked up the manufacturers, got their list of products, then found the ingredients.  </p> <p>As an aside, I have to imagine that the target market for many of these products has its bulls-eye right here in Berkeley, where the vegans look upon vegetarians as insincere poseurs, ersatz Dr. Strangelove apologists for global thermonuclear annihilation. </p> <p>So imagine my amusement and the gleeful profundity of my schadenfreude when I found that the product called Okra Pepsin (sounds vegetable-y, right?) contains what the manufacturer claims to be a ‘proprietary blend’ (they don’t need to worry about me stealing the secret formula) containing bovine orchic extract.  Perhaps they use an extract of orchids that look like cows.</p> <p>Not exactly.  The go to slaughterhouses, ask if there are some testicles lying around, and then, you know, extract.</p> <p>Why did this teenage girl need this?  I couldn’t guess.  She was also taking products using ground thymus glans from slaughtered animals including cows and sheep and maybe other species.  And another product with adrenal glands.</p> <p>Hey, in some places they consider organ meats a delicacy.</p> Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-81973226201756543182011-09-02T20:12:00.001-07:002011-09-02T20:12:22.504-07:00Pharmacogenetics and Race in the Medical Record<p>There’s a discussion on a physician site I subscribe to about whether ‘Race’ should be included in the general demographics information of electronic medical records.  Here’s the reason it should.  Now that we are every so slowly receding from the political correctness of the last couple of decades of the 20th century, medical researchers are finding out that there are differences in both disease risk and care for certain groups of people.  We’ve know for years that your child’s chances of certain genetic conditions were different based on your and your reproductive-partner’s genetic background.  Everyone has known that children of Ashkenazi Jewish heritage (more or less of Eastern European background) were at higher risk for a terrible genetic disease called Tay-Sachs.  Dark-skinned people of African descent were at higher risk of sickle-cell disease; white kids of cystic fibrosis.  Finally, in the last decade or so, researchers have found the freedom to study some important medical problems, and they have found out important things.  Here’s a good summary of some findings in the growing field of pharmacogenetics, which looks for differences in the response to different medications.</p> <p><a href="http://circ.ahajournals.org/content/118/13/1383.full" target="_blank">Racial differences in response to cardiovascular medication.</a>  [It’s pretty readable for non-doctors.]</p> <p>It has been found, generally speaking and for example, that there’s a difference in response to a common blood anti-clotting medicine in Black, White, Hispanic, Asian people.  This could be really important to know.  Though not a cardiologist, I have the impression that treatment guidelines have incorporated some of these findings, and you might get a different dose or medication depending on your ethnicity.</p> <p>Have I sold you on this?  </p> <p>We have always known that different people respond differently to a given medication or dose.  Sometimes doctors have to try different formulations or doses to get the therapeutic response that will help the patient.  Clearly, there’s something about the way that patient is metabolizing the therapy that is special.  Presumably, it’s genetic.  Note—it might not be.  Grapefruit and grapefruit juice, for example, is a very potent inhibitor of (and this is common knowledge) the CYP3A4 form of the P450 enzyme.  A lot of drugs get digested by this enzyme.  Blood pressure drugs, heart rhythm drugs, cholesterol drugs, sleeping pills, anxiety drugs, antidepressants, antihistamines, some birth-control pills, some immune-suppressant drugs and some anti-HIV drugs.  Chances are really good that you or someone you love is taking a medication affected by grapefruit, especially by grapefruit juice.  Organic or not.  Did the people studying these drug-responses ask their subjects about grapefruit juice intake?  I don’t know.  </p> <p>I’m bothered by the idea of having an ‘Ethnicity’ in your child’s medical chart.</p> <p>So far, a lot of the research in this emerging field of Pharmacogenetics (also Pharmacogenomics) isn’t.  It’s really PharmacoRacialist research.  There’s painfully little genetics and lots of studies of ‘racial groups.’  </p> <p>I’m not trying to be politically correct here.  I wouldn’t doubt that epidemiologic research done in a remote Chinese village is probably representative of a relatively limited genetic pool.  True genetic research in the U.S. has depended for decades on relatively closed and technically inbred communities among the Amish.  One of the reasons behind the excellent and expert genetics professionals in Utah is precisely the multigenerational stability and consanguineous inbreeding available for research.  Genetics research looks for a link between subjects.  A lot of this current research has only an ‘ethnic’ label as the common link.</p> <p>Partly, it’s the government’s fault.  Seriously.  The Census is probably the most important way our tax dollars get divided.  And, perhaps with good intentions, the government wants to know about the ‘racial’ makeup of this country.  </p> <p>As far as I can tell, this is the latest official information from the Office of Management and Budget, which manages the Census.   </p> <p><a href="http://www.census.gov/population/www/socdemo/race/Ombdir15.html" target="_blank">US Census Directive 15</a> </p> <p>Everything is going to be bases on the census, and the racial distinctions are sociopolitical, no longer genetic or medically-based in any way.  If you think certain groups need to be kept track of, write your congressperson.  </p> <p>From a medical ethics point of view, there is clearly emerging data suggesting that different treatments or approaches might be optimal for those with different genetic ancestries.  These distinctions are unlikely to overlap much with meaningless Census distinctions, such as 'Hispanic' (which, after years of debate, has apparently been changed to “Hispanic or Latino.”  The 'Asian or Pacific Islander' category will be separated into two categories -- "Asian" and "Native Hawaiian or Other Pacific Islander."  Hey, at least the islanders live on islands for pete's sake, at one point in the 19th-century genetically isolated in the Darwin-in-the-Galapagos sense.  My Korean and Chinese families don't think they are Japanese.  What about Filipinos or Indonesians where different islands can mean different origins.</p> <p>I have a family with 2 Chinese grandparents on one side and 2 grandparents from Portugal on the other.  They recently immigrated here from Brazil--what are they?  What are their 2 adorable kids?Are they Latino because Portuguese is a Romance Language?  Hispanic because they are from South America?  Asian because the kids have those sort-of-Asian eyes?</p> <p>There’s an easy reality check.  Ask the Spanish-speaking people you know.  Believe me (and the US Census), they are all around you.  When I lived in Utah, which I considered to be the least ethnically-diverse place I had ever lived, we had a medical clinic that was pretty much 90% Spanish-speaking.  These families lived right there among, well, you know who, in Salt Lake City.  Here’s what I have noticed.  Ecuadorians hang out, mostly, with their fellow Ecuadorians.  They may have travelled through Mexico to get here, and they speak the same language (to me).  When a friend from Venezuela went out with me in Boston many years ago, he could tell immediately that people we met were speaking with accents from Peru or Guatemala or Cuba.  I’ll say he could tell if people came from Puerto Rico, but he said that he couldn’t understand much since they spoke so fast and dropped so many syllables.  He sometimes complained that he was too impatient to wait for a Colombian to finish the sentence.   He could tell when they started speaking—but not by how they looked.  It was a revelation to me when I attended the wedding of a distant relative in Paris.  Also there were relatives from Nice (on the Mediterranean coast of France).  My relatives said it was impossible to talk to them because “…they speak with such a heavy Southern accent.”  It took me a while to figure this out.  It was hard for me to reconcile Hercule Poirot and The Dukes of Hazzard.</p> <p align="left"><a href="http://lh6.ggpht.com/-PSNz65fP9Vo/TmGa8AeczMI/AAAAAAAAA80/MTEt3tUR2vc/s1600-h/poirot%25255B5%25255D.jpg"><img style="background-image: none; border-right-width: 0px; padding-left: 0px; padding-right: 0px; display: inline; border-top-width: 0px; border-bottom-width: 0px; border-left-width: 0px; padding-top: 0px" title="poirot" border="0" alt="poirot" src="http://lh6.ggpht.com/-4Hyojd4XAEI/TmGa-DRUAFI/AAAAAAAAA84/xbIjBMQbaQc/poirot_thumb%25255B3%25255D.jpg?imgmax=800" width="294" height="221" /></a> <a href="http://lh5.ggpht.com/-_oSTWdXTdFE/TmGbDbPussI/AAAAAAAAA88/ew4-_gIpl7Y/s1600-h/Dukes_of_Hazzard_Wallpaper_10_1024%25255B11%25255D.jpg"><img style="background-image: none; border-right-width: 0px; padding-left: 0px; padding-right: 0px; display: inline; border-top-width: 0px; border-bottom-width: 0px; border-left-width: 0px; padding-top: 0px" title="Dukes_of_Hazzard_Wallpaper_10_1024" border="0" alt="Dukes_of_Hazzard_Wallpaper_10_1024" src="http://lh4.ggpht.com/-UIx47WST6B0/TmGbFeUZWhI/AAAAAAAAA9A/wV5y9OQivWE/Dukes_of_Hazzard_Wallpaper_10_1024_thumb%25255B6%25255D.jpg?imgmax=800" width="295" height="222" /></a>[Tasteful?  Professional?  Oh come on, what did you really expect?]</p> <p>I think this is an ethics discussion because even with demonstrable medical distinctions, how does the working doctor categorize the folks sitting in the exam room, and their variegated offspring?  Do we wing it on skin pigment (I all shades of dark kids and light kids from curiously mixed parents).  </p> <p>My personal opinion is that the idea of race is a sad vestigial construct without helpful meaning.  Here's what I might need to know:  have any of the child's relatives had sickle-cell disease?  Cystic Fibrosis? Hemophilia?  It wouldn't help me to have a place on the chart for 'ethnicity.'  But in the Social History section of my computerized charting program, I will note if a child is adopted and from where.  I will note there if there are medically-relevant familial risk factors.  </p> <p>And what about those medical distinctions I noted above that ‘everyone has known for years?’  Even if this were true for one very long historical era, until World Wars and intercontinental migration, it isn’t very true here in California.  When I first moved here from Utah in 1999, I made a comment to one of the hematologists at the local children’s hospital about not seeing much sickle-cell disease in Utah.  She said she had a clinic full of white kids with sickle-cell, and I felt as ignorant as I was.  Here in California, every baby is screened for sickle-cell at birth (since 1990).   Everyone has known, since 1885, at least, that Mongolian Spots (benign bruise-like markings often appearing on the lower back of babies) were much more common in Asian children.  This was first noted, as a fact, by Dr. Erwin Bälz [I couldn’t make this stuff up!], the German-trained personal physician to the Meiji Emperor.  It was only around 100 years later that these were found to be correlated with skin pigment—the more pigment you had, the greater the chances of a mongolian spot.  But they are harder to spot in babies with very dark skin.  So they were noticed more in babies of Asian descent who had more pigment that Laplanders but less than equatorial Africans.  Ira Gershwin said it best:  <em>It ain’t necessarily so</em>.</p> <p>It turns out that the whole ‘ethnic’ idea is largely confounded by genetics.  It’s certainly true that my ancestry is tough to follow prior to immigration from southern Russia.  Nobody kept track of peasants and who they mated with.  Still, there are lots on great kings who have kids with serving wenches.  And from there, it’s all down hill straight to me.  Which leads to this:  I’m descended from Charlemagne.  Yes, that Charlemagne.  Perhaps less likely an ancestor for you if your family recently came from Africa or Asia.  Your folks came from Africa in the 19th-century?  We can both attend the Charlemagne family reunion.  Just arrived?  Maybe not Charlemagne, but definitely Nerertiti.  Just like me.  Read this <a href="http://www.theatlantic.com/magazine/archive/2002/05/the-royal-we/2497/" target="_blank">article from The Atlantic Magazine</a>.  It will likely affect your view on race forever.  You can’t judge a book by its cover.</p> <p>Because I don't think racial labels are generally helpful, I also believe that they are a potential problem. I wouldn't want my calling a patient 'white' when they are 1/16 Native American to interfere with their self-description. This may have legal implications, perhaps for Federal contracts or programs. Will it help them or hurt one of my patients in gaining a scholarship to define their race in a certain way, especially if whatever institution looks to their physician or medical record for verification? If I don’t think I, a fairly observant physician, can tell what race you are by looking at you, I certainly don’t have confidence that—even with training—college students working for the summer can categorize your ethnogenetic heritage when they come to your door to help with the census and try to give you a careful look in the hallway outside your apartment door by the dangling blinking buzzing insufficient fluorescent light that you’ve been bugging the cheapskate landlord to fix for months.   </p> Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-75743917330844983872010-08-06T07:12:00.000-07:002010-08-06T07:12:00.176-07:00Mystery Diagnosis—the Doctor’s RoleMore than a year ago, I <a href="http://drwolffe.blogspot.com/2009/03/postpartum-depression-fathers-comment.html">wrote about</a> a little-known entity that I have sometimes diagnosed in a mother who is complaining about wrist pain. Called <i>Nursemaid’s Wrist</i>, it is hard to find online or even in many medical textbooks. It has nothing whatever to do with <i>Nursemaid’s Elbow</i>, which is something that kids can get. Nursemaid’s Wrist is a pain in the wrist that adults, usually mothers or those who care for infants, get from repetitively stooping to pick up a baby.<br />
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It’s easy, of course, to underestimate the weight of a baby. The average birth weight these days is over 7 pounds, and by the time the baby is 4 months old, it might be double that. If the baby were a bowling ball—professional bowler weight—it would seem quite heavy. A 4-month-old weighs about the same as a 2-gallon container of water. It’s easy to see how someone lifting and moving that kind of weight can get sore. But they are moving that object with considerably more care than they might a plastic jug of water or a bowling ball. The muscle tension required for fine movement control while holding on to a heavy weight puts an enormous strain on the whole mechanical system. Some muscles of the body seem well designed to handle massive enlargement and strengthening if circumstances required it. Biceps and shoulders, and the muscles of running and leg movement are good examples. Except for a protective covering of skin, they have a good blood supply and can pretty much expand from exercise to whatever size is needed. Though we’ve all seen photos of shockingly-massive bodybuilders, much of the muscle <i>size</i> they have is in these muscle groups. The fact that babies are considerably more adorable than, for example, steel weights, gives us the motivation to keep picking them up. Weightlifters, however, are not looking to build up or enlarge those fine-motor muscles, which are usually invisible even in the most defined physique.<br />
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The wrist problem occurs because those fine-control muscles, of the hand and fingers and forearm, are threaded though a remarkable system of lubricated sheaths to keep everything operating smoothly. They are threaded through notches to keep them from tangling or getting caught on angles of our bones and joints, and they slip through guide-channels so that they don’t restrict the range of motion of our joints. With enough repeated exercise, just like lifting a barbell, those little muscles get stronger—and bigger. If they get even a little too big, they start rubbing the inside of the sheath they pass through, they rub against each other, and they don’t slide as easily through their notches. This leads to irritation, inflammation, and pain. Carpal Tunnel Syndrome is the best known of these, but there are others. Treatment is simple, if inconvenient with a baby around. Immobilize the problem area, ice if possible, and anti-inflammatory medicine like ibuprofen.<br />
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This leads to the important question of this post. The same question has come up before and probably will again. What, exactly , is my job?<br />
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I’ve worked in other practices where the pediatrician’s job is reasonably clear. Since I was paid a fixed salary and the practice was paid a fixed price per visit, there was constant pressure from management or the owner/partners to do as many visits as possible. There was never any kind of incentive, even appreciation, for doing a good job, being thorough, ending a visit without the child screaming and traumatized.<br />
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When I started my own practice, I wanted to do things differently. I knew, of course, that the business model of the factory-production design of medical-care delivery was the way a doctor could earn a living. There are some really good reasons that nobody else practices the way I do. Still, I wanted to have the feeling of taking care of kids and dealing with the whole person.<br />
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That sounds great, but it is so different from my training and experience that some really confusing issues have come up. In the 8-minute pediatric visit, the doctor has decided that your kid’s upset stomach is from a virus and not appendicitis, tells you to keep up with fluids, and has left. That, to be blunt, is the standard of care. Teasing out the history of stomach aches, the recent weight loss, and a recent history of food refusal could take an hour, especially if the doctor actually tries to ask the child. And what about symptoms in the parents? These could hold an important clue to what could be going on in a child.<br />
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Where does my care of the child end and care for the parent begin? All of my insight about postpartum depression stems from my belief that it’s not all about the mother. It’s the mother-baby system that somehow isn’t working optimally. Helping the mother is <i>de facto</i> helping the baby, who is indeed my patient. In the same way, I would strongly urge any parent to wear a <a href="http://drwolffe.blogspot.com/2009/06/buckle-up-for-safety.html">bicycle helmet</a>. My patient needs you. Without a head injury.<br />
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Which leads to the case at hand. A mother, mid-30’s, was in today with her baby. The baby was fine, but mother was wearing black neoprene wrist supports. I asked what was going on. She said that she had been having wrist pain and went to her doctor, who told her she had carpal tunnel syndrome. Here’s where my role gets confusing. What could she be doing that could give her carpal tunnel syndrome in both wrists at the same time? I didn’t think she was working in a parts-assembly factory or on a computer since the baby was born 3 weeks ago. She wasn’t, she confirmed, and after asking her a few more questions, it was clear that this wasn’t carpal tunnel. Do I tell her her doctor was wrong? <br />
<img alt="hand with arrow1" border="0" height="429" src="http://lh3.ggpht.com/_IwgfwdBQlpw/TEpMs9ylyyI/AAAAAAAAA70/gi0X29pYtCI/hand%20with%20arrow1%5B6%5D.jpg?imgmax=800" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" title="hand with arrow1" width="451" /> <br />
She pointed to where it hurt, which was the same on both left and right. Uh, that’s not where carpal tunnel hurts. It wasn’t where nursemaid’s wrist hurts, either, and that was what I had been thinking. I touched where she said it hurt, and she confirmed a little bit of pain. I asked her to hold her hand bent in a certain way, then I pressed her thumb across her palm. This hurt a little, too. In this position, I pressed on the spot pointed out by the arrow in the picture above. She jumped. This was the <i>Finkelstein Test</i>—I’m not making that up. I know, it sounds like an algebra mid-term from high school. (He published this in the late 19th-century, I think.) Her reaction led me to her diagnosis.<br />
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<i><b>DeQuervain’s Tenosynovitis</b></i> isn’t something that people assume they have. It occurs mostly in women, mostly in their 30’s and 40’s. It is thought that long before Dr. DeQuervain stuck his name to it more than 100 years ago, it was known as <i>mother’s wrist</i>.<br />
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If a little knowledge is a dangerous thing, what about knowing about the Finkelstein Test? I suppose it would be right to say I couldn’t be positive about her diagnosis, but I was pretty sure this is what she had. <br />
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Here are some of the issues for me as a physician:<br />
<ol><li>I’m not a doctor for grown-ups. Do I mind my own business even if I think I’ve got a clue—and maybe they don’t? </li>
<li>Do I say something cautious like, ‘Maybe you should get another opinion.’ Isn’t my opinion another opinion?</li>
<li>If I say, ‘Have you looked into DeQuervain’s Tenosynovitis? It’s going around,’ what is the message I’m really sending?</li>
<li>If I say, ‘I believe you have DeQuervain’s Tenosynovitis,’ what is my next obligation? Do I have to treat it or suggest treatment?</li>
<li>What if I’m wrong?</li>
<li>How much work do I have to do, especially since I can’t get paid for any of it? Officially, the mother is not my patient.</li>
<li>Since I was bold enough to bring up the fact that I can’t get paid anything for diagnosing or treating the mother, it’s obvious that this fact doesn’t reduce my potential liability.</li>
</ol>So here, too, is a problem with medical specialization. I presume that if the crippling pain were bad enough, this woman’s repeated visits to her primary care physician would eventually have led her to an orthopedic surgeon. Hopefully they have already paid for their college-age child’s BMW (not that I’m cynical about it), and will not simply advise the woman to have hand surgery when a splint and some Advil is all she might need. In the meantime, my patient—a sweet baby who needs to be held and nursed and changed and loved by his mother—will suffer. <br />
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Let me go one step further. If I know the diagnosis, if I can help this woman’s suffering, don’t I have some sort of obligation to help? Am I required to look the other way because of my contract with her health-insurer? In this case, of course, there isn’t anything life-threatening that would meet the criteria of <i>what any reasonable person</i> would do. This comes up, for example, when somebody is obviously gravely hurt and anybody—not just a doctor—would call for help. <br />
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Do you think I’ll leave it at that? I didn’t think so. This case is a proxy for treating even my own patients for mental health problems. Though child mental health care (and to a lesser extent adult mental health, as well), is usually either completely unavailable or nearly unavailable; though it is unaffordable if available; and though access to it is severely limited by health insurance, physicians are generally precluded from providing this care. So even though I’m willing to do it, I do a good job—especially with certain problems, I’m available and I’m willing to take about 20-30% of what they would usually have to pay, insurance companies will not pay me to diagnose and treat most mental-health problems. Some won’t even let me prescribe the appropriate medications. (I can prescribe them, but they won’t pay for them.)<br />
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And it’s a proxy for the inadequate recognition and treatment of postpartum depression. This is seen by me, diagnosed by me, treated by me. I get paid nothing for this, yet there’s no one to whom I can refer these women. I’m lucky that one of the authorities in the field is nearby and will take referrals—without taking insurance. After her, however, it’s me.<br />
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Just because I make no secret of believing I should be paid for my work doesn’t mean I won’t do what’s required of me. By me. So I had to create my own practice where the family of the baby got what it needed for the benefit of the baby. That, in the big picture, is Holistic Medicine.<br />
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I found some information on DeQuervain’s Tenosynovitis on the internet and printed it out for her. Treatment required a completely different kind of splint, which I also described. I don’t know the name of her doctor and didn’t ask who it was. But I deeply suspect that there were only a couple of reasons that she was still suffering in pain. Either the doctor didn’t know about this unusual diagnosis, or didn’t listen carefully enough to the patient. It was in her description of the the problem, the timing of its onset, and the exact location of the pain that eliminated diagnostic possibilities like carpal tunnel syndrome. I think these are both potential problems: a doctor who doesn’t know or a doctor who doesn’t listen. Nobody can know everything, and this is an unrealistic goal. But it would be great if doctors would spend the time to listen carefully, and then be open about not knowing. When that happens, good doctors hit the books.<br />
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As a closing aside, this is an ongoing pattern in <i>Every Patient Tells a Story</i>, a book about unusual diagnoses that I like a lot and <a href="http://drwolffe.blogspot.com/2009/08/every-patient-tells-story.html">reviewed</a> in this blog a while ago. Though the author was kind about it, the first doctor to see these unusual problems often didn’t make a correct diagnosis. But at some point, all the patients described finally saw a professional who wouldn’t give up, even if they didn’t know. They reasoned it out, did what homework was needed, and got to the diagnosis. Of course, they weren’t paid more for this extra work than the doctor who said, because it would take the least time, ‘carpal tunnel syndrome.’Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-5655092061527190822010-07-30T07:42:00.000-07:002010-07-30T07:42:00.437-07:00Vaccine Refusal and Ethical Issues<span style="color: black;"></span><br />
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<span style="color: black;">All the families who bring their kids to see me know that, in general I’m a supporter of childhood vaccination. On balance, the risk to your child of a devastating or lethal disease with known and terrible effects seems to dominate the risk of vague eventual possibilities of problems that are either unproven or completely debunked. This post is not about why you should vaccinate your baby. Though you should.</span><br />
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<span style="color: black;">I’m in a pretty privileged position. None of my patients comes to me just because my name was on the list from the insurance company. A parent picked me, researched me, got my name from a friend or coworker. Sometime, I’m gratified to say, they get my name from a nurse in Labor and Delivery or from one of the lactation consultants or midwives. Some of my most difficult cases come to me on the recommendation of my pediatric colleagues who have practices of their own.</span><br />
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<span style="color: black;">So it’s what is generally called a self-selecting group. They are here because they want to be here. When parents expecting their first baby come to interview me, many don’t know my views on vaccination. Perhaps it’s a result of being located here in Berkeley, but I don't get parents who have heard that vaccines are harmful, and want to learn my professional opinion. I get those who say they want me to be their child's doctor because they have read or heard about me, but have made up their minds about vaccines. I wonder what they really want from me. If they don't want my medical expertise, they why are they coming to me? How can I help them? I hope that I will always provide the best care I can, but I was not trained in and do not know how to provide some reduced level of care.</span><br />
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<span style="color: black;">What prompted this observation is a comment I read on one of the informational websites for physicians. A very smart academic doctor pointed out that when we treat families who refuse vaccinations, we are really being asked to provide substandard care. He argued that if we send these families elsewhere, we have lost the opportunity—perhaps many opportunities—to educate them and help them appreciate the value of this intervention.</span><br />
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<span style="color: black;">It makes sense to engage with these parents. Most of them are extremely well-educated and literate. I would love to give them literature on the subject, cite references, tell them my own horror stories to counter the ones they heard from the internet, the parent group, or in the check-out line at the local organic market. I'd love to tell them that one of the local Montessori schools was closed twice in the last year by the Public Health Department for being a center of major pertussis epidemics. But I get the sense that they are not interested in receiving this information, or perhaps just not from me.</span><br />
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<span style="color: black;">The parents of every child make essential health decisions every day. They manage the diet, activity, and safety of their children. Hopefully, they balance protection with freedom, and find a way to let the child ride a bicycle but still make them wear a helmet. I don’t think I’m the only one who is shocked when driving in a parking lot and a toddler is walking along without holding a grown-up’s hand, while they walk far behind, texting. That’s not OK! I keep my mouth shut when this happens, but I mutter unflattering things as long as my car’s windows and doors are closed.</span><br />
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<span style="color: black;">But I am required, as much by my own standards as those of my state licensing board, to practice at very least at the standard of care. If the kid needs an antibiotic, I prescribe an antibiotic. For this reason, doctors shouldn’t be complacent with the nonvaccinating parents. It seems like a strategy of engagement is a reasonable way to go.</span><br />
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<span style="color: black;">But I'm scared. In the past couple of weeks, I saw in my office a pair of former preemie twins. They are now about 6 and 8 pounds or so, and just got out of the intensive care unit. They are over 2 months old. Having unvaccinated kids in my office would seem to put them at substantial incremental risk. What is my responsibility to them?</span><br />
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<span style="color: black;">That's not the only reason I have problems seeing unvaccinated kids in my practice. I feel so strongly about the importance of a meaningful doctor-patient relationship that I'm unclear about my role in their care. If I prescribe a medication to help your child breathe but you don't give it to your child, and instead use what your homeopath recommends, why did you consult me in the first place? If HIB vaccine could save your baby's life (or brain) but you refuse it, how much trust do you really have in me, my judgment, my training? It's better to bring your child to an advisor you really trust, whose expertise you respect, who can provide the care you really want and value.</span><br />
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<span style="color: black;">I have absolutely accomplished one of the goals I set out for myself when I started this practice. I have patients and families that I know and who respect my guidance. This is probably a logical point at which to note that this doesn’t mean slavish obedience! I expect my own doctors to give me their very best professional advice, and in return I promise them—though this is unspoken—that I will take it seriously and do the best I can. I haven’t always followed what they suggested. Occasionally, I thought they were wrong, or didn’t understand all the aspects to my situation or complaint. Most often I just couldn’t do what they wanted. I couldn’t afford it, couldn’t spare the time, couldn’t make it work for me in some important way. But it has never been because I thought they were stupid, uninformed, or malicious. It wouldn’t say good things about me if I continued to go to a doctor like that.</span><br />
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<span style="color: black;">So if I recommend that you let me painfully inject into your baby something you believe to be poisonous, toxic, or unproven, or if by recommending this your belief is confirmed that I am little more than a meretricious shill for the Big Pharma cabal, why would you want me to see your child?</span><br />
<span style="color: black;"> </span><br />
<span style="color: black;">Sometimes, when the prospective parents are interviewing me but before they storm out of the office, the reason comes out. I’m not really going to be their baby’s doctor. I’m the safety net for the naturopath, homeopath, or chiropractor who will really be managing the baby’s care. Then, if something goes wrong, they can bring the baby to me.</span><br />
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<span style="color: black;"><span style="color: black;"><a href="http://lh5.ggpht.com/_IwgfwdBQlpw/TD0kJem60II/AAAAAAAAA7E/ku7OVbEoph0/s1600-h/car%20seat%5B6%5D.jpg"><img align="right" alt="car seat" border="0" height="400" src="http://lh6.ggpht.com/_IwgfwdBQlpw/TD0kJhBuZuI/AAAAAAAAA7I/D1Ee7q4a634/car%20seat_thumb%5B4%5D.jpg?imgmax=800" style="border-width: 0px; display: inline; margin-left: 0px; margin-right: 0px;" title="car seat" width="323" /></a></span></span><br />
<span style="color: black;">So the first ethical problem I have with treating families that don’t vaccinate is the fundamental nature of their request. They have asked me, with their full consent, <b>to provide substandard care</b>. When asked about this, a physician said that it was like the family refused to use a car seat for the baby. They ask the pediatrician, however earnestly, ‘What’s the best way to hold the baby while driving?’ Not only isn’t there a good way to hold the baby, but it would be unethical to do the research which could tell us if holding one way is 100 times more potential lethal than using a car seat but holding a different way is only 92 times more potentially lethal than using a car seat.</span><br />
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<span style="color: black; font-size: small;">This is a line from a common translation of the Hippocratic Oath: <i>I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.</i> There isn’t much about doing less than my ability because the helpless baby has parents with...issues.</span><br />
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<span style="color: black;">But the second ethical problem is obvious. Though it doesn’t come up in Hippocrates, it’s a central tenet in medical ethics. <b>Autonomy</b>. The patient has the right to make decisions about themselves and their treatments. With children, it’s generally understood that this means that the parents get this autonomy. When exactly this ends, by the way, is unclear. Legally, kids who are 18 acquire most of the medical rights of adults. This is confused, of course, if mom and dad are still paying for the health insurance. And, varying state by state, teenagers of a certain age can ask for and receive contraception or contraception counseling. Sometimes psychological services. Babies...not so much. Our society makes an implicit assumption that a baby’s parents have the best interest of the child at heart. Luckily and almost always, that’s true. The parents who choose not to vaccinate aren’t trying to hurt their baby, they are trying to protect it in the best way they know. Given this complete and unquestionable lack of malice, don’t they deserve the autonomy we all expect?</span><br />
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<span style="color: black;">And one more thing. If a parent came to my office obviously intoxicated, I wouldn't let them drive home. Maybe I’d call a taxi, maybe I’d drive them home or call someone to pick them up. I would intervene in some way to protect them, their child, the community of unsuspecting and unwarned drivers on the road who all agree to follow some shared set of rules that protect them all. I don't know how to resolve this ethical dilemma between their autonomy and my responsibility. When they decide not to vaccinate, it's not like holding the baby without a car seat—it’s loosening the straps a little bit in every baby's car seat. What's my obligation to them?</span><br />
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<span style="color: black;">So I think there’s a third ethical problem<b>: my responsibility</b> as a physician in the community, perhaps as a citizen. It would be wrong to cry out, ‘Fire!’ if there was none. But do I have an obligation to cry out if I see one?</span>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com1tag:blogger.com,1999:blog-795027104294386040.post-5750415662146845362010-07-16T08:42:00.000-07:002010-07-18T05:07:54.122-07:00Anxiety--College Boy and Autonomy Issuesbart-map<br />
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Peter was at college here in Berkeley, and needed a physical exam form filled out for a summer job he had applied for. He came in with his parents. I asked them if they were worried about anything in particular and they said that he had been very healthy. But they wished he'd get out more. Maybe be a little more...outgoing. He looked very relieved when his parents left the room.<br />
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"Gosh," I said, "I thought they'd never leave!" He smiled briefly. I asked how college was going, if he had a major.<br />
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He said, politely enough, looking at the floor, "It's going OK. Don't have a major." Didn't I recall that he was interested in Economics? "Yes, but I didn't get a good feeling from those people." Meaning, I took it, from those in that department. How about people in other departments? I told him I thought there was a lot to be said about finding a group where you feel like you fit in. "Maybe, but I don't fit in." Still no eye contact.<br />
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"You haven't made a lot of new friends?"<br />
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"None, really."<br />
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"Are you in touch with your friends from high school?"<br />
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"I had two friends in high school but they are going to college in Hayward [Cal State]." It is a sad fact of suburban life that the logistics of socialization are often very cumbersome for children. (This is very different from my experience growing up where public transport was great and cheap.) But he was 21, not 14. What about borrowing a car from his parents? "I don't drive."<br />
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"Why not? Didn't they have driver education in your high school?"<br />
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"Yes but I stopped taking it after the first day. It was just too dangerous." But his mom and dad drove, I pointed out. "But I won't drive with them at night. Anything could happen. No," he added for emphasis, "I definitely don't want to drive."<br />
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Most 16-year-olds have, at least in their minds, cut from magazines the photos of the cars they want to have. A car, or access to one, or even without access but having a driving license, meant adulthood, liberation from the control of their parents, freedom. Most American teenagers have much clearer dreams of owning their own car than they have of owning their own home someday. I think that this is less prevalent among those growing up in urban settings. (A wealthy high-school classmate of mine had his own car, but I don't know where he drove it (let alone parked it) and neither I nor most of my other classmates were envious.) But this is California, where having a car or wanting one is or should be considered an essential developmental milestone, like walking or potty training. When he said that he didn't want to learn to drive, whatever alarms were not already ringing for me started to go off. "What about going to Hayward on BART?" [Bay Area Rapid Transit--a not very extensive system, but fast and reasonably comfortable and clean. And ] I knew he lived in a town with a station.<br />
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"That goes under the Bay!" he explained as if I has somehow been misinformed about this fact. But it didn't between Berkeley and Hayward.<br />
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At some point, I stood up to wash my hands and examine him. I went to put my stethoscope on his chest, but stopped. "Gosh, Peter. Have you been gardening? Working with paint solvents?" His hands were red, very dry-looking and irritated. He denied this but said that he washed his hands a lot. Mine were not so raw, and I typically washed them 20 times a day, sometimes more.<br />
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"I know. I'm a bit of a germophobe."<br />
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He was attending college locally. So I asked him if BART was uncomfortable for him, why wasn’t it a problem taking the public transit bus to school? He told me that he walked to his college campus, about 3 miles or so from his home. He admitted that not using public transportation was a real barrier to making and sustaining new friendships at college.<br />
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Continuing in this line, I was worried about what would come next. As I would ask any patient his age, I asked if he was dating anyone. I assumed that this would be logistically difficult for him, given his transportation constraints. He said he wasn’t in a way that concerned me. Sometimes I get a disappointed response, when the college kid wished they were dating somebody. Sometimes it’s a blissful yes they are. He looked at me at me with an odd expression of confusion. Now I was confused about why he was confused. I asked him to clarify what he was thinking.<br />
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He told me that he wasn’t dating and convincingly claimed not to know why people did. Let me be really clear here: I asked about just dating, nothing more intimate. Yes, he knew classmates in high school went on dates or wanted to and talked about it. He knew they did in college. I asked if he knew how his parents met. Like most of us, their relationship started with dating. But he didn’t really see why people did this. There were so many obstacles that he pointed out. Getting together in a certain place and time, which is a key part of the definition of a ‘date,’ is very difficult if one of the people has to be within walking distance of their home. Holding hands seemed unappealing to him, and kissing appeared positively unhygienic. I asked if he would like someday to have a family of his own and a mate. He said that he would but he didn’t know and couldn’t picture what kind of a person that would be or how he would get to there from where he was.<br />
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I spent about an hour with him, much of it trying to figure out the level of isolation to which he was willing to subject himself.<br />
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I told him he had anxiety. I recommended many things, including trying some medication. I was willing to work with him in any way that I could. He was willing to commit only to think about these choices, or if he wanted to do anything at all. So deeply did he see his perspective as an accurate view of the world that he didn’t see it as a problem in his life. I asked about continuing to live with his parents, and he didn’t see a problem with that, or limiting for school or work to a walking-radius around his parents’ house in Berkeley. Gently, I tried to point out that it might be difficult to meet somebody under these circumstances, but he was blind to this. He didn’t try to reconcile his dream of having a family with his disinterest in looking for somebody with whom to start that family.<br />
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handicapped sign<br />
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Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?<br />
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An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.<br />
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He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.<br />
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But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.<br />
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He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.<br />
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Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.<br />
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This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.<br />
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Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.<br />
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Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.<br />
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Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.<br />
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Let me be explicit about some of the ethical issues associated with this case.<br />
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1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality? Does the doctor have an obligation to do more than educate, inform, and offer help?<br />
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2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?<br />
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3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-10472551416831942232010-04-16T06:14:00.000-07:002010-04-16T06:14:00.132-07:00Cultural Sensitivity<a href="http://lh5.ggpht.com/_IwgfwdBQlpw/S5CjAmVuKBI/AAAAAAAAA4o/76xVPEJmc9I/s1600-h/linkage%20tree-2%5B3%5D.jpg"><img alt="linkage tree-2" border="0" height="225" src="http://lh3.ggpht.com/_IwgfwdBQlpw/S5CjAxevEKI/AAAAAAAAA4s/Hi9WRBIn2bY/linkage%20tree-2_thumb%5B1%5D.jpg?imgmax=800" style="border-width: 0px; display: inline;" title="linkage tree-2" width="385" /></a> <br />
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A delightful couple, pregnant with their first child, came to the office to interview me, to help them decide if I was the right pediatrician for their baby. We had a lovely chat and I felt that I was doing well. At the very end, they asked a question. “Do you have many Asian patients? Do you find you have to ask questions a different way with them or that you have to take a different approach?“ I took these questions as an inquiry about my level of cultural sensitivity. I had a long answer. For the record, though, these people looked by their facial features to be of Asian ancestry; the last name appeared to be of Japanese origin.<br />
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“It’s the Bay Area, “ I replied. “What are the odds?“ They agreed it was pretty likely that I had some Asian patients. This was the beginning of my reply.<br />
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I told them I took care of a group of about 8 or 10 families from Mongolia. They all live near each other because only a couple of them speak any English at all, and the language barrier is substantial. taking care of them has sometimes been a challenge. there are no patient-education materials available in Mongolian. AT&T has available translators via telephone in dozens and dozens of languages, but Mongolian is not among them. I called UNICEF at the United Nations in New York. They did send people to Mongolia, but they had no patient information. Same story when I contacted the World Health Organization in Geneva, Switzerland. At one point I had a polite exchange of emails with the Minister of Health in Ulan Bator, Mongolia. He or the person composing the emails under his direction and signing his name, had good English-Language skills. His office had no written materials on child health in Mongolian. These families are Asian. Am I culturally sensitive with them? Probably not. Since communication is so difficult, we need every extemporaneous sign language technique we can come up with just to convey information.<br />
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So cultural sensitivity is not helped by a language barrier. I take care of these Asian patients, but do I take care of them differently? Yes, I suppose so, but it’s not because of a cultural divide.<br />
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I’m reminded of a classmate in medical school. When he was 14, his parents and he joined many others on a small boat headed blindly from Vietnam out into the South China Sea. Obviously they made it, and he’s now a fine surgeon. What should I know to deal with his family in a Vietnamese-friendly way? Are Koreans different?<br />
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When I was in business, there were no courses that were required, but everyone knew that Japanese investors and businessmen expected certain salesmanship behaviors when they were entertained in New York. In Japan, a completely different set of rules applied. I wasn’t called cultural awareness, it was called good business. In Hong Kong, it was often thought best not to mention that you’d just had a successful series of meetings in Tokyo.<br />
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So what was this nice couple asking me? If I had other patients who, by their visible bodily characteristics, appeared to be of Asian descent? Nearly half the human race is of Asian descent. Were they asking if I treated my patients of Japanese descent as if they were Japanese? I don’t know. How many generations have been born in the United States?<br />
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I take care of a nice family, for example, with a hyphenated last name. They are all American citizens. They say that they are Brazilian. When their kids were born, I encouraged the parents to speak only Portuguese to them at home. The mother’s ancestors were from Portugal. She looks like a European might. The father’s ancestors were Chinese. He looks Asian. The kids are…adorable. Is this an Asian family? I don’t think even the father’s parents speak much Chinese, back in Brazil. How Asian to you have to be? How Asian to you have to <i>look</i>?<br />
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No institution with which I have been associated over the last 20 years or so has failed to offer--actually require, I think--a course of some sort in cultural sensitivity. As demanded, I have wasted valuable hours in these courses. In one, the head of a fabulous Spanish-language health clinic gave a presentation on cultural awareness to the Latino community. Assuming that language wasn’t a barrier, what could I do with that? Ask a proud Ecuadorian if they identify more with Mexicans than with Americans. Ask someone from Spain. Will I learn about the distinctions of all those who speak Spanish in a short course or lecture on cultural sensitivity?<br />
I have a family from Yemen. Devout Muslims, they appreciate that I never extend my hand to the mother. I try to be respectful and to the point. I don’t even close the exam-room door when I see their kids and the father isn’t with them.<br />
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I think that doctors--people in general--look fake when they try to be someone they’re not. I also think that doctors can be particularly culturally insensitive. But I think it’s cynical political correctness to require learning cultural sensitivity. What they really need to learn is just sensitivity.<br />
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There’s no way that patients will perceive a doctor to be sensitive in a 5-minute visit. The doctor you’ve never met, comes in while reading the chart for the first time, doesn’t know your name, does humiliating things to you, then leaves without hearing your complaints or insights. In which culture is this considered acceptable? What part of the world do you have to be from to feel better after this encounter?<br />
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If physicians are going to be culturally sensitive, they must first spend enough time with the patient to listen. Maybe they can take a course on reading body language and eye contact, tone of voice or listening skills. Maybe they can learn to interrupt just a little bit less. This would go a really long way towards sensitivity to what a patient really needs. I don't think it's helpful to put on an air of paternalistic cosmopolitanism—like an anachronistic white man's burden—that says to patients that overeducated well-to-do Americans can feel inappropriately self-confident about learning in an hour what they have taken a lifetime to master.<br />
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It's nice if you and your auto mechanic grew up in the same neighborhood. But it's a lot nicer if you find a mechanic who treats you well, listens to your complaint, and actually fixes your car. Which one would you choose?<br />
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Medical management (and this applies equally to corporate management) shows astounding hubris to impose an unsupported belief that patients will perceive as a better experience a visit with a doctor who has memorized a few facts about your grandparents' country of origin. Whether the patient is from Mongolia or Malaysia, Brazil or Burundi, I don't pretend to be something I'm not. If doctors could spend more time, could simply have more empathy, listen to their patients and think about what it's like to live a day in their shoes, cultural sensitivity would just be sensitivity.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-74377787849788183332010-04-02T16:54:00.000-07:002010-04-02T16:54:00.769-07:00Piecework Economics and Slow Medicine: Churn Rate<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/_IwgfwdBQlpw/S4w6RKdscTI/AAAAAAAAA4M/WESNpUIWOG8/s1600-h/butterchurn.bmp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="http://3.bp.blogspot.com/_IwgfwdBQlpw/S4w6RKdscTI/AAAAAAAAA4M/WESNpUIWOG8/s400/butterchurn.bmp" width="285" /></a></div><blockquote><div align="justify"><b>“Piece rate is more suited to repetitive crew work (e.g., boysenberry picking, vineyard pruning) than to precision planting, fertilizing, or irrigating. As the tie between individual work and results is diminished, so is the motivating effect of the incentive on the individual.” </b><i>--Gregorio Billikopf</i></div></blockquote>It’s the money, stupid. I don’t write about money much, though I haven’t forgotten everything I used to know about it. I try to keep both this blog and <a href="http://www.drwolffe.blogspot.com/">The Empathic Pediatrician</a> about medicine. Sometimes, however, te topics of money and medicine overlap.<br />
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Primary-care doctors like me are paid by the visit. More visits, more money. There’s a huge incentive to see patients as quickly as possible. This can be called efficiency if you’re the insurance company paying for it. If you’re the patient, what is it?<br />
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It’s certainly not to your advantage. I strongly believe—more strongly as I become more experienced—that taking the time to get to know a patient, which in my case is typically a child, has enormous benefits and increases efficiency, though defined within a different parametric model.<br />
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I found <a href="http://www.cnr.berkeley.edu/ucce50/ag-labor/7research/7calag06.htm">this fantastic essay</a> on piecework economics by Gregorio Billikopf when he was at UC Davis working on farm worker pay systems. It’s balanced and well thought-out. Farmers have to be fair and consistent in the way they pay people in order to keep them motivated. Deception and mistrust are always possible in the context of thin profit margins and hard work, however, so they have to be careful to honor their commitments.<br />
Doctors who do a lot of procedures have accomplished such dominance over the medical system that they are paid per procedure. More procedures, more money.<br />
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Everybody, as far as I know, is stuck with the same 24 hours in a given day. How many visits can you do in that day? I know of physicians doing 40 visits in 8 hours, and taking an hour for lunch. That’s about 5 or so minutes a visit. With the time needed for physically moving from room to room, what do you think? 4 minutes? You might have a chance to say that your chest hurts but not explain that you can’t afford your heart medicine.<br />
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The specialist doing procedures has even more incentive to perform quickly. If a patient is seen who might or might not benefit from an intervention, which choice would the doctor make? What if the procedure cost $2000? What if they could do 10 or more in a day?<br />
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Obviously, I wouldn’t be writing about this if I didn’t think it was a problem. As always, I hope, my view is not a dogmatic one.<br />
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As in so many things, the people who run medicine are so comfortable in their Procrustean Bed that it would be irrational of me to expect from them a measure of horizontal thinking. That’s not quite fair, I guess. They haven’t walked 30 years in my shoes.<br />
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This post is really about Portfolio Analysis.<br />
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About 7 or 8 years ago, I made a house call to a modest home. I examined the toddler in the living room, while mom was in an adjoining room. I had made a lot of house calls, and thought it was interesting that I was seeing the kid alone when the mom was obviously concerned enough to call me to come over. The child was OK—I think she felt better just because I came to the house and looked her over. It was a brief awkward moment, since I didn’t know if I should just call out to the mother that I was done. The girl sensed this, and took me by the hand into the other room. “She’s trading,” the child explained.<br />
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There, in front of 2 big screens filled with numbers, charts, and several moving tickers, was the child’s mother. “I’m done,” I said. After a brief discussion of the illness I added, “nice setup.”<br />
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She went on to tell me that she had quit her job and was trading stocks full-time. She described a little bit about the amount of information she had at her disposal. She also described her confidence in being able to make money consistently, day after day, by taking advantage of small movements in stock prices. I wished her the best of luck, and left the house as quickly as I could. I knew some things that she just didn’t know.<br />
She had only limited experience of a couple of years with financial markets. Nearly every model of market activity makes some fatal and incorrect assumptions. I knew this because I had looked for and failed to find this kind of <i>El Dorado</i> she thought she knew. For example, she and her model assumed that markets were continuous. Which is to say that if things turned against her she could get out. That’s true until it stops being true. There are many times that the markets drift up or down for years at a time, until the one day that a world leader dies or a bomb goes off and all the markets are suddenly closed. She could wake up broke. And the illusion she had of information quality was astonishing to me. She was getting information many minutes behind those who knew it first. She wasn’t seeing trades—she was seeing the <i>history </i>of trades with a 15-minute delay. The pros, just like used-car dealers, often kept the best for themselves.)<br />
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Sadly, this delusion applies to professionals, too. Maybe that’s obvious from the amount of our money they lost in the last couple of years while getting paid so well for it. There’s now a substantial body of important research that shows that professional investors—the managers of big and well-known mutual funds and pension funds of all kinds—simply don’t do better than you would do if you just bought one of those stock indexes and left your money sitting there. In fact, the more they tried to beat the market by thinking they could pick the stocks that would outperform and get rid of the stocks that would underperform, the worse they did. In professional jargon, this is called the <i><b>Churn Rate</b></i>. It’s a measure of how often the manager was buying and selling, buying and selling, with every iteration costing transaction fees and causing taxable events. For doing this, and doing worse than doing nothing, the manager’s substantial pay was deducted from your investment return. You paid for it.<br />
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And this is a part of how I look at this aspect of the backwards financial incentives facing physicians. There’s no financial incentive to get the patient well, but there’s a big incentive to increase turnover. What patients need is simply not considered in any part of the system.<br />
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I would like to get to know each child, each family. If insurers had the long-term perspective of somebody investing for their distant retirement, they’d see it my way. Much slower, more thorough visits to cover every issue. Continuity with a single doctor who can manage some of the burden of a chronic medical problem. This would result in reduced need for future and costly interventions, fewer emergency visits for unaddressed problems, less need for expensive medications, and happier, healthier patients. It would <b>save </b>money. Most physicians, I think, want to provide really good care. Let them, and they will.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-82079338991057161742010-03-15T00:39:00.000-07:002010-03-15T00:39:00.297-07:00Ethical Dilemma: Do the right thing or keep the patient?Robert is one of my troubled teenagers. To him, his parents seem outrageously restrictive and inflexible. No particularly innovative insight is needed to recall the times in ones life when parents seem less like a tugboat, pushing and pulling us ahead, and more like an anchor, holding us behind. He came to me for an ADHD evaluation, in the course of which I noticed his itchiness, and thought he should get some allergy testing.<br />
For most of his 15 years, his family moved every few years as dictated by his father’s diplomatic career. Now stationed here, his European parents have lived all over the world. They had just begun a stay in Thailand when Robert was born. He was scrawny then (as he is now) and became jaundiced. I have <a href="http://drwolffe.blogspot.com/2010/01/jaundice.html" target="_blank">written previously</a> about jaundice in a newborn. Though his parents didn’t remember the levels in his blood, they were told that his jaundice was quite serious and that the baby needed a blood transfusion.<br />
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The idea behind transfusion for this problem is simple enough. If we take out the blood that’s packed with bilirubin--the natural breakdown product of hemoglobin that can build up in the blood--and replace it with blood without bilirubin, then it’s much less likely that bilirubin will get deposited in the baby’s brain. It’s the treatment of last resort, and his mother was told that it was necessary at the time. This is 15 years ago, remember, and technology has improved since then. Even so, I’m not experienced enough in international medical practices to know the level of vigilance used to screen donated blood in most of the world.<br />
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When I proposed doing some blood tests for allergies, given his history of itchiness and runny nose, his mother asked if I could do a test for Hepatitis. She told me about the tranfusion in Thailand, and I added the blood test to the laboratory order form. His test result indicated that he had been immunized against Hepatitis A and B. The test was ambiguous for Hepatitis C. I looked up his specific test result, and the references I looked at said that he should get a follow-up test or two to be sure he didn’t have it. This didn’t seem ominous to me, just something that needed to be done to be thorough.<br />
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I called his parents to discuss the tests, and mailed them copies of the test results and a printout of the reference interpretation that indicated the necessity of another test. I tried not to make a big deal out of it--but I was clear about what needed to be done. I asked his mom if she wanted me to mail her another lab form or if she’d pick one up in the office. She said it would have to wait. She explained that it would have to wait until we do another round of allergy or other blood tests.<br />
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She asked me not to tell him about the test.<br />
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Huh? It’s not like the lab sucked a half-dozen tubes of blood out of his arm without him knowing about it. She told me that he doesn’t know anything about the transfusions, the jaundice. Somehow, she said, it never came up. I was confused--wasn’t he there when I filled out the lab form? Where was he when his mother told me the story about the jaundice? I couldn’t remember. During the long visit, he got up to go to the bathroom. Was that when she told me the story about him as a baby in Thailand? She never told me not to tell him anything, and I just assumed….<br />
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I was silent for a long time on the phone, and she asked if I was still there. I do not withhold anything from my teenage patients. Already struggling with trust issues (parents usually try to convince their teenagers that sex is lousy and nobody should think about it), I have found that the only dependable way to establish trust with a teenager is to be 100% open with them all the time. If they want to keep something from their parents, I try to use my best judgment to support them or to explain why I disagree and push them to do the right thing. I am always very clear about the secrets I cannot keep, such as those making me fear for the child’s safety. It doesn’t work the other way around: when I am occasionally asked by a parent to keep something from the teenager, I just say no.<br />
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Many times, for example, I have been asked by a parent to test a child for drug use. I tell them that if they want to find out if their kid is using drugs, ask the child directly. Perhaps surprisingly, many teens will be quite honest about it. If they aren’t, the parent might want to try another tactic. But I am the child’s physician, not parole officer. [There are circumstances, most of which occur in emergency rooms, in which a drug test is sometimes done without consent. That’s true for adults, too, by the way.] I have never tested a competent teenager for anything without telling them about it. I felt manipulated by the mother.<br />
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I told her that I thought this was a bad idea. If he had hepatitis and she (and I) knew about it, surely she would tell him. She agreed with this but noted that if he didn’t, why should he have to worry about it? There’s usually only a few days between lab test and result, I pointed out. That didn’t seem like a lot of worry.<br />
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I looked at it a different way. If he didn’t have the disease, yet found out that we had tested him for it, the trust I had built with him would be gone, and could never be re-established. And the trust of his parents would be a mess. I told his mother that this was a dangerous plan from the point of view of her relationship with her son. She said that he was already unhappy, and didn’t think he could handle the anxiety. <br />
That upset me. Many studies on adults clearly show that the paternalistic witholding of bad news is universally counterproductive. Paradoxically, it increases patient anxiety (we tend to fear worse scenarios than the actual bad scenario), and damages the relationship between patient and whoever it is who was supposed to be telling them the truth. Often that’s a doctor, but it might be a family member. So her assumptions about how this bright, sensitive teenager would take the news either way was simply misinformed. Inevitability is the elephant in this room. Even if I don’t tell him, he’s going to find out. Maybe not today, not tomorrow, but someday he will. And when he does, she may lose him over this. Who is she really protecting? His delicate sensibilities or her denial of a lifelong lie that she would now have to confess to her teenager?<br />
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Getting to the point, I am <a href="http://lh6.ggpht.com/_IwgfwdBQlpw/S2qHw6WkGEI/AAAAAAAAA3g/HA1Q53XKuuk/s1600-h/screw%5B3%5D.jpg"><img alt="screw" border="0" height="105" src="http://lh4.ggpht.com/_IwgfwdBQlpw/S2qHxDqJG9I/AAAAAAAAA3k/R9N3VYRDjSc/screw_thumb%5B1%5D.jpg?imgmax=800" style="border-width: 0px; display: inline;" title="screw" width="240" /></a> ed. If I take it upon myself to tell him, she’ll fire me and the damage to the relationship that his mother fears will come about. If I don’t tell him, I am facilitating this lie and being bullied into doing the wrong thing. And when he does find out, I’ve lost him just the same.<br />
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I did my best to convince her to have a heart-to-heart with this nice boy and apologize profusely for her mistake. With the troubled kids I see, they get themselves into this same situation all the time. They don’t do the big project for their least-favorite class, but say they did it, thinking that they will catch up in a few days. Then it’s a week overdue, then a month, then suddenly mom and dad get a call about summer school. Maybe we’ve all been there, maybe there’s a MasterCard with our name on it about which this all seems hauntingly resonant. It’s the human condition, and I was sympathetic to her situation. But I was angry about being pulled into it unawares. I was tricked. How can I trust her in the future? How can her son?<br />
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Now what do I do?<br />
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Please comment and let me know what you think I should do.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-32756375101511724712010-02-28T19:19:00.000-08:002010-03-01T13:12:52.483-08:00Honesty vs. Hope: An Ethical Dilemma<img alt="wolf1" border="0" height="373" src="http://lh5.ggpht.com/_IwgfwdBQlpw/S11EPeRmArI/AAAAAAAAA24/gjY25ESVLQc/wolf1%5B5%5D.jpg?imgmax=800" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" title="wolf1" width="378" /> <br />
<div align="center"><i><b>Lupus pilum mutat, non mentem</b></i></div>At our last visit, Franklin spoke to me in private. “Will it get better?” he asked.<br />
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“Will what get better?”<br />
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“My parents.” His parents had recently been suggesting to him that his antidepressant medication cost should come out of his allowance and if he were more like his two younger brothers, star athletes and students, he would be costing them a lot less. He needed to get away from them any way he could. He played X-Box video games. Given his ADHD, this was the perfect escape, and would hold his attention for hours. But this bothered his parents quite a bit. They didn’t feel like they were being responsible parents if they let him play video games for hour after hour. So they decided that he was to play no more than 1 hour.<br />
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Most parenting authorities would agree with this restriction, I think. I, too, think that it’s reasonable for parents to restrict the amount of time a kid is playing video games. It’s reasonable to limit the time to 1 hour. <br />
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But I know something else: it’s completely arbitrary. Yes, there are studies that show that increased screen time is correlated with obesity, social dysfunction, and other problems. But at what duration do those problems suddenly occur? Nobody knows or has looked at that. Is 15 minutes safe? What about 120 minutes? Because I believe <a href="http://drwolffe.blogspot.com/2009/12/television-3-brave-new-world.html" target="_blank">television is a drug</a>, how much of a dose will cause some effect, and what dose will cause trouble? Franklin may not have been familiar with the research in this field, but he knew in his gut that the 1-hour limit was arbitrary, and that his parent picked it out of thin air. He also knew that he was unnaturally thin, didn’t snack, got plenty of exercise, and that whatever social problems he had weren’t caused by his screen time. His parents made another mistake. When they insisted that he reduce his video game time by hours, they didn’t offer him any alternative ways to spend those hours. He was doing well in his classes, and keeping up with his assignments.<br />
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When he spoke to me in private, he told of many little remarks made by his parents. They weren’t directed at him, they weren’t meant to hurt his feelings. They weren’t insults or denigrating. They were, however, part of the family lexicon. He recalled this statements in precise detail, and I don’t doubt him at all. Sometimes they came when a parent was talking on the phone to a friend or relative, sometimes it was a statement between the parents, and sometimes it was something said <i>sotto voce</i> to one of his younger siblings. Franklin heard them all, and he knew what they meant. ‘We can’t go because Franklin….’ ‘Why can’t Franklin be more like you? You never cause us any trouble.’<br />
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Families have a jargon all their own. Big companies have this, the military has this. Sometime restaurants do, too: <i>Adam and Eve on a raft</i> famously meant poached eggs on toast. <i>And wreck ‘em</i> was added if you wanted scrambled. When his brothers fought, sometimes one would teasingly call the other Franklin; a parent would smirk.<br />
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So he asked me one of the hardest questions I have been asked. He asked if it would get better. The easy way out would have been to say one truth, ‘I don’t know.’ I can’t predict the future, so I could have fallen back on that dependable standard. But he wasn’t really asking me for a prediction, with dates and times for the coming apocalypse, for example. Just as so many parents do, he was asking my professional opinion. Based on my training and experience, my intelligence and intuition, what did I really think? Would it get better?<br />
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This is an ethical problem, too. Do I make him feel better or do I tell him the whole truth as I know it, not just a statement that happens to be a true ‘I don’t know?’ When I ask my own doctors if something will get better and they say they don’t know, is this the whole truth?<br />
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I knew a more substantial truth than ‘I don’t know.’ I knew from my own family and from the families I knew since childhood, from the families of my parents’ friends in their retirement community. And I knew from the children I have seen grow from babies to high school students. Most parents have told me that their teenagers ‘were the same way’ when they were infants, maybe easily frustrated or easy to comfort, restless or relaxed.<br />
In Franklin’s life, I had become about the only person he opened up to. It was a great privilege and he deserved more than facile answers. I told him once that I would always be honest with him. I said, “No, I don’t think it will get much better.” I don’t know if this was what he wanted to hear. If I had sounded upbeat and tried to assure him that it was going to get better, would he have believed me? How long would he give that prediction to unfold if it didn’t get better? I suspect he expected the easy answer, ‘I don’t know.’ <br />
Though this was my best professional assessment, rolled into a single <i>No</i>, it wasn’t the whole truth, either. Dealing with some of the most difficulty kids, I can say confidently that even when we can’t change the difficult child, we can change how we understand them and deal with them in ways that make those interactions much less frustrating. This increasingly educated and empathic approach often helps a lot in reducing the number and intensity of explosions. In Franklin’s case, I found myself with a type of role reversal. I told him what I often tell parents of particularly problematic kids. Pick your battles carefully. If you know that something will provoke an explosion, then whose fault is it when the inevitable happens?<br />
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Change your expectations of them, and that will cause you to change your expectations for yourself. Be the grown-up.<br />
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I reviewed with him the situations most likely to cause battles. I asked him the same questions I ask parents of difficult children. What was your last fight about? Did you win? If you did, was it worth it? Did the child learn a lesson and now won’t do that ever again? (The answer is always <i>no</i>, by the way.) Do you feel good about it? Does the child feel good about you because of it? I ask the same follow-up questions if they say they didn’t win the fight. If it wasn’t worth it, if nothing was learned or gained by it, would you like to do it again? If not, then don’t fight about it. It takes two to make an argument. Be the grown-up, be the first to walk away and say you’re sorry. You may lose a fight but gain a child. Maybe these parents have already lost Franklin. But I have to help him make the most of the goodness inside him. What do I call this advice? It's not <i>parenting</i>. Is it <i>childing</i>?<br />
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The Latin proverb at the top of the page means <i>The wolf changes his coat, not his disposition</i>. Readers need only look as far as their own aging parents. Are they very different from when you were a kid? Do they treat you or talk to you so much differently?<br />
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<span style="font-family: "Courier New",Courier,monospace;">On another note, have you taken my survey yet? I know all the questions seem similar, but they're not. I'm trying to find out how to compose a committee at the hospital, or maybe designate a person, who you would have make decisions for your loved one--your parent, your child, maybe you--who cannot make decisions for themselves. Sure, you may have made all kinds of thoughtful arrangements, but what if they can't get in touch with you? What if they can't even get information about this loved one? Scary stuff, I know. But several times a year, the hospital's doctors find themselves in this predicament. </span><i><b><a href="http://www.surveymonkey.com/s/KRXFB3H" style="font-family: "Courier New",Courier,monospace;">Take the survey</a></b></i><span style="font-family: "Courier New",Courier,monospace;"><i><b>,</b></i> and help. </span>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-88615361516076004692010-02-05T04:21:00.000-08:002010-02-05T04:21:00.535-08:00Worst Possible Scenario Survey<a href="http://lh4.ggpht.com/_IwgfwdBQlpw/S2Esy9fXONI/AAAAAAAAA3E/kQz_akZCk0c/s1600-h/levitt-carriage-cropped%5B4%5D.jpg"><img alt="levitt-carriage-cropped" border="0" height="537" src="http://lh4.ggpht.com/_IwgfwdBQlpw/S2EszeqZeaI/AAAAAAAAA3I/pNyGSlwIBB4/levitt-carriage-cropped_thumb%5B2%5D.jpg?imgmax=800" style="border-width: 0px; display: inline;" title="levitt-carriage-cropped" width="370" /></a> <br />
This post isn’t just about pediatrics, it’s about a practical problem. I don’t know the answer, so I need the help of my readers. That means you.<br />
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Phyllis, 88, is brought to the hospital, via the Emergency Room, acutely ill. No one at the hospital knows her personally, and the person can’t, for various reasons, help to identify who she designates as a decision-maker for her care. She is not able to help with this crucial information. Somebody in this circumstance is unlikely to be able to consent to certain aspects of their own care. If she is not competent to designate a surrogate, it’s hard to imagine her being competent to consent to a complex procedure. <br />
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Let me clarify some assumptions. The good people at the hospital don’t wait around for Phyllis's neer-do-well adult daughter (too close to home?) to call back from the spa before they perform CPR. They have established protocols for life-saving interventions. If you can’t tell them what you want, they will try to err on the side of keeping you going. It’s reasonable to assume, in my experience, that the strangers who work at the hospital--even the ones with poor bedside manners and weak social skills--don’t mean you any harm and want to help you the best way they know how. Yes, the courts can always appoint someone. But that could take days or weeks, and would you be happier with who gets assigned to you get that way? <br />
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Maybe you don’t think this applies to you, and maybe you’re right. Maybe you carry your living will or advanced healthcare directives, signed and notarized, next to your body everywhere you go. Maybe it’s a long (usually several typed pages) tattoo. But avoid it though we mostly do, any of us could be in this scenario. Certainly, our aging parents could be. And though I don’t like to bring it up, a child could be. <br />
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But I’m not asking about the immediate needs. If you need an IV, they give you an IV. But this is about the worst case scenario, not just a bad case. Does your mother want to undergo an agonizing series of procedures to provide a possible but not guaranteed few extra weeks? What about another round of chemotherapy when 4 awful previous trials didn’t help? What about life support--would she want mechanical breathing, external heart or kidneys? Under what circumstances yes or no? <br />
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I have written before about problems in medical ethics, and <a href="http://drwolffe.blogspot.com/2009/07/problems-with-medical-ethics-perimortal.html" target="_blank">complained</a> about ethicists who seem obsessed with these rare cases. But this is a purely practical question. I visit my mother every week—what would I want for her?<br />
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In the ethics discussion, I learned that this is pretty rare. Though many people don’t have advanced directives, most have some connections to family or others who can help. But several times a year, somebody like Phyllis is in the ER--very sick, not able to make her own decisions, not able to designate somebody to help with this serious decisions. There isn’t one right answer of who, under these circumstances, should get this responsibility for, in essence, a stranger. Who would you want? Who would you want for your parent (the one you like)? Who would you want for your child?<br />
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Here are some choices: <br />
<ul><li> The doctor on duty should do it. She or he is a pro and knows what’s best. </li>
<li> A small committee of experienced care providers should make these decisions. The group would consist of a doctor, nurse, social worker. </li>
<li> A diverse committee should make these decisions. This group has care providers like a doctor, nurse, and social worker, but would also include a layperson from the community, maybe a religious leader from the community. </li>
<li> A group of people with ethics experience who are extra careful not to impose their own biases onto this stranger. </li>
<li> It’s important that the people on the case NOT be directly involved in my care. That way, they won’t push their own departments or pet procedures. Maybe they will have a little better overall perspective on the risks and benefits of interventions. </li>
<li> Regular community doctors should be involved, since they have the most personal connections to patients facing these serious decisions. </li>
<li> Specialist physicians should be involved, such as intensive-care specialists or surgeons, since they have the most expert knowledge of the interventions that might be decided upon.</li>
<li>Doctors shouldn’t be involved. Consulted for their expertise, but I’d prefer regular people like me to make decisions for me. <br />
The hospital should assign somebody, or a small group of people, to look out for me during my whole stay. That way, this person or group would get to know my case and have a consistent approach. </li>
</ul><br />
Here’s how most hospitals handle this, by the way. They make up a rule. Sometimes their Ethics Committee makes up a rule, sometimes some other group or executive. Then everybody follows the rule. As far as I know (granted, not that far) nobody actually asks potential patients. That’s you. <a href="http://www.surveymonkey.com/s/KRXFB3H" target="_blank">DO THE SURVEY</a>! It’s short. <br />
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For the record, I don’t know the answer to this problem. This is one of the scenarios, by the way, that seem complex and subtle to my adult-medicine colleagues. Yet every child is this patient—not able to give consent, not able to designate somebody. We think of children as part of a package, which includes a family or caretaking adult. What happens when only the child part of the package shows up? Please help me figure this out and <a href="http://www.surveymonkey.com/s/KRXFB3H" target="_blank">DO THE SURVEY</a>.<br />
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<span style="font-size: xx-small;">The photo above, from my collection, is by Helen Levitt from 1942. I think it’s really funny, and is thus appropriate as therapeutic relief for this blog post.</span>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-14643971566192922572010-01-19T05:02:00.000-08:002010-01-19T20:48:47.188-08:00The Ethics of Vaccination, Part 1<a href="http://1.bp.blogspot.com/_IwgfwdBQlpw/StQqf_ET9cI/AAAAAAAAAlI/qCZ3XMDwWac/s1600-h/polio+child+iron+lung.jpg"><img border="0" src="http://1.bp.blogspot.com/_IwgfwdBQlpw/StQqf_ET9cI/AAAAAAAAAlI/qCZ3XMDwWac/s400/polio+child+iron+lung.jpg" /></a><br />
In the unstudied ethics of primary-care pediatrics, is the particularly dark and unexplored corner of vaccination.<br />
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As my readers know, I suspect that ethicists suffer from <a href="http://ethicalpediatrician.blogspot.com/2009/08/problems-with-medical-ethics-perimortal.html">Perimortal Obsession</a> and the natural desire to be quoted in the media commenting on the latest <i>rara avis</i> of medical dilemmas. But this alone doesn’t explain why this topic is so carefully avoided. As I’ve pointed out again and again, the common ethical problems encountered in primary-care medicine every day are apparently unattractive subjects for professional academic ethicists.<br />
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There are several important ethical issues that apply to childhood vaccination as we do it here in the United States. Each of these is worthy of a symposium of its own, but I’ll just list these as they come to mind, and put them here on the internet for all to see. Maybe an ethicist (who already has tenure) will dare to pick up the gauntlet. In fact, this is just a prologue to an ethical issue associated with vaccination that only presented itself to me a few weeks ago. The rest of this list has been smoldering for a long time. I should note for the record that I believe childhood vaccination to be the greatest breakthrough in pediatric health ever made. I discourage parents who choose not to vaccinate their children from joining my practice (that’s a big topic on its own!). So these ethical issues assume <i>a priori</i> that the usual vaccinations we give are safe and effective.<br />
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The keystone ethical problem in pediatrics is doing something to somebody who is not giving their consent. A lot of the general parenting problems I get asked about fall into this category as well. Often parents will be unaware of their conflict between doing what they know is best for the child and doing what the child likes. Broccoli vs.. ice cream. Bedtime vs.. staying up. This is one of the hardest parts of any good parent’s job. But can we justify vaccination ethically on this basis?<br />
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What is the ethical obligation of the parents to other parents, to the community as a whole. Even if we concede that parents sometimes have a sucky job and have to make decisions that hurt their baby because the baby will be better for it, should they hurt their baby in order to help some other baby? This is just what herd immunity is all about. At what point, ethically and epidemiologically, is there a breakeven between the suffering of one child and an abstract public health benefit?<br />
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Notwithstanding the vaccinations that are ‘required’ for school entry, what should the ethical guidelines be that determine how a parent chooses to waive these requirements. Here in California, you don’t need to prove anything or claim anything. Just that you sign the following statement: <br />
<blockquote><blockquote><blockquote><i>I hereby request exemption of the child, named in the front, from the immunization requirements for school/child care center entry because these immunizations are contrary to my beliefs. I understand that in case of an outbreak of any of these diseases, the child may be temporarily excluded from school for his/her protection.</i><br />
</blockquote></blockquote></blockquote>It’s pretty shocking to me, honestly, that the serious consequence warned of in the statement is that your kid may be asked to stay home for a few days. Considering the overwhelming statistical likelihood that any outbreak of one of these vaccine-preventable diseases probably started with an unvaccinated child, it’s curious and disappointing to know that the parent is being warned neither of the potential for harm their child represents to everybody else, nor of the potential for death or serious illness with life-long injuries that they have chosen for their own child.<br />
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<a href="http://4.bp.blogspot.com/_IwgfwdBQlpw/StQqklTLfRI/AAAAAAAAAlQ/AzOk8bnwD2Y/s1600-h/polio+3c+stamp.jpg"><img align="left" border="0" height="256" src="http://4.bp.blogspot.com/_IwgfwdBQlpw/StQqklTLfRI/AAAAAAAAAlQ/AzOk8bnwD2Y/s320/polio+3c+stamp.jpg" style="display: inline; margin: 0px 10px 0px 0px;" width="182" /></a><br />
I believe that physicians must give honest answers to patients. That’s not an ethical problem. But I am often asked if a baby really needs polio vaccine. I give an honest answer: it’s still around in certain parts of the world, but not here in the United States; it’s a really, really bad thing to get, and cause permanent disability; it seems to be preventable with the vaccine; a polio vaccine has been used for about 50 years, and the problems with it have been few. But do they need to get the shot? There’s plenty of cases of <a href="http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm">Japanese Encephalitis</a> in the world, and there’s a vaccine for it. But people get in in South Central to East Asia. If you’re traveling to Borneo, it’s probably a good idea to get the vaccine. But kids here probably don’t need it, so they aren't required to get it. <a href="http://www.who.int/features/2004/en/gallery1_popup.htm">Polio</a> is much less widespread in the world (thanks to vaccination) than Japanese Encephalitis, and there are no cases in North or South America. If the parents take the child to certain parts of Africa or Central Asia, it’s probably important to be vaccinated. Yet kids here are required to get 4 or 5 shots of it.<br />
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I get a lot of similar questions about Hepatitis B vaccine, which is often given within 1/2 hour of birth. It’s spread, generally, by tainted blood products, sharing needles and syringes, and intimate contact. So even a cautious parent would be right to suppose their child won’t be at risk until adolescence. I don’t think this argument holds up, by the way, though it’s right as far as it goes. What isn’t considered are the accidents, the hypodermic needle your happy 2-year-old brings over to you in the park to show you what she’s found, the thing your kid picked up that turned out to have some unidentified blood on it.<br />
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Is it ethical to give some vaccines in infancy just to take advantage of a time when the patient can put up the least resistance and won’t remember the assault? Should we wait until they can willingly participate—though we know that almost none of them would? Is it ethical to give an adult patient a medication that causes anterograde amnesia, then do something unpleasant to them? They suffer just the same, but they don’t remember it afterward. Is that the same as not suffering? This is common practice, by the way for procedures like endoscopy (from either end). Somehow not remembering the pain and choking during the procedure is considered equivalent to not having any pain.<br />
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There's a deep ethical inconsistency with this belief. If the patient is not able to give consent (they have a serious developmental delay, they have brain damage or severe mental illness, for example) would we allow a painful procedure without pain control measures? I think and hope this would be considered barbaric and potentially license-losing for the physician. In what functional way, exactly, is this hypothetical severely-impaired person different from a 12-month-old? Maybe none of these hypothetical patients will remember the procedure. Why is this not OK, yet doing pretty much the same thing on an adult who is drugged not to remember the procedure (same pain, same outcome) is a cottage industry? I'm not questioning the benificence of the parent or medical guardian involved. The difference, of course, is the adult's ability to be informed about the pain and the drug and the amnesia, and to consent to it. (The fact that laypeople consent to such a procedure is no testimony for it. Remember that virtually no insurance companies will pay for second opinions. Besides, what incentive is there for the proceduralist to innovate new and less painful ways to practice?)<br />
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There’s a little bit of new research which suggests that babies may indeed remember the pain of vaccination. Even if they don't, it's not a strong enough ethical argument to claim that the baby won't remember the pain of the shots. It's painful, they don't consent.<br />
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<a href="http://4.bp.blogspot.com/_IwgfwdBQlpw/StQqnLNtWSI/AAAAAAAAAlY/yqRfLats4m0/s1600-h/polio+salk+stamp+33c.aspx"><img align="right" border="0" src="http://4.bp.blogspot.com/_IwgfwdBQlpw/StQqnLNtWSI/AAAAAAAAAlY/yqRfLats4m0/s400/polio+salk+stamp+33c.aspx" style="display: inline; margin: 0px 0px 0px 2px;" /></a>Perhaps it's a universal truth that so many issues eventually touch upon money. It is a mystery to me why palliation is so often difficult for insurers. Surely pain is something that binds us together as humans. Is it ethical not to use devices or techniques which can make vaccination less painful? These do exist, but they cost real money. Given the thin margins on vaccines for most physicians, use of these products could make the doctor lose money on every shot. Do they have an ethical obligation to pay for the privilege of giving vaccinations? Do insurers have an ethical obligation (oxymoronic, I admit) to pay for things that reduce the pain of vaccination? Or is that a lifestyle choice? I think it's worth a post of its own.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com2tag:blogger.com,1999:blog-795027104294386040.post-66820581860888438512010-01-10T00:09:00.000-08:002010-01-10T21:47:33.717-08:00The Ethics of InterventionI received a note from a parent:<br />
<i>I am wondering if you had any thoughts on developmental optometry. My daughter has a severe learning disability and several people have suggested looking into visual training combined with behavioral therapy. She is an effusive and happy kid who seems to have potential but there are multiple issues such as ADD, auditory processing and visual perception which have left major gaps in her development. Sorry for the out of the blue query, but I'm only interested in talking to people who I know think outside the conventional. Have plenty of those voices.</i><br />
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This is what I wrote back, about a week later:<br />
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In a <a href="http://drwolffe.blogspot.com/2009/07/fever-8-hot-days.html">blog post</a> from about 6 months ago, I describe a process of making a diagnosis of a rare disease from a set of common symptoms. I repeat the maxim that if it walks like a duck, quacks like a duck, it's almost certainly a duck. For many diagnoses, this circumstantial evidence is all we ever get. For many important diagnoses, there is no definitive test, no reagent that turns blue, no antibody that clumps. Just a set of circumstances that only when taken together constellate into an ominous cloud.<br />
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Of course, in my current profession I describe this phenomenon in the cloak of medical diagnosis. I’m sure that jurisprudence and John Grisham novels are filled with innocent people cornered by circumstantial evidence. But circumstantial evidence is how we naturally categorize the world. It’s why we back away from barking dogs (“Oh she’s just a puppy,” the oblivious owner seems always to say as they restrain the bloodthirsty beast with a chain previously used on the anchor of a battleship), and think twice before lending Uncle Dave the money he wants for his can’t-miss real-estate development in Arizona.<br />
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I have an unusually large number of patients with autism of many varieties. The genesis of this is simple enough. Even the kids who are the most reluctant to see the doctor seem to be OK with me. That I get along with these sometimes difficult kids isn’t lost on the parents. The autism community is relatively communicative, and word-of-mouth has brought many of these families to me. All of these parents have had to change their entire view of their own lives and plans. And I never fault them for seeking explanations everywhere and seeking hope anywhere it is offered.<br />
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Regular readers of my blog you should know that I am getting somewhere with all this, though it may seem like I’m taking the scenic route. Hey, you get what you pay for.<br />
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The last prologue comes from what I used to do for a living, 25 years ago. Ironically, that has repercussions in current events though not in my own life. I was in that very first crop of analytically-skilled people on Wall Street. Though my very first task was computer programming, I had a very intuitive and creative view of theoretical finance and an ability to model things quantitatively that were hard to understand in words. I did some of the first work on options on futures, then options on currencies, then options on mortgages and then things got really exotic. It was fun and interesting work. Though we didn’t have the term at the time, it was the very beginning of what are today called derivatives. (Don’t worry—it’s the scenic route, not a dead end.) Here’s how derivatives really work[ed]. By inventing unique financial instruments, the inventor is the only source of typically complex analysis by which a proposed buyer can evaluate that investment. Think of it this way. Your jeweler shows you a certificate which attests to their being a licensed appraiser. She gives you an official form with a seal that says that she appraises a certain diamond at $5,000. She then offers to sell you that very diamond for $4000. So is she losing money on the deal? If you buy it for $4k, will you be able to sell it for the same amount? This diamond example doesn’t pass the test of daily experience, and we know (circumstantially) that there’s a sometimes yawning chasm between wholesale and retail prices. We used to call it the bid-ask spread. But with a diamond, you could presumably take it to another appraiser and yet another, who aren’t trying to sell you anything. With complex and new derivatives, only the seller had the definitive valuation model. In short, it was never clear what, if anything, those institutional investors could get for the things if they ever wanted to sell them. Worse, it has become clear that they nearly always didn’t fully understand what they were getting. I now know better than to refer a child to certain Ear-Nose-and-Throat doctors unless I have already decided they need to have their tonsils out. Because everybody I send over there gets told they need to have their tonsils out. I’m in no position to recommend otherwise, since they are the experts. But somewhere there’s a very happy BMW salesman. The corruptive power of conflicts-of-interest in medicine has been well studied and documented. But, in my humble opinion, it’s like the old joke: why does a dog...?Because he can. As long as physicians were allowed to own their own pharmacies, they prescribed more. When they owned in-house x-rays (as many orthopedists do), everybody was needing x-rays. There was always an intellectually-justifiable therapeutic or diagnostic rationale for the intervention. And funding for skeptical research (‘outcomes’ research) was hard to come by since peer-review was communally infected. Eventually, some has been done and the two examples I cite, pharmacies and x-rays, are now rare. Except for dentists and orthopedists. And podiatrists. And don’t get me started about chiropractic.<br />
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So this leads me to the 30 or so hours of research I did on developmental optometry.<br />
<ol><li>I couldn’t find any evidence—none—that it worked for any of the problems for which it appears usually to be prescribed, with the possible exception of unambiguous vision problems, and these are treated conventionally (and effectively).<br />
</li>
<li>Kids with eye and/or vision problems often have problems in school, for obvious reasons. These difficulties, just like school difficulties from any other cause, certainly can lead to a cascade of problems which can be difficult to tease out from the germinating cause. It saddens me when I find kids in remedial reading that simply needed glasses, or when I’m asked to do an ADHD or behavioral evaluation on a child who’s bored in class because they can’t see what the teacher is writing. Since I do so much work with kids who have ADHD or problems that look like it, I have documented many cases (some are in the blog) of children with attention problems caused by everything from anxiety to itching.</li>
<li>All the favorable evidence that appears most<i> bona-fide</i>, passing itself off as peer-reviewed unbiased medical research, is by practitioners who either are or claim to be believers in the usefulness of the intervention. They sell the intervention. Yes, I am keenly aware that the same is true for most of the difficult-to-duplicate medical interventions such as surgeries. Indeed, that’s why it is still unclear whether coronary bypass surgery (done by heart surgeons) is superior to angioplasty (done by interventional radiologists or cardiologists). Everybody who can do the research which just might show the inferiority of their approach makes an outrageous living from it. So I’m not putting down the poor optometrists, who since the advent of internet contact lenses and no-prescription reading glasses have found themselves disintermediated from the high-margin businesses they used to be in. They are just looking for their own piece of the pie. In many ways, much of the published research I looked at reminded me of things I have read in the New England Journal of Medicine from 100 years ago. Logical, convincing, completely supported by entrenched conventional wisdom and proven by anecdote. (The ‘alternative’ autism treatments are often like this.)</li>
<li>Maybe it’s my obvious skepticism, but I’ll come back to that joke about dog behavior. Even the professional sites seemed designed less to remediate an underdiagnosed public-health menace than to drum up business. Particularly shocking to me are <a href="http://www.childrensvision.com/symptoms.htm">sites like this</a>. I used to give a lecture every year at UC Berkeley about ADHD, and one of the slides I showed was a self-diagnosis test for adult ADHD taken from a website. When the students took the test, just about everybody qualified as having ADHD. According to this test, “If your child’s total score is more than 20, [there’s] an 80% chance of having a vision problem that is interfering with learning.” It was easy to get to 20 if your child has the following: doesn’t like reading or writing; has itchy eyes; has a hard time finishing assignments on time; gives up easily; is clumsy; homework takes too long; daydreams; or gets in trouble for being off-task at school. The site has a search engine which offers to find an optometrist who is a member of this group. </li>
<li>Though I worry about families getting sold false promises, and paying for certain unproven services, I found no evidence of direct harm caused by these interventions. I haven’t left my MBA at the door, however, and besides the conflict-of-interest issues it increases my suspicion enormously to have learned that developmental optometrists often request visits weekly or even more often than that. For months. So just as for chiropractic, I can’t help but be left wondering what exactly are the criteria for claiming success? When do you decide this isn’t working? Whenever you stop, will the practitioner always say that improvement was just around the corner but you are to blame for the failure because you didn’t stick with it? Is there a test on which you child will score higher after the intervention? Does the test correlate with anything important in your child’s life or simply validate the intervention? </li>
<li>As a doctor who diagnoses and treats kids with complex tangles of dysfunction, I worry a lot about the ‘collateral damage.’ This is the inadvertent damage you do to the child and to your own relationship with the child while trying to help them. Surgery may save you, but it doesn’t come without pain and lifelong scars. Bringing the child to a doctor every week gives them an unambiguous message that there’s something wrong with them. They better improve, because if they don’t they will lose hope in their own recovery. They internalize your belief and the doctor’s belief (or sales pitch) that they have a serious problem that needs to be fixed. If they don’t see results they can become hopeless and guilty. They can believe that they are imperfect in your eyes for having the problem and that they have failed you by not improving with the treatment you make them participate in. Once the child has taken on the role of the sick child, how will you convince her that she’s better? With my patients, I take a lot of time—often more than an hour—to talk to the child about this. Do they think there’s something wrong? Does she think that Daddy is disappointed in her? Does he want her to be something she’s not or achieve something she thinks she can’t?</li>
<li>And of course, there’s a serious opportunity cost. I saw, this year, a 15-year old with untreated ADHD. ( <a href="http://drwolffe.blogspot.com/2009/12/looks-like-attention-problem.html">part 1</a> and <a href="http://drwolffe.blogspot.com/2010/01/looks-like-attention-problem-part-2.html">part 2</a>.) The longer his parents went without getting him conventional—and heavily proven—treatment for his conventional problem, the longer he stayed failing at school and the more depressed he became. This wasn’t going to end well. There are many vague but serious problems along both the autistic and learning-disability spectra. Your child might not fit into a recognizable unifying diagnosis. This ambiguity tends to increase anxiety. But there are many available methods for helping a specific problem, such as reading problems. (I usually insist that kids having learning problems get their vision and hearing checked thoroughly.) So choosing one intervention might additionally cost precious time catching up with a professional reading tutor.</li>
</ol>Here’s my various bottom lines, based mostly on my training in physics: break problems you can’t solve into smaller problems you can solve. And I started this with, ‘if it walks like a duck....’<br />
<ul><li>Developmental Optometry doesn’t pass my whiff test. The only people who support it are those who sell it. Testimony from desperate parents, sadly, is not enough for me.</li>
<li>I don’t know what your child’s learning/reading issues might be, but these are heavily studied and though no one intervention works for everybody, there’s usually something available that can help. (Best reference ever: Sally Shaywitz’s <a href="http://astore.amazon.com/theempatpedia-20/detail/0679781595">book on dyslexia</a> (<a href="http://www2.scholastic.com/browse/article.jsp?id=1493">see also</a>)).</li>
<li>I’m fiercely protective of my patients. Even what appear to be benign interventions can have long-lasting and <a href="http://en.wikipedia.org/wiki/Chaos_theory#Distinguishing_random_from_chaotic_data">chaotic implications</a> in the most butterfly-effect kind of way. Doing nothing, on the other hand, isn’t necessarily better. Gosh, that doesn’t seem to be helpful.</li>
<li>There is no such thing as alternative medicine. There are only tested things and untested things. I met you a couple of times. You probably won’t meet a Developmental Optometrist who’s smarter than you are. So decide for yourself. Do your own research. Ask what their training is, how many ‘sessions’ it’s going to take, and how you’ll be able to tell if it’s working. Ask what happens if it doesn’t help by 6 weeks or 6 months. (Well managed ADHD medication, prescribed appropriately, makes an obvious improvement within days, sometimes hours.)</li>
<li>For heaven’s sake, get a second, independent, diagnostic eye exam. Don’t mention this intervention. Go to an ophthalmologist and get her a thorough eye/vision test. If this evaluation is materially discrepant from that of the developmental optometrist (no matter what they recommend for therapy), get yet another independent evaluation. Remember that a diagnosis is not the same as a treatment.</li>
</ul>How did I do? I hope you didn’t expect a thumbs up or down. My critical take on this is not because I’m dogmatic—I have the same hesitations about a lot of traditional interventions by a lot of high-powered interventional specialists. It seems I often end up after one of these obsessive patient-centered-research jags chanting some combination of ‘Show me the money!’ and ‘Show me the chakra!’<br />
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I will help in any way that I can.<br />
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WolffeDr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com2tag:blogger.com,1999:blog-795027104294386040.post-61547705138159818292009-11-16T00:26:00.000-08:002009-11-16T00:26:25.910-08:00The Very Generous Aunt<a href="http://lh3.ggpht.com/_IwgfwdBQlpw/SnVMu-1a04I/AAAAAAAAAe8/OloeenFBAIg/s1600-h/Nestles%20mother%20book%201%5B4%5D.jpg"><img alt="Nestles mother book 1" border="0" height="548" src="http://lh6.ggpht.com/_IwgfwdBQlpw/SnVMwbXP2yI/AAAAAAAAAfA/L-WKkIpvyzY/Nestles%20mother%20book%201_thumb%5B2%5D.jpg?imgmax=800" style="border: 0px none; display: block; float: none; margin-left: auto; margin-right: auto;" title="Nestles mother book 1" width="414" /></a> When a baby is born at the local hospital, the clerk in Labor and Delivery calls the pediatrician identified by the parents. The call I received one night about 3:00 AM was a little hard to understand. Granted, I had been awakened. But I asked the clerk for the patient’s name. ‘Oran…,‘ she said, then ‘Oranolantu…,‘ then ‘…bat…. “Do you mean Oranolantubaataar?“ I asked. Relieved, she told me I had a healthy big baby girl to come in and take a look at. I knew the family, and took care of the 4-year old son. I told her I’d be in later that morning. She politely told me that everyone in Labor and Delivery would really like me to come in now. I got dressed and went to the hospital, fearing the worst.<br />
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The Charge Nurse for L&D, who is the supervisor of all the nurses and operations of the department except for the obstetricians, and always one of the most experienced veteran professionals there, met me at the elevator, before I entered the ward. She said she’d never seen anything like it and didn’t know if it was OK and wanted me to evaluate this and write a note about it in the chart. She was afraid the hospital might get sued, and maybe a little afraid of losing her job. When I walked into the room, I was not prepared for what I saw.<br />
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The mother I knew was smiling happily in bed. Her labor had been relatively short with this second child, born about 2 hours earlier. She greeted me warmly in her broken English. I looked around. “Where’s the baby?” I asked her. She pointed to the chair next to her bed on which was a young woman. ‘Sister’ was her one word introduction. This woman was bare-breasted and nursing the newborn child.<br />
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I had never seen anything like it. I met with a group of the nurses, the charge nurse, and others.<br />
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The transition from unencumbered adult to parent is always unforeseeably and indescribably enormous. It seems that in recent years, the pressure on new parents has continued to build. The parenting shelf in the bookstore has become a whole section with many aisles. Perhaps it’s a good thing that you now can choose to learn what one author thinks you should have been expecting while you were expecting and another author claims to help you raise a child who is an over-achieving, healthy, gifted, socially adept, high IQ athlete who knows both how to control her temper and who goes to sleep without problems. (My approach to advising parents is almost always to ask the child to provide the right guidance. They usually know.)<br />
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Why has this proliferation of parenting advice taken place? The simple answer is that there’s a market for it. Publishers are aware of the demand and are in the business of meeting it. What’s behind this demand? <br />
The desire to produce a text on childrearing <a href="http://www.illinoismedieval.org/ems/VOL12/hanawalt.html">isn’t new</a>. Especially with the industrial revolution, the idea gradually took hold that maybe there was a ‘right’ way to raise kids.<br />
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Especially for the new parent, and the new mother in particular, these books can seem like an essential reference. There is a tendency for new parents and new mothers in particular to feel that the ‘success’ of nursing the baby, soothing the baby, even bathing the baby is a great burden that falls on them and them alone. If things aren’t going exactly right in the first days and weeks, it’s hard for new mothers not to see that as a personal failure. This is a major contributor to postpartum depression. But what has caused this crushing pressure? Is this part of Eve’s curse (Genesis 3:16)?<br />
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<a href="http://lh5.ggpht.com/_IwgfwdBQlpw/SnVMxcniLhI/AAAAAAAAAfE/vnZDUliTm9Q/s1600-h/brosamer%5B7%5D.jpg"><img alt="brosamer" border="0" height="600" src="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVMzBfyUmI/AAAAAAAAAfI/p_eQc4hMJGc/brosamer_thumb%5B5%5D.jpg?imgmax=800" style="border: 0px none; display: block; float: none; margin-left: auto; margin-right: auto;" title="brosamer" width="409" /></a><br />
I don’t think so. According to archeological evidence, and <a href="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVM0lRMUeI/AAAAAAAAAfM/z1g8I8B0xWY/s1600-h/teenage%20caveman%201958%5B4%5D.jpg"><img align="right" alt="teenage caveman 1958" border="0" height="240" src="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVM1GACpjI/AAAAAAAAAfQ/5YahxaaRGRk/teenage%20caveman%201958_thumb%5B2%5D.jpg?imgmax=800" style="border: 0px none; display: inline; margin-left: 0px; margin-right: 0px;" title="teenage caveman 1958" width="154" /></a>according to countless cave-people movies, humans most likely never went through a phase of living in completely isolated family units. The idea, maybe born out of the settling of the American West, that there would be settlers who lived a hardscrabble life by themselves on a ranch the size of some European countries, is not one that has typically existed elsewhere in the world. Sure there are subsistence farms and always have been, but they are small and the families live close to other families. <br />
And, finally I’m getting to the point, all the households are multigenerational. With marriage as teenagers, there would usually be grandmothers and even great-grandmothers living with the new mother. There would be sisters and aunts with their babies, too. And despite the considerable work all the women were required to do, some of the work of childcare and an enormous amount of cumulative experience and wisdom would be easily available and given.<br />
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Though it’s a good guess that midwives, people with special expertise in childbirth, have been around for a long time, Lactation Consultants are likely a newer breed. Within a multigenerational household, there would be lots of sources of advice about sore nipples and babies who don’t latch well. I suspect that postpartum depression has always been with us, but some of its pervasive contributors--isolation, the feeling that every need of the baby must be met by the mother, the sense of failure if the mother’s milk hasn’t come in by day 3 or 4--would be so very much relieved by having a crew of experienced and trusted peers who know what the heck they are doing.<br />
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The baby’s mother was from one of the Mongolian families I take care of. Some speak no English at all. But they all live very near each other in one neighborhood of Oakland. Many bring their kids to me. Her sister had given birth a few months earlier, and was still nursing her own infant. In their culture, this wasn’t unusual--it was simply what was done.<br />
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About a hundred years ago, and for millennia before that, <i>wet nurses</i> were common. Women who couldn’t nurse or those who could but had the resources to avoid this task of the masses, would employ a woman whose lactation was maintained by her continued employment. There were few alternatives. (The picture above is from a booklet produced about 1900 by Nestle, for a product called Nestlé's Food, which was among the very first commercial baby formulas. It’s from my collection.) But before there were professional wet nurses, there were women who would share their supply with the less fortunate, or the babies who had survived childbirth when their mothers did not.<br />
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One of the nurses asked if it was hygienic. Honestly, I didn’t know. I suppose, in these days of Universal Precautions and doctors afraid to touch you without gloves on, I could see what the concerns might be. There are some diseases which can be transmitted through breast milk, along with many medications. As politely as I could, I tried to get a little medical history from this other woman. She spoke almost no English, and the postpartum mother was translating my questions—I think. She’s the one who told me ‘she OK’ and left it at that.<br />
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I told the L&D crew it was OK with me and I would write an order in the chart explicitly allowing it.<br />
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<br />
<span style="font-size: 78%;">The woodcut from 1550 is by Hans Brosamer and is from my collection. It shows the creation of Eve, her temptation, and the expulsion from the Garden of Eden. The poster from the 1958 movie <u>Teenage Caveman</u> was part of the collection I sold in 1992. Produced by—who else?—Roger Corman, I think it was <a href="http://www.imdb.com/name/nm0001816/">Robert Vaughn’s</a> first starring role.</span>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-38680307896392438412009-10-20T05:09:00.000-07:002009-10-20T05:09:00.296-07:00Every Patient Tells a Story<a href="http://1.bp.blogspot.com/_IwgfwdBQlpw/SocwOIZfQBI/AAAAAAAAAiA/X4bubABIabs/s1600-h/everypatienttellsastory3.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5370314099993296914" src="http://1.bp.blogspot.com/_IwgfwdBQlpw/SocwOIZfQBI/AAAAAAAAAiA/X4bubABIabs/s400/everypatienttellsastory3.jpg" style="cursor: pointer; display: block; height: 400px; margin: 0px auto 10px; text-align: center; width: 263px;" /></a><br />
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You just don’t feel right. Maybe you’re a little more tired than usual. Your muscles themselves seem weak. That’s odd, since you lift weights nearly every day. Maybe you’re just pushing yourself too hard. Over a few months, you notice that your handwriting is hard to read, and it takes both hands to lift a cup of coffee. In the Emergency Room, they said that you weren’t having a heart attack and sent you home. Then, gradually, your fingers seem less sensitive….<br />
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In this remarkable book, Dr. Lisa Sanders opens a new and original window into the diagnostic process. As patients, we’ve all had a sore throat or sprained ankle, and the doctor’s work seemed obvious: do a test, get an x-ray, write a prescription. But sometimes we don’t have a straightforward collection of complaints that we could have figured out by ourselves. Is the headache I had a few days ago somehow connected to my cough today? How do doctors make sense of the information we give them?<br />
<br />
She’s got great material. As the long-time author of the <span style="font-style: italic; font-weight: bold;">Diagnosis</span> column in the <span style="font-style: italic;">New York Times Magazine</span>, she has been collecting the stories of diagnostic hits and misses for years. She uses her network of medical contacts to find the valuable pearls of seeing patterns in what looks like chaos. Her column’s focus on diagnoses that aren’t obvious always makes for compelling reading that can’t be put down.<br />
<br />
But there’s a lot more in this book than a compilation of some of her columns. In her <span style="font-style: italic; font-weight: bold;">Diagnosis </span>writing, she seems like an invisible narrator, allowing us to observe a medical detective story unfold before our eyes.<br />
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<span style="font-weight: bold;">Every Patient Tells a Story</span> has plenty of those medical mysteries. But Dr. Sanders has shared not just the events, but her own insight into the process. She’s completely candid about missed diagnoses, tests that should have been done, questions that should have been asked—including instances when she was the physician who might have done better. She does not hesitate to point out the dangers of skimping on the physical examination of every patient, and has convincingly written about changes that need to be done to change medical education in a way that brings physicians back to basic exam skills and diagnostic thinking.<br />
<br />
The book’s focus is not the detective stories, though they are fabulously written and fascinating to read. It is the process of discovery that clearly interests her. Why do some doctors miss something again and again, even though it’s right in front of them? Why do others see what’s hidden? How can we teach doctors to see the forest for the trees? Computer technology would seem to lend itself well to the understanding and improvement of this kind of analytical task, in which diverse bits of information are processed into a coherent result. She examines the development of artificial intelligence models for making a medical diagnosis, with data to illustrate their weaknesses and strengths. (They’re not quite here yet.)<br />
<br />
Dr. Sanders makes her strongest arguments when pointing out a major weakness in physician behavior. The title, <span style="font-weight: bold;">Every Patient Tells a Story</span>, says exactly what she means. Doctors need to listen to what the patient has to say. Again and again, the trail of clues—even to the most obscure and unlikely diagnosis—starts there.<br />
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This is the most interesting book I have read in years. I couldn’t put it down. The narrative stories are fascinating, and her insight is right on target. Everyone who’s ever been a patient, and certainly every doctor, should read it.<br />
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The book moved me in many ways, so this won’t be the only blog post about it. If there’s a unifying theme to the book, it’s the importance of doctors listening to what patients say. Yes, she points out at length how many doctors don’t do or don’t respect the physical exam. She describes interesting cases in which basic observation would have provided a crucial diagnostic clue, yet the doctor didn’t observe—or maybe didn’t see—what was right in front of her. I don’t know if this was the work of her editor, but she does a very good job of staying ‘on topic.’ That’s a reasonable thing, and makes the book focused and coherent reading.<br />
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Dr. Sanders gives convincing proof that doctors are skimping on the physical exam of their patients, and doing a particularly poor job listening to patients. Many of the stories she recounts hinge on a key physical observation, or an event the patient described but didn’t seem important at first. She describes some new educational methods to improve these weaknesses. For example, doctors in training are now required to pass a practical exam on interacting with and examining a patient.<br />
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That’s a great idea, but I’m very pessimistic about its long-term impact. Here’s a statistic I’d love to see that she did not mention in the book: for a perfect score in this practical patient exam test, how much time would be necessary? Even if it wasn’t done by a medical student—I want to see the head of a patient-care department do it. Even if that department chairman had the notes in her hand (the teacher’s edition of what tasks had to be done in that exam to have a perfect score), how long would it take? I know nothing about this effort, and I applaud it. But when I read about it in the book, I started to think: introduce yourself, wash your hands thoroughly, find a seat and sit; describe what you’re going to do, ask some basic demographic questions. Most important in the interview: ask open-ended questions, listen to the patient’s complete answer. I figured that before even the most organized and experienced interviewer got to the physical exam, quite a while would have gone by. 15 minutes? 30? More?<br />
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Many medical practices schedule patient visits every 20 minutes. Some places I know are every 10 minutes.<br />
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I discussed this in my series of posts called <a href="http://drwolffe.blogspot.com/2009/03/slow-medicine.html">Slow Medicine</a>. I’ll add, after reading this book, that if the factory model of medical care is, as Dr. Sanders shows, likely to result in missed diagnoses and frustrated patients, it’s much, much more of a problem with children.<br />
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In pediatrics, the patients often don’t get to tell their story. I believe that every child does tell a story about themselves. The only way to hear it is to take the time to establish some level of rapport with the child. With many children, and with children the doctor is meeting for the first time, that’s just not possible in 5 or 10 minutes.<br />
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Until doctors stop getting paid per visit, the irresistible pressure to see more patients and spend less time with each one will force those laudable lessons of medical school into the dusty trash bin filled with good ideas.<br />
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<br />
Book Review, Part 2<br />
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The key success factors that make diagnoses appear for some and stay hidden from others are pointed out in compelling clarity by Dr. Sanders.<br />
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She's just the right person to do this, too. Writing her column in the <span style="font-style: italic;">New York Times Magazine</span>, <span style="font-style: italic; font-weight: bold;">Diagnosis</span>, she must see hundreds more cases that she can possibly write about. Each of the cases are intricate, and even for relatively common conditions the diagnosis often hinges on one key piece of information—sometimes a few pieces. And very often, the clues are there in the patient's own words. Sure, a specific test might confirm it, or rule out some alternatives, but in many of these mystery cases, the patient's story is indeed the single most important factor.<br />
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This has led her to important insights into the method of diagnosis, and the impediments to teaching it. She cites evidence that key physical exam skills continue to weaken among recent trainees. I recall hearing that when I was in medical school 15 years ago, and an older colleague confided that he had heard it 35 years ago also. (I speculate that the optimal exam skills are probably found in places where there is not enough technology to do the work for the physician, but there is just enough to validate the doctors findings. Maybe this should be called the<span style="font-style: italic;"> second world</span>, somewhere between First and Third.)<br />
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And most importantly, she documents the failures of listening skills among doctors. Frequent interruptions, closed-ended questions, and premature closure of the differential diagnosis are cited by example and in research studies. Her thorough approach assesses the impact of artificial intelligence decision models and innovations in hands-on medical education. As I pointed out in my previous essay[link to epts1] on this great book, however, the current economic model of physician-patient interaction is likely to put irresistible pressure on the examining physician to keep visits short, questions closed, and interruptions as frequent as ever.<br />
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<span style="font-weight: bold;">Every Patient Tells a Story</span> is about doctors. How they think, how they approach patients, problems, and data. It's particularly brave of her not to sugar-coat the stories of several doctors missing an important diagnosis because they didn't do the full job of examination and history-taking. She never says, but it's clear by example, that some doctors are just more motivated and tenacious than others about getting to the bottom of a patient's problem. Dr. Sanders does a superb job of pointing out what some did right.<br />
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But there's another book here, too. It's the unwritten shadow book, this same book, these same stories, through the looking glass. Sanders gives the reader insight into what is usually invisible to them—the intensely caring physician who's calling all her colleagues and spending time in the library for the benefit of a patient. The mirror book would give the physicians insight into what Sanders shows to be completely invisible to <span style="font-style: italic;">them</span>: what the impact of a rushed or absent physical exam means to the patient, how the frequent interruptions feel, the frustration of not being able to tell the story that every patient tells.<br />
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Illness often affects us in unanticipated ways. For a child, the new feeling of feeling bad is usually unfamiliar and frightening. Fortunately, the relationship I have with most of my patients is helpful under these circumstances. Kids are usually not afraid of me. Many awaken and tell their parents that they need to see Dr. Wolffe, just because they think I'll make them feel better. I'm not interjecting this to brag—I think it gets to an important part of the patient-side of Every Patient Tells a Story. Usually, when I see a sick child, I don't start even by talking to the parent in the exam room. I am totally focused on the child. I always start by asking them if anything hurts. They generally will tell me, often to the surprise of the parent. I ask them to tell me how it happened, what it feels like, and when it started (this last is often the least dependable of the questions, and sometimes results in a 3-year-old telling me that her ear has been hurting for 5 years, while holding up 2 fingers). Only rarely does a parent not interrupt. This is done, I know, with the best of intentions, to help give me the most accurate information on which to base my professional assessment. They stop when I hold up my hand and indicate that I want to listen to the child, but they will get their turn soon.<br />
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Here's why I do it. It makes the child feel better. To them, their symptoms are not just uncomfortable. The symptoms are out of their control, and appear to trigger actions by their parents that are obviously concerning and also out of their control. This all can be very anxiety-provoking. I purposefully give them this opportunity to voice these anxieties in a safe place, where they can say it their way and I will listen to them and respect them.<br />
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One of my patients just started preschool for the first time. Every morning before he was to leave, he complained of a stomach ache.<br />
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Just like adults and headaches, there are stomach aches of all different kinds and intensities. It didn't take a particularly intense interrogation to figure out that the child wasn't having any other gastrointestinal symptoms. The pain started on the first day of preschool, when mommy was leaving for work. A couple of times she called in sick to stay with him. On those days, his abdominal pain vanished as soon as she said she'd stay. I gave the mother some ideas of behavioral things to try to make the transition easier, and told her to call and let me know how it was going. Realistically, no exam was going to help me make a diagnosis in this happy active boy who was running and jumping around in my office. But I knew that the exam could have a powerful effect on the patient. I had listened to him tell his story. But he had to know that I would understand his pain when I examined him. Carefully, without joking, I listened to his chest and stomach. I looked in his ears and mouth, felt his neck. And last, I slowly examined his abdomen. I had a serious expression on my face, as if searching for something. Finally, I spoke to his mother directly, with him in the room. She's a school principal—but I used mostly 1-syllable words in my most grown-up voice and cadence. '<span style="font-style: italic;">I can see what the problem was,</span>' I said thoughtfully. '<span style="font-style: italic;">I'm sorry he was so sick and his tummy hurt so much. I think it's all better now and it won't hurt any more.</span>'<br />
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OK, maybe the analogy to this use of the placebo effect isn't perfect. But I hear it from adults all the time. 'The doctor saw me but he didn't even examine me.' I hear it from my mother.<br />
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I believe there is something important in gentle physical touch. During a physical examination, the touch isn't as a friend, and sometimes elicits pain. But the touch of the doctor's hands is more than a one-way data cable from patient to doctor, providing resources to the diagnostic algorithm. The patient is getting information, too. The patient's information is not examined in <span style="font-weight: bold;">Every Patient Tells a Story</span>. I suspect some of the information is about the caring of the physician. But the deliberation of the touch, how unhurried it is, how focused it is on finding out just where it hurts are all things that I suspect every patient perceives. And patients value this as well.<br />
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This is more than a placebo effect. Obviously, when we don't feel well, it's good to have somebody available who's a sympathetic and patient listener, a good observer, with a gentle and caring touch. That would make anybody feel better. But I think there's an important feedback loop here that has a real impact on the Story that Every Patient Tells. It's the rapport, the unrushed atmosphere in the exam room, the openness of the examining physician that elicits that story. And hearing that story--<span style="font-style: italic;">listening</span> to that story--can sometimes determine if the patient lives or dies.<br />
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<br />
Book Review, Part 3<br />
What, exactly, is a physician’s ethical obligation to a patient? Though not discussed in the book, <u><b>Every Patient Tells a Story</b></u>, the question lingers in my mind after a careful reading.<br />
<br />
A man with chest pain is seen in the Emergency Room. They do all the appropriate tests to rule out a heart attack. They send him home. He told them about the tingling in his fingers, but they <span id="SPELLING_ERROR_0">didn</span>’t really consider it. Is the definition of the ER physician’s job to diagnose the patient? Or is it to rule out diagnoses? Many ER docs, I think, would like to diagnose a patient if possible. But if not, their basic responsibility is to rule out diagnoses that must be treated immediately or conditions for which the patient must be admitted. If you’re not acute, and don’t need to be admitted, you can go home. The ultimate decision node in the the ER decision tree is whether or not to send home. It’s not about what the patient has, it’s about what the patient <i><span id="SPELLING_ERROR_1">doesn</span>’t</i> have.<br />
<b><u>Every Patient Tells a Story</u></b> is the most important book I’<span id="SPELLING_ERROR_2">ve</span> read in years. Dr. Lisa Sanders discusses, through riveting case stories and her own accumulated insight, how diagnoses are made. Her own considerable experience in documenting case reports of unusual and difficult diagnoses, from years of writing the <b><i>Diagnosis</i></b> column in the <i>New York Times Magazine</i>, has left her in a unique position to see the diagnostic process in both minute detail and in overarching trends.<br />
<br />
Again and again in the book, difficult and sometimes obscure diagnoses are presented as exciting detective stories. The stories <span id="SPELLING_ERROR_3">wouldn</span>’t have made it into the book, I suspect, if they were obvious or straightforward. Often, the right diagnosis is missed again and again, by generalists and by specialists. I’ll ask again, what is the obligation of the physician? Are there limits?<br />
<br />
I like to think that I’m like the doctors described in some of these stories. When faced with a seriously ill patient without a working diagnosis, they are tenacious, nearly obsessed. They call their doctor friends, they contact experts they don’t know personally, and they go to the library.<br />
<br />
A little girl I take care of was brought in by her mother. She had a fever for a couple of days, but <span id="SPELLING_ERROR_4">wasn</span>’t complaining of any pain or other symptoms. Her mother was particularly concerned about a tick she removed from the girl’s abdomen about a week before. They were at a lake house, and the 3-year-old was swimming naked. The tick was tiny, not engorged, and could not have been attached for more than a couple of hours. Mom removed the tiny thing with her fingernail. A day or two later, there was about 1 cm (less than 1/2 inch) of redness around a tiny black spot where the tick was. The redness went away in another couple of days, and until the fever, mother <span id="SPELLING_ERROR_5">wasn</span>’t concerned. Having gone to medical school in Connecticut, I feel pretty secure in my basic knowledge about Lyme disease (named for the town of Lyme, Connecticut).<br />
<br />
Here’s why I reassured the mother that this was unlikely to be Lyme disease. Generally, transmission of the disease requires the tick to be attached for at least 24 hours. The classic rash of Lyme disease, <i><span id="SPELLING_ERROR_6">erythema</span> <span id="SPELLING_ERROR_7">migrans</span></i>, is one I’<span id="SPELLING_ERROR_8">ve</span> seen several times. It has the distinctive look of an archery target, and 70-80% of people who have Lyme get the rash. Here in California, the <a href="http://www.cdc.gov/ncidod/dvbid/lyme/ld_rptdLymeCasesbyState.htm">incidence of Lyme disease</a> is about 2 cases per million people (some other examples: Wisconsin 324 per million, Connecticut 873 per million). So it’s also just pretty unlikely. So I reassured her that unless the child had other symptoms, I <span id="SPELLING_ERROR_9">wouldn</span>’t recommend that we take her to the lab for a test for Lyme disease. But I said I’d look up some of the other possibilities to see if she needs to be worried about other diseases. It <span id="SPELLING_ERROR_10">wasn</span>’t a lot of research, not nearly as much as I have had to do for some diagnoses, nor as much as was done by some of the doctors working on the mystery diagnoses in <span style="font-weight: bold;">Every Patient Tells a Story</span>.<br />
<br />
But I know this much for sure: nobody pays me for that time. Nobody pays me to pay another professional I might call for advice, just as nobody pays me for the time I spend on the phone coaching other doctors who call me for advice about their own mystery cases. I was impressed with the tales of caring and motivated doctors who clearly spent time in medical libraries and online and on the phone in order to make the difficult diagnoses in this great book. I know that they <span id="SPELLING_ERROR_11">weren</span>’t paid for that time. Is it their ethical obligation to the patient to do this work? Is the obligation of the physician ‘best efforts’ or, as in most malpractice cases, ‘at the standard of care?’ Or is the obligation to ‘do what it takes to get it right?’<br />
<br />
I often point out that the current model under which we provide medical care, in which doctors are paid per visit is not always compatible with optimal care. But now I have a new concern. If doctors are paid for a visit—and indeed, patient-related work that <span id="SPELLING_ERROR_12">isn</span>’t done face-to-face with the patient is usually not paid—and if working for free is not ethical, are doctors obligated to work for free, on their own time, until they get a diagnosis for the patient? Presumably, the patient benefits. But economically speaking, the physician is effectively donating her services not to the patient but to the payer, the insurance company. It’s the insurer which gets the economic benefit of hours of additional physician work with no incremental cost to them. It is the insurer who has the most incentive to keep paying the doctors the way they do, to keep them churning through patient visits as fast as possible.<br />
<br />
What is the ‘standard of care’ in the stories that are described in this book? (Or in the case reports described in her fascinating column, <i><b>Diagnosis</b></i>? It’s not getting the diagnosis right. If it were, then there would be a long trail of physicians who <span id="SPELLING_ERROR_13">didn</span>’t meet the standard in these cases.<br />
<br />
Does the doctor have an ethical imperative to listen to the patient? It’s certainly appropriate professional behavior to be polite, but to <i>listen</i>?<br />
<br />
If you’re the patient with the mystery diagnosis, however, what do you do? Who do you see? Some primary care doctors shunt difficult diagnoses automatically to specialists, just to save time. Sometimes, they send these patients to me.<br />
<br />
<br />
As a primary care physician, I see an additional problem. When I have a real mystery, I do sometimes send my patients to specialists with the assumption that their specialized training and experience will give them insight I don’t have. And it frustrates me and my patients when, as so often happens, I am told that while they don’t know what’s wrong with my patient, they are sure the problem <span id="SPELLING_ERROR_14">isn</span>’t in <i>their</i> department. [I guess that’s why they make so much more money than I do.] What is their ethical (not contractual) obligation?<br />
<br />
Is the job of the specialist to rule things out? Who gets to rule things in? And let's be blunt about it--it's easier and quicker to cross things off a list of possible diagnoses than it is to think of new things to add to a list. Whose job is that?Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com1tag:blogger.com,1999:blog-795027104294386040.post-8003397500469290482009-10-12T04:39:00.000-07:002009-10-10T10:25:49.330-07:00Problems with Medical Ethics: Perimortal Obsession<div class="wlWriterEditableSmartContent" id="scid:0767317B-992E-4b12-91E0-4F059A8CECA8:d0336563-f9e2-4d35-8dc1-c4e4122c0066" style="margin: 0px; padding: 0px; display: inline; float: none;">Technorati Tags: <a href="http://technorati.com/tags/ethics" rel="tag">ethics</a>,<a href="http://technorati.com/tags/medicine" rel="tag">medicine</a>,<a href="http://technorati.com/tags/primary+care" rel="tag">primary care</a>,<a href="http://technorati.com/tags/death" rel="tag">death</a>,<a href="http://technorati.com/tags/perimortal" rel="tag">perimortal</a></div> <p><a href="http://lh5.ggpht.com/_IwgfwdBQlpw/Smt6JzCmJNI/AAAAAAAAAb8/OzfgdjCRzAU/s1600-h/scythe1%5B5%5D.jpg"><img title="scythe1" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" alt="scythe1" src="http://lh3.ggpht.com/_IwgfwdBQlpw/Smt6LUlqBmI/AAAAAAAAAcA/DYNNTwHPKVc/scythe1_thumb%5B3%5D.jpg?imgmax=800" border="0" height="297" width="396" /></a> </p> <p>Some of the most wrenching and difficult issues for us humans to resolve occur in circumstances near the end of life. The animal world has, I think, a pragmatic approach to leaving the crippled zebra behind for the lions as the rest of the herd runs away. It’s not so easy for us. It’s important to bring these difficult issues out into the open air. The current world of medical ethics continues to do an excellent job of figuring out what the issues are and helping the rest of us find rational ways of looking at these problems. </p> <p>I did a search on <a href="http://www.ncbi.nlm.nih.gov/pubmed/" target="_blank"><span class="blsp-spelling-error" id="SPELLING_ERROR_0">PubMed</span></a>, the National Library of Medicine online medical research reference source. I searched:</p> <p align="center">ethics AND death</p> <p>and got 12,416 publications.</p> <p>In pediatrics, there are grave and important decisions to make when babies are born with such severe developmental problems that their survival is in doubt. How much should we do? What interventions truly help this baby, and what interventions just prolong the suffering? Should we treat every such afflicted baby the same, or will it matter what State the baby is in, or what doctor it has? There’s a lot of healthy discussion in the bioethics world about babies on the edge of viability.</p> <p>Likewise, it is partially to the credit of <span class="blsp-spelling-error" id="SPELLING_ERROR_1">bioethicists</span> that we now have ‘living wills’ and ‘advance directives’ which can guide our loved ones and caregivers if we cannot. This is a genuine advance in medical care, and has prevented a lot of suffering. (More on this in a later post.) </p> <p>Despite this help with some of our most difficult choices in life, the bioethics field, in some ways, has chosen the easiest path. It’s true that one thing we all have in common is our mortality. Perhaps we also share a reluctance to deal with it, talk about it, and plan for it. About 65%of Americans die without a will.</p> <p>This is the easy path because there are no right answers. The case will eventually end in a concrete way. Was the right thing done? Academically speaking, it <span class="blsp-spelling-error" id="SPELLING_ERROR_2">doesn</span>’t matter, since the focus will have shifted to the next edge-of-survival case. </p> <p>I’ll say again that I’m glad that smart, literate people are concentrating on this. If I were ever pregnant with a severe brain injury and a fetus hovering at the age of survival, separated from my husband and father of this fetus but with a new live-in partner who <span class="blsp-spelling-error" id="SPELLING_ERROR_4">doesn</span>’t get along with my parents who are divorced because one of them is a fundamentalist believing in predestination and eternal afterlife so thinking that my demise will result in relief from suffering and ascent in grace and the other a devout believer in the sanctity of all life who insists that every possible intervention should be exhausted, then I’m sure I’d be happy there was an Ethics Committee at the hospital. That way, the burden would not fall on just one doctor to populate the daytime talk shows.</p> <p>In fact, these cases do occur, and they highlight important topics we might never have thought of.</p> <p>But they <span class="blsp-spelling-error" id="SPELLING_ERROR_5">aren</span>’t common. It’s also an easy path for professional <span class="blsp-spelling-error" id="SPELLING_ERROR_6">bioethicists</span> precisely because the situations are so vanishingly rare. The very fact that a medical case has <a href="http://lh4.ggpht.com/_IwgfwdBQlpw/Smt6Q7ENnqI/AAAAAAAAAcU/YLt3mOGlhw4/s1600-h/ivorybilledwoodpecker5.jpg"><img title="ivory billed woodpecker" style="border-width: 0px; display: inline; margin-left: 0px; margin-right: 0px;" alt="ivory billed woodpecker" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Smt6Rd8bKaI/AAAAAAAAAcY/CTrYrdliql0/ivorybilledwoodpecker_thumb6.jpg?imgmax=800" align="right" border="0" height="59" width="74" /></a>made it onto the news, that bioethics <span class="blsp-spelling-error" id="SPELLING_ERROR_7">bloggers</span> are blogging about it, means a <span class="blsp-spelling-error" id="SPELLING_ERROR_8">priori</span> that it’s a rare bird. For every case like this, there must be thousands and thousands of problems that occur every day for which doctors receive no guidance but their own gut feel. There are ethical questions that arise every day, but publications and debates on these issues are few. Nobody gets interviewed on TV for this.</p> <p>Hank, a very bright 15-year-old patient, came to my office a few months ago to talk to me. He was sent by his mother because his unstable moods and erratic actions were a serious problem for him both at home and at school. His parents were divorced, and both had new partners. He came to the office by public transportation, after school. After we talked about what had been going on, I told him I thought he needed a mood-stabilizing medication. He thought that would be OK, and we talked about possible side effects. I asked him explicitly if he would be willing to try the medication, and take it just as prescribed. He said he would, but only if I <span class="blsp-spelling-error" id="SPELLING_ERROR_9">didn</span>’t tell his mother.</p> <p>Though he moved between his father’s and mother’s homes, he was aware of differences in his life at each place. Mom had better food, a well-stocked refrigerator, and was easy-going about bedtimes and curfews. Dad had better video and video games, and was more lenient about computer access but stricter about curfew. His mother, he told me, had sometimes used his previous medications as a threat or as a crutch to explain his behavior. She’d say ‘you need a higher dose’ or ‘I liked you better when you were on….’ This hurt his feelings. If he was arguing with her, he figured, maybe there was a good reason for it. Maybe she was actually wrong about something. His dad never did this. As he told me this, he was completely calm and rational. I believed every bit of his description—and I thought he was right. </p> <ol> <li>Should I have seen him without a parent there in the office? </li> <li>Are there topics of discussion that are off-limits? </li> <li>Should I insist on telling his mother? </li> <li>What if his mother calls and asks me what we talked about? Am I required to tell her the substance of our conversation? </li> <li>What if she asks about my diagnosis and plan for him? <span class="blsp-spelling-error" id="SPELLING_ERROR_10">Doesn</span>’t she have a right to know that? </li> <li>What will happen to my relationship of trust with this teenager if I say I won’t tell his mother but then I do? </li> <li>What will happen to the teenager’s care if he stops trusting his doctor? <em><strong>He</strong></em> is my patient. I am responsible for his care. What’s best for him? </li> <li>If I tell the father, and he pays for and picks up the medication, is he obligated to tell the mother (with whom he hardly ever speaks)? </li> <li>If I want to monitor the patient once on medication, I will want him to return weekly for at least the first few weeks on medication. Who makes these appointments? Do I have to cover up the fact that the kid was even seen? </li> <li>Even if I agree not to tell his mother, do I lie to her? If she asks if her child is on medication, do I say no? (OK, this is an easy one, since I am not willing to lie.) </li> <li>In fact, California law does permit a minor to consent for certain mental health services without a parent. Other states vary, but many have similar provisions. </li> </ol> <p>These are just some of the questions that arise from this one actual encounter. </p> <p>From this single visit, the questions, I think, can be grouped as follows:</p> <ul> <li>What are the doctor’s legal obligations? </li> <li>Of the legal obligations, which are subject to interpretation and judgment? (Would my license be in danger if I did tell the parent, but not for a day or two?) </li> <li>What are my obligations to the patient? <ul> <li>Do these obligation vary by chronological age? </li> <li>What about developmental maturity? (Surely a mature 12-year-old should have more autonomy than an immature teenager?) </li> <li>Are the obligations to the patient more important than the obligations to the parent? </li> </ul> </li> <li>What should I write in his chart? Should I document things he tells me that he <span class="blsp-spelling-error" id="SPELLING_ERROR_11">doesn</span>’t want a parent to know when they can request the chart at any time? </li> <li>Is this mix of obligations changed when medication is involved? Is it changed when psychotropic medication is involved, as opposed to antibiotics, for example? </li> </ul> <p>I did a search on <a href="http://www.ncbi.nlm.nih.gov/pubmed/" target="_blank"><span class="blsp-spelling-error" id="SPELLING_ERROR_12">PubMed</span></a>, the National Library of Medicine online medical research reference source. I searched:</p> <p align="center">ethics AND “primary care”</p> <p>and got 837 publications. That’s about 1/15<span class="blsp-spelling-error" id="SPELLING_ERROR_13">th</span> as many as when I searched for 'ethics AND death.' I know the situations I’m in are common and happen every day, to me and thousands of doctors. </p> <p>Of course this is the tip of a very big and very cold iceberg. There will be more dispatches from this ice field soon. Climate change notwithstanding, it won’t be melting soon.</p> <p><a href="http://lh4.ggpht.com/_IwgfwdBQlpw/Smt6S5a5Y1I/AAAAAAAAAck/2Vh4NjS9dUk/s1600-h/iceberg1%5B3%5D.jpg"><img title="iceberg1" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" alt="iceberg1" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Smt6TV238UI/AAAAAAAAAco/0iDo4TBkghE/iceberg1_thumb%5B1%5D.jpg?imgmax=800" border="0" height="164" width="120" /></a></p> <p><span style="font-size:85%;">Epilogue: Here's what I did. I took the time to convince him to inform his mother. I told him that if he didn't and she found out he was on medication--and the chances were good that she'd find out somehow--she could use against him the fact that he wasn't honest with her. She could also stop trusting me, as part of this </span><span style="font-size:85%;">deception. That could change his access to me. I offered to call her directly, and explain in medical terms why </span><span style="font-size:85%;">I thought medication was a good idea at this time. Hank liked this and jumped on it. I told him that the next </span><span style="font-size:85%;">time she said something about his medication that he didn't like, he should say "Talk to Dr. <span class="blsp-spelling-error" id="SPELLING_ERROR_14">Wolffe</span>," and not </span><span style="font-size:85%;">argue with her about it. I would contact him directly and keep him informed about any conversations I have with either of his parents about his medication. I got a portable phone and took it into the exam room. I called his mother right then, with him there, and told him that I'd like him to start some <span class="blsp-spelling-corrected" id="SPELLING_ERROR_15">medication</span>. Sh</span><span style="font-size:85%;">e was OK with that. Hank was visibly relieved.</span> <br /></p> <a title="iweb counter" href="http://www.statcounter.com/iweb/" target="_blank"><img alt="iweb counter" src="http://c.statcounter.com/4961707/0/7bd2f96c/1/" border="0" /></a>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-28768619379642737982009-10-01T09:00:00.000-07:002009-10-01T09:00:01.612-07:00Problems with Medical Ethics: Holistic Ethics<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_IwgfwdBQlpw/SnPG7mzmfpI/AAAAAAAAAe0/xZCnihHlyRM/s1600-h/dental+xray+panoramic.aspx"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 160px; height: 72px;" src="http://2.bp.blogspot.com/_IwgfwdBQlpw/SnPG7mzmfpI/AAAAAAAAAe0/xZCnihHlyRM/s400/dental+xray+panoramic.aspx" alt="" id="BLOGGER_PHOTO_ID_5364850308459953810" border="0" /></a><br /><p>It’s been established that doctors who own their own x-ray machines do a lot more x-rays on their patients than doctors who don’t own their own machines. Some of this, no doubt, is because it’s so convenient, and the doctor could get results right away. But part of it is also the fact that the doctor will earn money not just from the visit but also from the x-ray. Knowing this, I recently changed dentists. <a href="http://lh5.ggpht.com/_IwgfwdBQlpw/Sm07c7T8LmI/AAAAAAAAAeE/UhygkrFQfAc/s1600-h/dentalxraymachine1.png"><img title="dental x-ray machine" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" alt="dental x-ray machine" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Sm07dVs1E7I/AAAAAAAAAeI/xfbf21Qq7X8/dentalxraymachine_thumb1.png?imgmax=800" border="0" height="164" width="141" /></a> </p> <p>I had a good dentist. But it really bugged me that every time I was there, he was selling me on…whitening products, tooth grinding products, and x-rays. That was the final straw. He told me that I needed a full set of x-rays every year. I had no dental insurance, and would be paying in cash. I asked if it were really necessary, and he told me it was essential. I asked him if this had <a href="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm07d9BZ5PI/AAAAAAAAAeM/FzLAxlt-1ok/s1600-h/teeth25.jpg"><img title="teeth2" style="border-width: 0px; display: inline; margin-left: 0px; margin-right: 0px;" alt="teeth2" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Sm07eOPSdhI/AAAAAAAAAeQ/075AOzCZcf8/teeth2_thumb3.jpg?imgmax=800" align="left" border="0" height="52" width="124" /></a> ever been studied, and if he could send over to my office any papers about the difference in outcomes between those people who went to the dentist and had x-rays and those who went to the dentist and didn’t have annual x-rays. He said he didn’t have a paper like that. So I got a new dentist, who is very nice. She examined me and told me that a crown was worn on one side. She said, “We should replace that.” It would cost $1200. I chose to wait until something went wrong with it.</p> <p>Why does the dental profession think it’s OK for every dentist to have their own x-ray machines? Is their conflict-of-interest somehow less powerful than a medical doctor’s? Are dentists immune from the influences of conflict-of-interest?</p> <p>Every now and then, I am sent a flyer from a company looking to produce for me bottles of vitamins and ‘supplements’ with my name on them. The idea would be that I’d sell the products in my office, telling patients that they need these products, and that the products are not available elsewhere. Obviously, they would be a lot more expensive than similar (maybe identical or superior) products you could get at the supermarket. I would give everyone the same advice: be cautious about the so-called professional—wait, <em>anybody</em>—who says you need to buy something you can only get from them.</p> <p>Of course this applies to physicians as well. Do you really need that follow up visit if you are fully recovered? Do you really need that follow up x-ray? Do you really need to return for all 16 visits? (I don’t want to seem too cavalier about this. It’s tempting to think we don’t need follow up care when we’re feeling OK. But that’s a serious mistake for many problems, especially the ones we might not feel, like diabetes or high blood pressure. Sometimes, even when the baby looks great, I really need to weigh and examine the baby every day.)</p> <p>The never-mentioned elephant in the room—one of several—will get me in trouble<a href="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm07egzKamI/AAAAAAAAAeU/hPmNh2ClO6E/s1600-h/elephant12.png"><img title="elephant1" style="border-width: 0px; display: inline; margin-left: 0px; margin-right: 0px;" alt="elephant1" src="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm07e_TVaOI/AAAAAAAAAeY/Z3MgxVk_8Yo/elephant1_thumb2.png?imgmax=800" align="right" border="0" height="121" width="160" /></a> here. [Maybe by burying it in the middle of this 4th post on ethics will I prevent the storm of backlash I expect.] Alternative Medicine.</p> <p>I want to keep this to a reasonable length, and not focus on safety or efficacy of alternative treatments. I reserve the right to rant at another time. The topic is ethics.</p> <p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/">PubMed</a> search of <em>ethics</em> has 139,072 references. A search of <em>ethics</em> AND <em>chiropractic</em> has 63. How come when my patients go to the acupuncturist, for example, they are told they need another visit, and another visit and another? How many visits does it take? Has this been studied? How come they are so often sold on various supplements and herbal remedies only available there in the practitioner’s office? Is it ethical to do business that way? Is it ethical to prescribe products which are untested? Do they need to disclose that the products have not been tested? Do they have to disclose that what’s on the label may not include stuff that’s in the product? Do the practitioners need to obtain some sort of informed consent for their procedures or for these untested products? Is it ethical for these other practitioners to raise doubts about the treatment plan I proposed? Is it ethical for me to raise doubts about the alternative treatments and medications my patient is taking? In <a href="http://drwolffe.blogspot.com/2009/06/squirmy.html">Squirmy</a>, I think it was the pharmacist at the ‘natural’ pharmacy who advised the parents to put calendula cream on their baby. Exactly which health care provider is ethically restricted in what they can say and which provider isn’t?</p> <p>In many places, there are laws and liability precedents that restrict what licensed physicians do. But surely the ethics of what is done with patients doesn’t vary with the initials after your name. I don’t think that my patients should get cheated or carelessly harmed by a doctor. Or a chiropractor, ayurvedic practitioner, naturopath or guru with a fleet of Rolls-Royces.</p> <p>In this series of posts, I complain that there’s too much attention placed on really unusual medical situations and not enough on common situations. But the field has developed a cadre of smart, perceptive thinkers who are very quick to understand some of the problem issues in patient care. It would be great if they looked at patient care from a holistic point of view, not just the patient-physician interface. Real-world medical decisions, faced by patients every day, touch on all aspects of their care. Their personal relationships, their supplemental caregivers, their medications and supplements, financial situation and alternative practitioners all influence the patient’s wellness. It would be great if our field of medical ethics could take its eye away from the telescope and see the whole Milky Way.</p> <p><a href="http://lh4.ggpht.com/_IwgfwdBQlpw/Sm07feUZTkI/AAAAAAAAAec/yKbhpZMJ4mI/s1600-h/milkywaycandy2.png"><img title="milky way candy" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" alt="milky way candy" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Sm07flnI2rI/AAAAAAAAAeg/ln4zdBoCmFg/milkywaycandy_thumb2.png?imgmax=800" border="0" height="160" width="160" /></a> </p> <p>There is still an ongoing debate about whether physicians can refuse to provide certain services depending on their own consciences. One side believes that doctors shouldn’t reasonably be forced to give a patient advice they don’t believe in—like using birth control, for example. The other side thinks that the patient won’t know what the doctor believes, and as their medical expert who is supposed to have their best interest at heart, so the doctor should present all available options, including choices they wouldn’t make personally, such as abortion. <a href="http://content.nejm.org/cgi/content/full/352/24/2471?ijkey=8ac369428c0d8b6e1c0bc4d11f846faeb360dd99&keytype2=tf_ipsecsha">In 2005, there was an editorial in the New England Journal of Medicine discussing the case of pharmacists who refused to fill prescriptions for pills that could terminate a pregnancy</a>. My letter in response was <a href="http://content.nejm.org/cgi/content/full/353/12/1301">published</a>, but here’s what I said, and I believe it more today, 4 years later:</p> <blockquote> <p><i>To the Editor:</i> It is curious that pharmacists might refuse to<sup> </sup>fill a prescription. Must all the prescriptions they fill result<sup> </sup>from morally acceptable diagnoses? The Health Insurance Portability<sup> </sup>and Accountability Act of 1996 (HIPAA) does not allow breaches<sup> </sup>in confidentiality about diagnoses and therapies so that strangers<sup> </sup>can make individual judgments about whether to cooperate in<sup> </sup>treating a patient. A prescription may be written for a diagnosis<sup> </sup>of which the pharmacist is unaware (e.g., oral contraceptives<sup> </sup>to treat ovarian dysfunction). There are many other people involved<sup> </sup>in every patient's care. What if receptionists refused to make<sup> </sup>an appointment or refused to give the physician a telephone<sup> </sup>message because they did not approve of something? The pharmacist<sup> </sup>might refuse to fill a prescription, the cashier might refuse<sup> </sup>to sell the prescribed item, or the driver of the distributor's<sup> </sup>delivery truck might refuse to transport it. Why is the pharmacist's<sup> </sup>moral judgment dominant? Ethically, there should be open disclosure<sup> </sup>that some prescribed drugs, products, or services will not be<sup> </sup>provided. Disclosure is also ethically required for diagnoses,<sup> </sup>symptoms, or clinical issues about which the pharmacist, health<sup> </sup>care worker, or others in the chain of health care delivery<sup> </sup>have such feelings that their cooperation in the care of patients<sup> </sup>is compromised. Will this trend inevitably lead to a balkanization<sup> </sup>of medicine, whereby patients will go only to doctors of their<sup> </sup>own sect, who prescribe only for pharmacists of that sect, and<sup> </sup>refer only to specialists of that sect? Shouldn't patients be<sup> </sup>warned?<sup> </sup></p> <p><sup></sup> <br />Wolffe Nadoolman, M.D., M.B.A. </p></blockquote>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-25111709359608189772009-09-17T09:00:00.000-07:002009-09-17T09:00:02.751-07:00Problems with Medical Ethics: The Elephant<p><a href="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm08OznRe4I/AAAAAAAAAek/5hNHqDNQ23k/s1600-h/elephant24.png"><img title="elephant2" style="border-width: 0px; display: block; float: none; margin-left: auto; margin-right: auto;" alt="elephant2" src="http://lh4.ggpht.com/_IwgfwdBQlpw/Sm08QtcAxvI/AAAAAAAAAeo/BnbG_aA4kxY/elephant2_thumb4.png?imgmax=800" border="0" height="313" width="260" /></a> Fifteen years ago, I did part of my first pediatric training in the pediatric clinic of St. Raphael’s Hospital in New Haven. It was a nice hospital, well-known at the time for their excellent cardiac care. It was run by the Sisters of Charity of Saint Elizabeth, an amazingly generous order that really practices charity every day by helping those who need it most. Some of the nurses were in the order. The exceptional physician who ran the pediatric clinic was kind and really smart. I still use his home-made guide to pediatric neurological exams. We got along well.</p> <p>When Reyna came into the clinic, she didn’t look particularly sick, just in pain. She was clutching her abdomen. She saw one of the medical residents, higher in the feeding chain than a lowly medical student like myself. Abdominal pain is one of the most studied of medical symptoms, especially because it’s so common. One by one, the resident and I ruled out some of the things it could be. The girl was 16. We needed a pregnancy test. Oddly, there was some sort of a problem requisitioning one. In fact, the clinic didn’t have one on hand. Her pain got worse, and she was admitted to the hospital. That night, her pain worsened considerably. Blood tests showed no signs of infection. The head of the clinic told us that a pregnancy test wasn’t needed. Within a couple of days, she needed an enormous amount of intravenous morphine. Eventually, if I recall correctly, she was taken by ambulance to Yale-New Haven Hospital for emergency surgery that fixed—and ended—her ectopic pregnancy. Maybe the doctor in charge knew a lot more than me about pediatrics. But I am still affected by my memory of this girls pain. Where was his ethics committee?</p> <p>Every hospital I’ve ever entered had an office for chaplains. I think this is a good thing. Not meaning to joke about it, my <a href="http://drwolffe.blogspot.com/2009/07/lollipops.html">post about lollipops</a> discussed my rationale for using a partly physiological and partly placebo intervention to make a child feel better. I have described <a href="http://drwolffe.blogspot.com/2009/05/claire-6-tastes-like-chicken.html">my use of hypnosis to help with an anxiety disorder</a>. I think that if a child, if any patient, will feel better after an intervention of some sort, I’d like to use it if it’s safe. For the devout, the counseling of a religious guide can make an important difference in their quality of life. I respect it and recommend it when appropriate.</p> <p>There is no bigger elephant in the room in which medical ethicists sit around and sip their lattes than religion. The topic is deeply taboo, and I can’t help but wonder if my email address will be unceremoniously ripped from the bioethics listserv database.</p> <p>At a major national meeting a few years ago, I went to all the sessions given in ethics. In one, a discussion was promised concerning the ethical issues of contraception counseling and prescribing for teenagers. One side brought up the sobering statistics we all know about teen pregnancy and STDs. The other side argued that since condoms only work 95% of the time, that’s a 5% failure rate. Since that’s not acceptable, the only reasonable counseling for physicians to be doing is to tell teens is that abstinence is the only effective form of contraception.<span style="text-decoration: underline;"><br /></span></p><p><span style="text-decoration: underline;"></span> More than a decade ago, I attended Georgetown University’s Intensive Bioethics Course. It was well-organized and I learned a lot. After the first couple of days of lectures, I asked why every lecture on any topic, with no exceptions, included mentioning what The Pope had said on the subject. It was Georgetown, and I was not naive about who ran the place. But I didn’t think it was an insulting question. I really wanted to know why my patients—atheists, Jews, Hindus, and Wiccans—might be affected by this*. Are religious leaders, whether laypeople or divinely chosen, gifted in unraveling of ethical complexities by their career success?<br /></p> <p>In what way, exactly, does holding a title of religious training qualify a person to sit at the medical ethics table? Are they guided by their training or constrained by it? Do their opinions apply only to their flock? What about the rest of us?</p> <p>A rigorous principle of contemporary medical ethics involves disclosure. It might be in a grey area that all the objects in your doctor’s office—the post-it notes, the clipboards, the pens, even the magazines—have the name of a drug or drug company on them, but as long as the doctor discloses all the side income, then it’s OK. (They usually don’t disclose unless required to do so. Next time you’re in the doctors office, look around. How many of these ‘gifts’ can you spot?) Do we ever disclose religious affiliation? Should we? Should doctors disclose this? Should the hospital tell you that their ethics committee which has set the policy for pregnancy testing of unmarried teenagers is made up entirely of clergy handpicked by somebody who has a whole different set of values from you? What would happen if they did? Would parents of 16-year-old girls with abdominal pain bring their daughter there for evaluation? Here’s a scary thought: maybe they would prefer to bring them there.<br /><br />If there is some basic foundation of ethics based on truths we hold to be self-evident, what exactly is added by expertise in dogma?</p><p><br /></p><p><span style="font-size:78%;">The case I described above is a real one. It was a horrible experience for me, the resident, and of course the patient. She did fine. It was one of the most unethical events I have ever witnessed.</span></p><p><br /></p><p>*<span style="font-size:78%;">I really asked the question. What was I thinking? Like Peter Riegert walking into the Dexter Lake Club in 1978's <span style="font-style: italic; font-weight: bold;">Animal House</span>, suddenly, the huge auditorium fell completely silent. The lecturer awkwardly dismissed my question without answering it, and I was too humiliated to insist.</span></p><p><br /><object height="364" width="445"><param name="movie" value="http://www.youtube.com/v/v7QTe-TMCNc&hl=en&fs=1&color1=0x234900&color2=0x4e9e00&border=1"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/v7QTe-TMCNc&hl=en&fs=1&color1=0x234900&color2=0x4e9e00&border=1" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="364" width="445"></embed></object><br /></p> <p><span style="font-size:78%;"><br /></span></p>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-46307590790466882142009-09-02T06:00:00.000-07:002009-09-02T06:00:05.067-07:00Problems with Medical Ethics: Man in the Mirror<p>In <a href="http://drwolffe.blogspot.com/2009/07/problems-with-medical-ethics-perimortal.html">Perimortal Obsession</a>, I noted that a great deal of the work in medical ethics is focused on <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://1.bp.blogspot.com/_IwgfwdBQlpw/SnvpNPrHpsI/AAAAAAAAAfo/F2RdPmhYUz8/s1600-h/cassatthandmirror6.png"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 119px; height: 160px;" src="http://1.bp.blogspot.com/_IwgfwdBQlpw/SnvpNPrHpsI/AAAAAAAAAfo/F2RdPmhYUz8/s200/cassatthandmirror6.png" alt="" id="BLOGGER_PHOTO_ID_5367139794697037506" border="0" /></a>unusual near-death situations that, though interesting, have limited relevance to the daily practice of medicine. In my last post about the problems in medical ethics, <a href="http://drwolffe.blogspot.com/2009/08/problems-with-medical-ethics-recruiting.html">Recruiting</a>, I tried to point out that experts in ethics who were based at big and important institutions and medical schools really have no contact with the practice of medicine as I and tens of thousands of my primary-care colleagues know it. So it’s understandable that they are either unaware of the issues that face me and my patients or maybe they don’t see the importance.</p> <p>The work that is currently being done in the field of medical ethics is important and interesting. At some point in each of our lives, it may become sadly crucial as we are forced to make a wrenching decision about a baby, a parent, a loved one…or ourselves.</p> <p>In this series of posts, a theme that’s been repeated is the field's apparent lack of interest in the ethics of primary care. It’s curious to me that this disparity of focus has somehow developed.</p> <p>But not nearly as curious as the glaring lack of self-reflection amongst those who have made this their work. Who gets to be on an ethics committee? How are members chosen? Do the people who teach ethics to doctors actually see patients every day?</p> <p>The tasks of ethics committees in academic environments, besides working on perimortal crises, also often involve the important work of protecting patients who are subjects of medical research. (Disclosure: I sit on an IRB, an Institutional Review Board, whose task is to review and approve protocols for medical research.)</p> <p>Experts in medical ethics end up knowing quite a lot about new technologies and treatments, end-of-life care, and principles of patient rights. My experience in the work world suggests that people don’t get very far criticizing the company they work for, the industry they’re in, their boss or the top executives. I think this holds true for professional ethicists at big nonprofits also, such as hospitals or medical schools.<br /></p> <p>For the record, people who go into the field of medical ethics don’t do it for the money. There’s no pharmaceutical industry backing their work, and they don’t earn more by doing more of some kind of procedure. Indeed, some already find themselves walking on eggshells because they gently point out some of the questionable priorities of work being done at their own institutions.</p> <p>That’s not good enough.</p><p style="text-align: center;"><span style="color: rgb(0, 153, 0);font-size:130%;" ><span style="font-style: italic; font-weight: bold;font-family:arial;" >It's the money, stupid.</span></span><br /></p> <p>In one of my Southern California interviews for medical school, I was told to meet a faculty member at his medical office. A prominent kidney specialist (nephrologist), he had a big, busy office. I was greeted warmly by the receptionist, and didn’t have to wait long to see him. He was just a few years older than me, but was in much better shape. He asked what I thought of the stock market. As politely as I could—I was trying to get in, after all—I told him that I wasn’t really involved in the stock market and was really focused on medical school. He seemed a little frustrated <a href="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm06px29ZZI/AAAAAAAAAdo/2zNtJZhC6mI/s1600-h/kidneybeans2.png"><img title="kidney beans" style="border-width: 0px; display: inline; margin-left: 0px; margin-right: 0px;" alt="kidney beans" src="http://lh6.ggpht.com/_IwgfwdBQlpw/Sm06qcYrkSI/AAAAAAAAAds/MaYHJlpBigk/kidneybeans_thumb2.png?imgmax=800" align="left" border="0" height="160" width="160" /></a> when I left about 40 minutes later. He interrogated me nonstop for my opinion of <a href="http://en.wikipedia.org/wiki/Sector_rotation">sector rotation</a>, <a href="http://en.wikipedia.org/wiki/Elliott_wave_principle">Elliott Wave theory</a>, and insider stock tips. He asked if I knew anything about options. As it happened, I knew a lot about options, and like a fool, I told him that I did know <a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://2.bp.blogspot.com/_IwgfwdBQlpw/SnvqGGmc9FI/AAAAAAAAAfw/R0NU7FKXE44/s1600-h/redferrari5.png"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 160px; height: 120px;" src="http://2.bp.blogspot.com/_IwgfwdBQlpw/SnvqGGmc9FI/AAAAAAAAAfw/R0NU7FKXE44/s320/redferrari5.png" alt="" id="BLOGGER_PHOTO_ID_5367140771514086482" border="0" /></a>something about them. Politely, I felt him out about his understanding of <a href="http://articles.pointshop.com/investing/36097.php">Arrow-Debreu Theory</a> and the <a href="http://fedc.wiwi.hu-berlin.de/xplore/tutorials/sfehtmlnode36.html">Cox-Ross-Rubinstein model</a>. Every time I tried to bring the conversation back to why I wanted to go to medical school, he steered the other way. In the packed parking lot of his office was a meticulously polished candy-apple-red Ferrari with the license plate ‘beans.’ Maybe I can’t complain too much: I was admitted. </p> <p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/">PubMed</a> search of the word <em>ethics</em> turned up 139,072 published references in medical journals. A search of <em>ethics </em>AND<em> money</em> turned up just 536.</p> <p>It’s no secret among the general public what the main conflict-of-interest is for many doctors, especially those who use the latest technology, do the most procedures, and, yes, make the most money. So why does it seem like a mystery to those in the ethics field? Nearly 30 years ago, business ethics were an integral part of my business school curriculum. These days it’s part of nearly every course in most top business schools. The business ethics of medical practice were never mentioned, even in passing, in any of my years of medical training. The money of medicine has such a palpable taint that doctors never bring it up with their patients--the billing office does that for them. It is so taboo that it is never discussed in medical school, and those who want to talk about it are openly shunned. Yet the faculty with clout in major institutions are often the ones who bring in the most revenue for their struggling hospitals and clinics.<br /></p> <p>But though I may have been a reformed, life-changing convert, I went through training with my eyes open and—when I had enough sleep for rational thought—my mouth shut. My years and years of training and experience in finance made some things shocking to me. </p> <p>It is generally true that doctors who do things <em>to</em> you make a lot more—way, way more—money than doctors who do things <em>for</em> you. In fact, much of the payment system for doctors is largely controlled by procedure-type doctors. Why is this? Do they work harder? Are they smarter? Do they help you more? </p> <p>In medical school, somehow we got the impression that psychiatrists were among the lower paid. After all, they got paid by the hour, not per procedure. But we were never told that what your psychiatrist probably does with you is heavily influenced by lectures and reviews given by a very small group of department heads of psychiatry departments at major medical schools. Members of this elite club might earn a pretty good, even enviable, living from their faculty positions. <a href="http://www.nytimes.com/2008/06/08/us/08conflict.html?_r=1&adxnnl=1&oref=slogin&ref=health&adxnnlx=1212998653-LVr3y8JFh63W0e2WG4oReA">But they could earn a million dollars a year from ‘consulting’ and guest lecturing and speaking at educational seminars</a>. Even for Wall Street, that’s real money. Is it ethical for them to take this money from pharmaceutical companies? How about neglecting to disclose this to their institutions (officially, their employers)? Should they have to disclose to patients that the drug they are recommending is one that they are paid a staggering amount of money to promote? Would I, as a patient, really believe that this doctor has my best interest as his only priority? Is there a level of compensation at which a reasonable person would not be expected to remain unbiased?<br /></p> <p>Studies showed that when doctors owned their own x-ray centers, their patients ended up getting, on average, more x-rays. In some states this is now illegal. But most big hospitals need to support themselves, and so work in partnership with doctors who do procedures in order to stay in business.</p> <p>The comments and questions I would often receive while in training and occasionally since then, are telling. They went like this. ‘Wasn’t it awful working with all those greedy people on Wall Street?’ No, I replied. Most of the people I worked with were unbelievably smart, creative, and ambitious. Everybody was there to make money—it’s how you were measured. There was no deceit about it. But medicine, I saw, had many people who hid their material ambitions behind their job description. Maybe they were embarrassed by them. Maybe they knew that for them, patient care didn’t always come first. Every patient in America knows. Every doctor in America knows. It's the money.</p><p>I would be happy to volunteer to lead this effort, to define and examine the business ethics of medical practice.</p><p><br /></p><p><br /></p><p> </p> <p><span style="font-size:78%;"><em>The print at top is from my collection and is by Mary Cassatt.</em></span></p> <p><em><span style="font-size:78%;"></span></em></p> <div class="wlWriterEditableSmartContent" id="scid:5737277B-5D6D-4f48-ABFC-DD9C333F4C5D:8328e359-ec73-4e18-bcbf-e972910792cc" style="margin: 0px; padding: 0px; display: inline; float: none;"><div id="e1c992c3-015b-4d05-8305-c12e306f5a12" style="margin: 0px; padding: 0px; display: inline;"><div><a href="http://www.youtube.com/watch?v=vl8wX9D-l7M" target="_new"><img src="http://lh5.ggpht.com/_IwgfwdBQlpw/Sm06s0fsDbI/AAAAAAAAAd4/UlnAbon_fFk/video2a18d1d8f640%5B4%5D.jpg?imgmax=800" style="border-style: none;" galleryimg="no" onload="var downlevelDiv = document.getElementById('e1c992c3-015b-4d05-8305-c12e306f5a12'); downlevelDiv.innerHTML = "<div><object width=\"425\" height=\"355\"><param name=\"movie\" value=\"http://www.youtube.com/v/vl8wX9D-l7M&hl=en\"><\/param><embed src=\"http://www.youtube.com/v/vl8wX9D-l7M&hl=en\" type=\"application/x-shockwave-flash\" width=\"425\" height=\"355\"><\/embed><\/object><\/div>";" alt="" /></a></div></div></div>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com1tag:blogger.com,1999:blog-795027104294386040.post-7606938897046821772009-08-04T11:22:00.001-07:002009-11-16T00:21:15.653-08:00The Generous Aunt<a href="http://lh3.ggpht.com/_IwgfwdBQlpw/SnVMu-1a04I/AAAAAAAAAe8/OloeenFBAIg/s1600-h/Nestles%20mother%20book%201%5B4%5D.jpg"><img alt="Nestles mother book 1" border="0" height="548" src="http://lh6.ggpht.com/_IwgfwdBQlpw/SnVMwbXP2yI/AAAAAAAAAfA/L-WKkIpvyzY/Nestles%20mother%20book%201_thumb%5B2%5D.jpg?imgmax=800" style="border: 0px none; display: block; float: none; margin-left: auto; margin-right: auto;" title="Nestles mother book 1" width="414" /></a> When a baby is born at the local hospital, the clerk in Labor and Delivery calls the pediatrician identified by the parents. The call I received one night about 3:00 AM was a little hard to understand. Granted, I had been awakened. But I asked the clerk for the patient’s name. ‘Oran…,‘ she said, then ‘Oranolantu…,‘ then ‘…bat…. “Do you mean Oranolantubaataar?“ I asked. Relieved, she told me I had a healthy big baby girl to come in and take a look at. I knew the family, and took care of the 4-year old son. I told her I’d be in later that morning. She politely told me that everyone in Labor and Delivery would really like me to come in now. I got dressed and went to the hospital, fearing the worst. <br />
The Charge Nurse for L&D, who is the supervisor of all the nurses and operations of the department except for the obstetricians, and always one of the most experienced veteran professionals there, met me at the elevator, before I entered the ward. She said she’d never seen anything like it and didn’t know if it was OK and wanted me to evaluate this and write a note about it in the chart. She was afraid the hospital might get sued, and maybe a little afraid of losing her job. When I walked into the room, I was not prepared for what I saw. <br />
The mother I knew was smiling happily in bed. Her labor had been relatively short with this second child, born about 2 hours earlier. She greeted me warmly in her broken English. I looked around. “Where’s the baby?” I asked her. She pointed to the chair next to her bed on which was a young woman. ‘Sister’ was her one word introduction. This woman was bare-breasted and nursing the newborn child. <br />
I had never seen anything like it. I met with a group of the nurses, the charge nurse, and others. <br />
The transition from unencumbered adult to parent is always unforeseeably and indescribably enormous. It seems that in recent years, the pressure on new parents has continued to build. The parenting shelf in the bookstore has become a whole section with many aisles. Perhaps it’s a good thing that you now can choose to learn what one author thinks you should have been expecting while you were expecting and another author claims to help you raise a child who is an over-achieving, healthy, gifted, socially adept, high IQ athlete who knows both how to control her temper and who goes to sleep without problems. (My approach to advising parents is almost always to ask the child to provide the right guidance. They usually know.) <br />
Why has this proliferation of parenting advice taken place? The simple answer is that there’s a market for it. Publishers are aware of the demand and are in the business of meeting it. What’s behind this demand? <br />
The desire to produce a text on childrearing <a href="http://www.illinoismedieval.org/ems/VOL12/hanawalt.html">isn’t new</a>. Especially with the industrial revolution, the idea gradually took hold that maybe there was a ‘right’ way to raise kids. <br />
Especially for the new parent, and the new mother in particular, these books can seem like an essential reference. There is a tendency for new parents and new mothers in particular to feel that the ‘success’ of nursing the baby, soothing the baby, even bathing the baby is a great burden that falls on them and them alone. If things aren’t going exactly right in the first days and weeks, it’s hard for new mothers not to see that as a personal failure. This is a major contributor to postpartum depression. But what has caused this crushing pressure? Is this part of Eve’s curse (Genesis 3:16)?<br />
<a href="http://lh5.ggpht.com/_IwgfwdBQlpw/SnVMxcniLhI/AAAAAAAAAfE/vnZDUliTm9Q/s1600-h/brosamer%5B7%5D.jpg"><img alt="brosamer" border="0" height="600" src="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVMzBfyUmI/AAAAAAAAAfI/p_eQc4hMJGc/brosamer_thumb%5B5%5D.jpg?imgmax=800" style="border: 0px none; display: block; float: none; margin-left: auto; margin-right: auto;" title="brosamer" width="409" /></a><br />
I don’t think so. According to archeological evidence, and <a href="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVM0lRMUeI/AAAAAAAAAfM/z1g8I8B0xWY/s1600-h/teenage%20caveman%201958%5B4%5D.jpg"><img align="right" alt="teenage caveman 1958" border="0" height="240" src="http://lh4.ggpht.com/_IwgfwdBQlpw/SnVM1GACpjI/AAAAAAAAAfQ/5YahxaaRGRk/teenage%20caveman%201958_thumb%5B2%5D.jpg?imgmax=800" style="border: 0px none; display: inline; margin-left: 0px; margin-right: 0px;" title="teenage caveman 1958" width="154" /></a>according to countless cave-people movies, humans most likely never went through a phase of living in completely isolated family units. The idea, maybe born out of the settling of the American West, that there would be settlers who lived a hardscrabble life by themselves on a ranch the size of some European countries, is not one that has typically existed elsewhere in the world. Sure there are subsistence farms and always have been, but they are small and the families live close to other families. <br />
And, finally I’m getting to the point, all the households are multigenerational. With marriage as teenagers, there would usually be grandmothers and even great-grandmothers living with the new mother. There would be sisters and aunts with their babies, too. And despite the considerable work all the women were required to do, some of the work of childcare and an enormous amount of cumulative experience and wisdom would be easily available and given. <br />
Though it’s a good guess that midwives, people with special expertise in childbirth, have been around for a long time, Lactation Consultants are likely a newer breed. Within a multigenerational household, there would be lots of sources of advice about sore nipples and babies who don’t latch well. I suspect that postpartum depression has always been with us, but some of its pervasive contributors--isolation, the feeling that every need of the baby must be met by the mother, the sense of failure if the mother’s milk hasn’t come in by day 3 or 4--would be so very much relieved by having a crew of experienced and trusted peers who know what the heck they are doing. <br />
The baby’s mother was from one of the Mongolian families I take care of. Some speak no English at all. But they all live very near each other in one neighborhood of Oakland. Many bring their kids to me. Her sister had given birth a few months earlier, and was still nursing her own infant. In their culture, this wasn’t unusual--it was simply what was done. <br />
About a hundred years ago, and for millennia before that, <i>wet nurses</i> were common. Women who couldn’t nurse or those who could but had the resources to avoid this task of the masses, would employ a woman whose lactation was maintained by her continued employment. There were few alternatives. (The picture above is from a booklet produced about 1900 by Nestle, for a product called Nestlé's Food, which was among the very first commercial baby formulas. It’s from my collection.) But before there were professional wet nurses, there were women who would share their supply with the less fortunate, or the babies who had survived childbirth when their mothers did not.<br />
One of the nurses asked if it was hygienic. Honestly, I didn’t know. I suppose, in these days of Universal Precautions and doctors afraid to touch you without gloves on, I could see what the concerns might be. There are some diseases which can be transmitted through breast milk, along with many medications. As politely as I could, I tried to get a little medical history from this other woman. She spoke almost no English, and the postpartum mother was translating my questions—I think. She’s the one who told me ‘she OK’ and left it at that.<br />
I told the L&D crew it was OK with me and I would write an order in the chart explicitly allowing it. <br />
<span style="font-size: 78%;">The woodcut from 1550 is by Hans Brosamer and is from my collection. It shows the creation of Eve, her temptation, and the expulsion from the Garden of Eden. The poster from the 1958 movie <u>Teenage Caveman</u> was part of the collection I sold in 1992. Produced by—who else?—Roger Corman, I think it was <a href="http://www.imdb.com/name/nm0001816/">Robert Vaughn’s</a> first starring role.</span>Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com1tag:blogger.com,1999:blog-795027104294386040.post-52654934147559091682009-07-12T23:29:00.001-07:002009-12-28T00:10:54.423-08:00A Mistake<a href="http://2.bp.blogspot.com/_IwgfwdBQlpw/SlrPDPyJU_I/AAAAAAAAAYU/Z3e9-qee5uQ/s1600-h/hand1.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5357822361394041842" src="http://2.bp.blogspot.com/_IwgfwdBQlpw/SlrPDPyJU_I/AAAAAAAAAYU/Z3e9-qee5uQ/s400/hand1.jpg" style="cursor: pointer; display: block; height: 396px; margin: 0px auto 10px; text-align: center; width: 400px;" /></a><br />
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<span style="font-weight: bold;">“Experience is the name everyone gives to their mistakes.”</span> <span style="font-style: italic;">Oscar Wilde, from Lady Windermere's Fan, 1892</span><br />
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Yes, I know. Everyone makes mistakes. Every parent makes mistakes, nearly all of them invisible to a child. To a child, what we do has to be right just because we're doing it. Parenting books are filled with sure-fire techniques to get your kid to do everything from eating something besides white food to success in college. But those authors haven't met your children. Sometimes the best thing to do just isn't that clear.<br />
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Doctors make mistakes, too. In my particular line of work, I'm relieved to report, failure isn't usually associated with a really bad outcome--you know what I mean. Still, I look upon my job as making children feel better and making their lives better. I work hard at it and do my best.<br />
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<a href="http://3.bp.blogspot.com/_IwgfwdBQlpw/SlrOJwPnJ1I/AAAAAAAAAYM/k1YEj4sg67E/s1600-h/forceps+vertical.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5357821373675153234" src="http://3.bp.blogspot.com/_IwgfwdBQlpw/SlrOJwPnJ1I/AAAAAAAAAYM/k1YEj4sg67E/s400/forceps+vertical.jpg" style="cursor: pointer; float: left; height: 400px; margin: 0pt 10px 10px 0pt; width: 54px;" /></a>Three days ago, a favorite patient came to the office with his mother. He had acquired a splinter in one of the worst places to get one, the center of the palm of his hand. It's a bad place for several practical reasons, not for elaborate medical reasons. The skin on our hands is quite thick, not quite as thick as the soles of the feet, but very thick. Unlike the soles of our feet, however, our palms are covered with sensitive nerves for feeling things. Our palms have a flexibility that makes it difficult for us to flatten our palms completely. And once we start grasping things as babies, we never stop, so the muscles of our grasp are very strong. Lastly, the palm is fully visible to the motivated child.<br />
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He had been healthy and was playful with me when they first came into the office. He was glad to show me the splinter. It was clearly visible, only about 2 or 3 mm long. But it was in an awkward position, as if it had been put straight in and then broken off at the surface. Because of this foreshortening, it was difficult to see a way to expose the deepest part of the splinter without digging a deep hole in the center of his hand. The nearest part, however, was close to the surface, and should be an easy grab with my sharpest surgical-quality tweezers. Because of the thickness of the skin in the palm, I thought I could get it on the first try without hurting him.<br />
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After about 20 minutes of the most upsetting screams possible, as this child stared at me, wearing a headlamp, using needle-sharp instruments on him, I gave up in a sweat. I had to try a different way.<br />
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I prescribed some numbing cream for him, and asked his mother to bring him back with the cream, for me to apply. The next day, I put the cream on, covered it, then wrapped his whole hand in an elastic bandage so he wouldn’t mess with the cream. He was happy to play with the office toys for about an hour. He didn’t mind the unwrapping, or cleaning off the cream. But the screaming started as soon as the tools came near him.<br />
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Granted, these are some fairly scary-looking tools. Everything was shiny and needle-sharp. We had a reasonable control ratio. (I have defined this invented term—I wonder if it’ll catch on—as the ratio of adults to the age of the child, in years. In this case, the ratio was a usually-effective 1.0: there were 3 fully grown adults to a single 3-year-old child. The 3 adults didn’t have a chance of restraining this warm and affectionate child. I though it might be helpful to use the numbness provided by the cream to allow a small injection of local anesthetic, to really be sure he wouldn’t feel anything.<br />
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I won’t keep you guessing. That didn't work, and the 3 of us never got his hand still enough even to get a good look. I never took out the splinter. Luckily, I haven’t been exaggerating about the patient’s mellow personality, and though he was absolutely impossible to restrain for even 20 or 30 seconds so I could get the thing out, he was immediately forgiving, both of me and his mother.<br />
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First, some information about splinters. Usually, they have to come out. By definition, they are little irregular slivers of something, torn or broken off of something else. Broken or torn edges are rough, though you might need a microscope to see that. These rough edges can be packed with bacteria that can cause nasty infections. It’s a sign that you absolutely must get the thing out if it becomes swollen and red and painful to touch. It’s a particularly bad sign if this red/swelling/pain develops just a few hours after getting the splinter in the first place. If that happens, either get it out yourself, or if you can’t, get to an ER. In this case, there was no redness after a day when I first saw it. There was still no redness the following day. No swelling. It hurt him a little to press right on it, but not too bad.<br />
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So this was my mistake. Honestly, I don’t think it’s a mistake I make very often. I think of myself as a minimalist, using the least possible intervention that will have the best result for the child. It just looked so easy, no big deal, right there near the surface...all it would take was a few seconds of him holding still. But that’s a common error in judgement. I focused on what would be reasonable medically for all kinds of rational reasons. That wasn't an empathic approach. What was in the best interest of the child? How did <span style="font-style: italic;">he </span>look at this issue? He certainly didn’t see it as a problem that needed what appeared to be an inappropriately serious response.<br />
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He was right. Though most splinters need to come out, what happens if they don’t? If small enough, the body’s immune system can literally digest them, and make them disappear. Sometimes, the skin will push them out over time. And sometimes the body can wall them off with scar tissue, and they are with us forever. After a really long (maybe an hour) bath, the top layers of skin on his palm might be soft enough to come off with a vigorous drying, and that might take care of it.<br />
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His mother certainly thought it needed to come out, and I did too, at the time.<br />
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It's important to try and see things from the child's perspective. It's something I consciously try to do with all my medical encounters. This time, however, not so much.<br />
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Being sensitive to the child's viewpoint is really important--but that's not the same as letting that viewpoint dictate what has to happen. Part of the price we pay for having the privileges of being grown-ups is that sometimes we have to make tough, unpleasant decisions. Just because your children would like to play on the freeway doesn't mean you should let them!<br />
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If the splinter had been infected, it would be out.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0tag:blogger.com,1999:blog-795027104294386040.post-83883257687716956082009-04-18T18:03:00.001-07:002009-11-16T00:10:03.718-08:00The Bridgeport Paradox: Black and White in the Delivery Room<a href="http://2.bp.blogspot.com/_IwgfwdBQlpw/SeKi21WKKYI/AAAAAAAAAIc/PvTMKpSmQuc/s1600-h/diaper+pins.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5323996772422003074" src="http://2.bp.blogspot.com/_IwgfwdBQlpw/SeKi21WKKYI/AAAAAAAAAIc/PvTMKpSmQuc/s320/diaper+pins.jpg" style="cursor: pointer; float: left; height: 320px; margin: 0pt 10px 10px 0pt; width: 222px;" /></a><br />
Connecticut is one of the <a href="http://en.wikipedia.org/wiki/Connecticut_locations_by%20%20_per_capita_income">richest states </a>in the United States. Most of its many wealthy people live on the 'Gold Coast' which is within commuting distance to New York City and is along the shore of Long Island Sound. The richest county in Connecticut is Fairfield county, where low-density communities are filled with some of the most expensive private homes in America.<br />
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There are no major hospitals in these affluent towns, owing to their low population density. So when the rich and famous need a hospital, they go to the nearest major medical center, Bridgeport Hospital.<br />
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Bridgeport is an <a href="http://www.city-data.com/poverty/poverty-Bridgeport-Connecticut.html">island of poverty</a> in this sea of wealth. A booming 19th-century industrial town, it gradually ran out of most manufacturing jobs decades ago. It has double the state's average rate of people living in poverty, and triple the rate of the poorest poor—people living at less than 50% of the poverty rate.<br />
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When I did my required training rotation through Obstetrics, I was assigned to Bridgeport Hospital. It's a big urban medical center, with a busy Labor & Delivery ward. Almost all of the Obstetricians in the area had luxurious private offices located in the adjoining wealthy communities, where they served an exclusive clientèle, mostly white. For deliveries, however, even the fancy doctors used the great facilities at Bridgeport (in private rooms). Some of these doctors in private practice, along with the doctors on staff at the hospital, also worked with the patients from Bridgeport, mostly women of color. Most of these patients didn't have private insurance, and sometimes didn't have insurance at all. These patients often had less prenatal care, and less access to medical care in general for any of their other medical needs. Many had complex social issues associated with poverty which complicated their care.<br />
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In this context, I expected that the wealthy, private-paying patients with their private physicians would somehow get better treatment and have an easier time. For many types of medical problems, this seems generally to be the case, and I expected it at Bridgeport Hospital, where the stark contrasts in patient resources are dramatic.<br />
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The experience of my first day has remained deeply etched in my memory. I was told to wait at the nurse's station of the obstetrics ward. The screaming started within minutes of my arrival. It was the most disturbing sound I had ever heard. Clearly screaming in severe pain, the halls were filled with this sound which came from behind a closed door. I was new there, but I asked the nurse sitting next to me, who was browsing through a catalog for scrubs with cartoon characters, if we should go in there and help. She was very kind and explained that the obstetrician was already in the room and the woman had said that she didn't want any interference or medication. Within a couple of hours of this, a new patient was wheeled in to another private delivery room. With her was her husband, her doctor, and her personal secretary. After getting settled, the personal secretary left the room and sat in the waiting area. A second source of intense and disturbing screaming started coming from this room, too. Now there were two.<br />
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Before lunch, an ambulance brought in one of the local women, and the nurse sitting next to me dropped her catalog (by now she had moved on to a shoe catalog), and prodded me to come along. I didn't do anything at my first delivery, but I watched a very skilled doctor give this woman an epidural anesthetic. A couple of hours went by before she had her baby, which is about the most fabulous thing a person could witness. She pushed and was awake and happy when the delivery nurse put her new baby into her arms.<br />
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I don't know what happened in those private rooms, as I was never invited in. But this experience was repeated nearly every day I was there. I asked one of the obstetricians about it. She told me that many of her private patients refused all medications and wanted what she called the 'full experience' of childbirth and motherhood. She said this wasn't often the case with the inner-city mothers she treated in the hospital. She never really thought about it, and tried to give her patients what they requested.<br />
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So much suffering, both medical and otherwise, falls heaviest on the poor. What I witnessed was counter-intuitive: the rich were enduring unspeakable pain, and the poor were not. I'm not an obstetrician, but I do look upon my job as trying to ease suffering if I can. Were the poor women getting better advice than money could buy? Maybe they just had more common sense.Dr. Wolffe Nadoolmanhttp://www.blogger.com/profile/10872214677834263346noreply@blogger.com0