Category Archives: Health and Wellness

Seeing a Person You Love in a Number

A friend posted an article on her Facebook page discussing a recent research study out of Sweden showing that people on the autism spectrum have a decreased life expectancy. This friend has a child with autism. Autism coupled with learning disability, according to this study, is associated with the largest decrease in life expectancy. This friend’s child has learning disabilities along with autism.

My friend is scared.

On top of her worries about social isolation of her child due to her conditions, on top of worrying about her child’s place in society as she becomes an adult, on top of the fears of every parent about their children’s health and wellbeing and risks in general, my friend has had dumped on her frightening data clearly relating specifically to her daughter.

Only it doesn’t relate specifically to her daughter.

It is an aggregation of data that compares medical and mortality statistics of a pool of 27 thousand people with autism with that of a comparison group of 2-and-a-half million people without diagnoses of autism. It is not specifically about my friend’s child.

But it is about my friend’s child, because it is about every person with autism.

That’s the thing about statistics. They are about everyone, yet they are about no one in particular. That’s an aspect of practicing medicine in a world full of data that is particularly challenging, fascinating, and maddening. And people not practicing medicine have a similarly challenging, fascinating, and maddening time navigating this world of information.

Problem is, humans are extraordinarily complex. First, there’s the biological complexity of any multicellular organism, the variability due to genetics, the effects of environment, the interplay of internal and external forces. Then there’s psychology – individual predilections, societal influences – and how much of each of those is due to inborn versus external influences of the individual or of the interacting individuals of society? Even seemingly simple questions can become metaphysical – why are x and y correlated? Does x cause y? Does y cause x? Does a third thing cause both x and y? Do the combination of a third, forth, and fifth thing cause x under some conditions and y under a different set of conditions, some of which overlap the conditions which predispose x to be affected? Is there something inherent in x or y or both that lead to their association? What, if anything about the properties of x or y or the conditions that combine to give rise to certain outcomes are modifiable?

If my patient or my child or my neighbor ostensibly fits into a category being described in a general news article reporting on a scientific study, how much weight and credence do I give to it? What about a medical or scientific journal article? Does that specific person truly fit that category? If so, in what ways? In what ways does he not exactly fit? How important is the closeness of the fit? Even if a seemingly perfect fit, what does that actually mean for a specific individual? What exactly did the researchers look at? What did they miss?

The autism mortality article wasn’t meant for my friend. It wasn’t meant for the parent of a specific child with autism. It wasn’t written to alarm her. It was meant for society. It was meant for those who would influence the allocation of funds for medical research and social policy development.

Which means that the article was meant for my friend – a parent of a specific child with autism, a person who advocates for funding of research and services and societal support. It was meant to alarm/alert all of us, and my friend is one of all of us.

My job as a doctor is to take data and apply it to real people. To dissect the data, to judge the quality of research, to integrate it with what makes scientific and physiologic sense, to humanize it. My job as a friend, a neighbor, a family member, a general citizen of Earth, is to comfort and support others. So here is my reaction to that particular article as it relates to the person who posted it and to her daughter:

The article refers to a correlational study looking at aggregate numbers. Although the numbers and conclusions are laid out as straightforward, the actual data and meaning are exceedingly complicated. The study is a start, a call to look more closely at an overall population and see where dangers are. It is a study of averages – it is not a study of individuals. It leaves ever so many more questions than answers. It does not know your daughter. It does not know you and your husband and your other children. It does not know your child’s teachers or doctors. It does not know your social supports. Although this study does not know all of the above, it can help you as it draws attention to necessary lines of inquiry regarding a population (of which your child is a member) that needs serious attention.

This study was done in Sweden. We do not know how the data extrapolate to other countries. Are there genetic or cultural characteristics in the overall Swedish population that could affect these data? The data showed different main causes of premature death in two different populations of those with autism – those with learning difficulties and those without. We do not know if these differences hold true globally, and we do not know what other differences or characteristics play a part.

There may be specific age-related spikes for the most common causes of mortality which could skew the data. Distribution of data points is extremely important to investigate, not just averages. At what else did the researchers look? At what did they not look?

There are people looking at important questions: How can we begin discerning the causes of the disparities? How can we ameliorate the causes?

So many questions. So few answers so far. So glad people are asking the questions that will lead us to information that will help individual people, and in turn will help a population at large. And sending strength to all who look at a headline with numbers and in those numbers can’t help but see the face of their child.

A link to the original abstract: Article in the British Journal of Psychiatry

A link to a discussion of the article by an autism research and advocacy charity in the UK: Autistica’s call to action piece

Pet Parallels in End-of-Life Matters

(Note to my children – do not read this. Other people who are close to me – you probably want to skip it, as well.)

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year.

About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing with a veterinary emergency can provide us with some insights and practice parallels to dealing with human medical crises (Pet Practice). A veterinary crisis also has definite parallels to human end-of-life issues, and can highlight ethical concerns as well.

He was an older dog – old enough that my husband and I would occasionally mention animals’ life expectancies in front of our kids. The boys were well aware of what we were doing: “Mom, Dad, we know dogs don’t live as long as people, and you’re obviously trying to prepare us, but it’s totally going to suck when it happens, whether or not you remind us of how long dogs live.”

So he was older, slowing down in general, with a seizure disorder which had developed in his later years and was generally kept in check with medications (with one episode of multiple breakthroughs a month or two earlier), but reasonably active and happy overall.

The big scare I mentioned above came on pretty suddenly. He became progressively ill over the course of a day, and I brought him to the vet, who did a thorough exam and extensive lab work. It didn’t look good – obstructive biliary disease – and we were referred to a veterinary specialist for an ultrasound, expecting that it would show cancer.

I filled the family in on the details of what was happening, and I took him in for the imaging study. The ultrasound did not show cancer, but elucidated an issue that would be rapidly fatal if not addressed with emergent surgery.

I called my husband. Our dog was old. We didn’t have spare thousands of dollars lying around. We loved our dog. Our children loved our dog.

We happen to live about an hour-and-a-half away from one of the best veterinary schools in the country. I called them and told them what was happening. They said that we could bring our dog out there, and their estimate on the surgical cost was a bit lower than our local place.

I called my husband back. We talked again. Yes, our dog was on in years, but this was fixable. He could have a couple good years left in him. We would figure out a way to cover the cost. I brought him to the boys so they could give him a hug, and then I took him out to the veterinary school’s emergency clinic.

I brought the ultrasound disk and the lab results with me. They looked at everything, concurred with the diagnosis, and agreed that surgery was a reasonable option. “The other vet did tell you that the mortality rate for this surgery is about 30 to 35%, right?” Uh, no. No, he didn’t. How could I not have asked that?

I wasn’t going to change plans now. The odds were still in his favor, even if not what I had assumed. I gave him a kiss, signed the release forms, and gave the front desk my credit card.

And it worked. The surgery, though complicated, went well. He recovered. Within a few weeks, he was prancing and bounding and chasing rabbits like he did when he was much younger. We were so happy – we knew we had made the right decision. We played joyfully with him over the next few weeks.

And then he started seizing. Not just one breakthrough, but multiple. I brought him in. The vet upped his anti-seizure medications. He lost bladder control with the seizures, so I slept in the kitchen with him for the next two nights. He had more seizures. And his post-ictal (post-seizure) agitation kept increasing. It got worse through the next evening. His vet said there was nothing more he could do, and he sent us to the emergency clinic, which had a veterinary neurologist on staff.

The vet who was on duty that night in the emergency/specialty clinic was very kind. She said that it didn’t look good, but we were not without hope. She assured me they would do what they could overnight, she would keep me posted and I could come back in the morning to speak with the neurologist when he arrived.

So I headed back there the next morning. The neurologist said he recommended an MRI, since his seizure history sounded consistent with a brain tumor. The MRI would cost two thousand dollars. And then if it did show a tumor, and if it looked operable, we would have to decide whether to pay for and put him through brain surgery to remove it. He also said he had one other thing to try with medications.

I talked to our regular vet (a very smart man who had always given us sound guidance and advice), and he said that our dog had been through so much, that the prognosis was grim, and that if it were his dog he would not do surgery or the MRI (which would require anesthesia). I talked to my husband. We decided to give the neurologist’s pharmaceutical idea a try.

It didn’t work. The updates from the veterinary hospital throughout the day were very bad. We knew what had to happen. We told the boys, and we took them with us to the hospital so we could all say goodbye. It was a sad, tear-filled car ride.

They brought our doggie into a room with us. It was awful. He was horribly agitated, and he had lost his sight. He really didn’t show much, if any, sign of recognizing us. After hugging and petting him as much as and as best we could and saying what we needed to say, I told my husband and boys to wait in the waiting room. My husband wouldn’t leave me. The boys (12, 15 and 17 at the time) said they’d be ok and went out of the room together.

And then it was time. The vet gave me euthanasia consent papers to sign. I don’t remember exactly what they said, but I think I recall acknowledging the finality of the decision. And then it was really time. The vet asked if I wanted to stay. I said yes. I told my husband he didn’t have to stay, but he would not let me stay alone.

It was so very awful. So very, very awful. Our dog was clearly suffering. His agitation was severe – it had not been alleviated by any of the medications. I will skip the full play-by-play of the final actions, but I will describe a bit of what went through my mind.

“I have to be here. I have to stay here. Good pet owners stay until the end. I don’t want my husband to have to see this. I’m the doctor. I should be stronger than this. What am I doing? Why am I doing this? Am I doing the wrong thing? What if this is fixable? How much did money play into this decision? What kind of a monster am I? How can I do this to my family? Did I make this decision to stop him from suffering or did I make it to prevent me from suffering as I watch him? How can I do this? How can I not do this? Oh God, it’s done. What have I done?”

I stayed as long as I could, with my hand on his fur and my husband’s hand holding me. Then I had to get up. I had to go to the door. I kept talking to our sweet puppy dog. The vet still had her stethoscope on him. He had stopped breathing minutes prior but probably still had a few slow heartbeats left, but I just couldn’t stay any longer. I failed him in those last few seconds. He wasn’t alone, but it was someone else’s hand on him at the very end. The vet had no choice – she had to stay.

They handed us the bill at the front desk. We gave them our credit card.

We gathered our boys, held one another, and had a silent, tearful car ride home.

We grieved. And we recovered. But it took me a long time to recover.

This was a dog. Yes, he was our dog, our pet, a “member of our family,” but he was a dog, not a person. Yes, we all tend to anthropomorphize our pets, but I was not grieving his loss as I would grieve a person. We develop strong emotional attachments to our pets, and they symbolize responsibility, loyalty, and innocence. That wasn’t all of it. It was more complicated. It was much worse than when I had grieved dogs in the past as a child and teenager (and those previous times certainly hadn’t been easy).

I’m a doctor. I keep coming back to this. A big part of why I went into medicine was to prevent death. To promote life. To promote good health. To help give quality to life. And, when not possible to do the aforementioned, then to help support patients and their families through the loss of life. I have been with patients and their families numerous times at the very end of a life. It has been at times when my colleagues and I did everything we could to save a person but were not able. It has been at times when someone has chosen not to be resuscitated or to have “extraordinary measures” taken. It has been at times when the choice was to focus only on easing any pain at the end of life. It has been when removing life support. Some of those times were peaceful, and some of those times were frantic. But never, during any of those instances, did I myself do (nor write an order for someone else to do) something with the express purpose of stopping a heart. Even when removing  someone from ventilator support, we were removing a breath-sustaining machine (and therefore a life-sustaining machine), but the person’s respiratory system had already failed on its own – we were not purposefully making a person who was spontaneously breathing stop that breathing.

Almost two years ago, I signed papers authorizing a veterinarian to kill my dog. We use the word “euthanize” (“eu” meaning “good”, “than” meaning death, translating to a word that means “to kill painlessly,” generally to relieve suffering), which sounds much better than “kill,” but it doesn’t change what is done. Our vet told us we had chosen compassionately. In all reality, it probably would have been cruel to allow an animal to continue to suffer indefinitely with no understanding of what was happening, and it is not financially feasibly to put an animal on the comfort measures that we afford people at the end of life – our choice is a much harsher one with our pets. But still, I signed the papers to stop his breathing. What if I was wrong? I did not handle well the thought that I had chosen to end his life and that I could have made the incorrect choice. When I failed him in those final seconds, it was because I had failed myself. I second-guessed my thought process. I questioned my motives. I felt unworthy of him.

Those feelings hung with me heavily. There was an intense, deep feeling of guilt. Honestly, my really wrong decision probably was to have had him go through that surgery when he was so ill that month-and-a-half prior. It would have been a peaceful death if we had opted out of that surgery. There was nothing about the way he ended up dying that was peaceful. If only we had known then what was going to happen six weeks later.

People lament how much money we spend on medical care in people’s last few months of life. Policy experts and politicians look at the numbers and say we are wasting money and resources. People lament how so many people end up dying hooked up to machines in hospitals when they would much rather have died peacefully at home. But the vast majority of time I was working in a hospital, caring for people at the end of their lives, we had not known it would be the end. Surgeons did not usually advise surgery if they thought a patient was not going to live. We did not give people ventilator support with the expectation that they would not recover. And most of our patients did survive and return home, and get to celebrate another holiday or wedding with their families, and see more sunsets, and sing more songs – how many sunsets, how many songs are worth the cost of that care? More than once, even when an outlook was grim and we expected the worst, a person surprised us and recovered well beyond what we would have expected. And sometimes a person who we had expected to do well’s last moments were on a ventilator or with people pushing on her chest during CPR. We spend those resources and efforts at the end because we don’t know it’s the end.

We don’t know everything. And it’s really hard not to know everything. Especially when you’re the person who is supposed to have the answers.

Battling Buffoonery

My career is based on communication and empowerment within the medical world. I educate on the patient/family side and the medical professional side. It takes understanding and empathy from both sides of the stethoscope to optimize communication. It takes communication between both sides to bridge perceived power differentials. It takes work on both sides to change a culture of uneven power dynamics.

I read two Facebook posts within the past few days dealing with a culture issue that needs changing. This is a matter from the “general” as opposed to medical world, but that which is present in society-at-large certainly spills into medical or any other subset of society.

The first was written by a woman in her early forties, discussing the details of recent times (while in retail establishments) she’s received unwanted amorous advances from strangers (including a time when she had her young teenage son with her, and they included her son in the harassing conversation). The second post was by a friend whose 17-year-old daughter, who works weekends at a toy store, has been receiving come-ons from customers while their children play in the store. Both women experienced definite “ick” feelings as they were being harassed.

Thankfully, the majority of public interactions are not icky. These incidents referred to above are happily the exceptions to the general rule of civilized, respectful behavior. But although they are exceptions, they are not rare exceptions, and they are threatening.

I am close to the 17-year-old young woman. I feel perfectly comfortable offering her advice. And while I would like to tell her to respond to inappropriate comments with something to the effect of, “I cannot figure out why you would think it’s ok to say that to me,” I am hesitant to advise her to engage these people at all. I’m also hesitant to tell her to walk away. The first option places the power with her, while the second seems more like it leaves at least some power with the tasteless cad.

The problem is, it’s difficult to know whether the label “tasteless cad” is sufficient and accurate. If the issue is simply a lack of manners and a poor sense of humor, then perhaps pointing out the rudeness will help prevent the person from creeping out someone else. But what if the demonstrated disrespect reflects a fundamental disregard for the personhood of those harassed, and attests to a sense of entitlement? A challenge to that entitlement could theoretically provoke more of an assertion of power. Tough for a 17-year-old to gauge when it’s even difficult for a forty-something-year-old to do.

There are protections set up in schools and in workplaces (to prevent harassment from bosses or other employees), but there are no systematic protections regarding interactions with the general public. I would certainly report such matters to business management. A good manager will work to provide a safe environment for both employees and customers. Something as simple as placing a prominent sign reminding people to show respect to others can help establish expected conduct. Management can also ask someone to leave.

It’s more difficult when a store owner is the one engaging in the misconduct. If it’s the owner, I’d avoid that establishment and would warn others. A complaint to the Better Business Bureau or to the state Attorney General’s office may in some circumstances be warranted.

And for everyone’s well-being, we need to teach our kids by always modeling respectful speech and behavior – not reducing people to sexual objects, not describing relationships as conquests, and not indicating that it’s ever ok to make suggestive comments to strangers. If we witness inappropriate behavior, we need to show support to the person being hassled, and when possible we need to report the harassment (to management, to administration, etc., depending on where it is occurring). We need to hammer into our kids that it is never ok for others to harass them.

It’s better than it used to be, and we can all work together to keep improving our world. It will never be perfect, but the exceptions to civility should become increasingly rare.

Springing into the Pharmacy

Spring is here (although it may not yet feel like it). The days are getting longer. The temperature is slowly getting warmer. Green stuff will start poking through the ground and popping out on trees. We’ll see more of our neighbors, since they won’t be trying to get from their cars into their houses (and vice versa) as quickly as possible before they freeze.

Pollen allergies will start up again. And grass allergies.

So many people suffer from the watery, itchy eyes, itchy, runny nose, sneezy, general ickiness of seasonal allergies. And there are so many remedies in the aisle of the pharmacy – no prescription needed.

Several years ago, I spent the better part of an afternoon exasperated with our youngest son, who was maybe eight years old at the time. This was quite unusual. Unheard of, actually. Son number three tends not to piss us off. But he was acting really obnoxious. Not listening. Acting unruly. I was getting angrier at his behavior.

Then my husband (an engineer, mind you, not a doctor) said, “Didn’t you give him that anti-histamine a few hours ago?” Riiiiiiiight. He had had a reaction to some mosquito bites, so his pediatrician had told me to give him cetirizine to help quell the itchy welts.

Wonder-Doc over here hadn’t realized that her kid was reacting to a medication that affects the central nervous system.

As soon as my husband pointed out the obvious, my anger disappeared (replaced with a healthy dose of guilt), and I did a much better job of soothing my agitated son. And as soon as the drug was out of his system, he returned to his normal, sweet self.

The fact that something is available over-the-counter does not mean that it is completely safe/benign/without risk. This holds true for allergy meds, cold meds, or any medication for that matter.

Always read the bottle of a medication to see what potential side effects might be. Don’t drive when taking a medication unless you know how that medicine affects you and you are certain you can drive safely. Don’t take more than the recommended amount. Remember that any medication can interact with any other medication and that alcohol can interact with any medication.

Different people react differently to different things. Our middle son had taken that particular anti-histamine without any negative effects. Don’t assume that if a certain medication is fine for one person that it’s fine for another, or that if one person has difficulty with a particular medication that it’s bad for someone else. Talk to your doctor and your pharmacist with any concerns or questions.

A couple weeks ago, I was at the tail end of a cold. Our family was out in the car, and my eyes were itching and running non-stop. I had a post-nasal drip going and I was sneezing every two minutes. It was miserable. I needed an anti-histamine.

So we swung by a CVS and I picked up a small bottle of disolving-tablets-no-water-needed cetirizine. I took one. Within about an hour my eyes were significantly better and my sneezing frequency was cut in half. But for a short while I felt a little drowsy – almost as if I had had a glass of wine.

Available-without-a-prescription does not mean without-potential-consequences. Only take something if you really need it. Read labels. Ask questions. Watch for reactions. Listen to your body.

And enjoy getting back outside!

 

 

Vaccine Resistance – This is a long one….

Vaccines. Diseases. Measles. Big Pharma. Anti-vaxxers. Medical Industrial Complex. Individual rights. Herd immunity. Selfishness. Stupidity. Toxins. Chemicals. Autism. Encephalitis. Mercury. Thimerosal. Febrile seizures. Science. Anti-science. Pseudo-science. Alternative. Natural. Money-grubbing. Lying. Evil.

My Facebook feed has been blowing up with posts and memes related to vaccination. The topic cycles through the news and social media regularly and is prominent at the moment in the wake of the recent/current measles outbreak originating at Disneyland in California. People are angry. People are defensive. People are offensive.

I’m pensive.

Over the past several decades, vaccines have prevented millions of deaths. They are effective. There is no question about this. Current vaccines are exceedingly safe. There is no question about this.

Vaccines are not 100% effective. We need a high communal vaccination rate (generally 95% or more) to ensure “herd immunity,” which stops widespread epidemics and protects those who cannot, for medical reasons, be vaccinated, and those for whom the vaccine did not generate adequate immunity. Vaccines are not 100% risk-free, although the risk of a serious reaction is extremely small (for example, about a one-in-a-million chance of an anaphylactic allergic reaction to the Measles/Mumps/Rubella vaccine). Many vaccines have minor side effects, such as soreness at the injection site or a mild fever (the fever actually is a sign that your body is mounting an immune response to the immunization). The diseases the vaccines protect against have significant rates of severe complications (encephalitis – an inflammation of the brain which frequently leads to permanent damage, pneumonia (the most common measles-related cause of death), paralysis, sterility, blindness, deafness, death, etc., depending on the specific disease).

The scientific and medical establishment is in overwhelming agreement that everyone who can be immunized should receive all recommended vaccinations. The benefits far outweigh the risks. The vast majority of people in this country follow these recommendations.

And yet.

And yet we have pockets of people loudly protesting vaccines.

And some people listening to these loud protests and quietly forgoing immunizations for their children.

And this is a problem.

From the community health and welfare standpoint, this is a problem because there are enough people forgoing immunizations to impair our herd immunity. Those who are most vulnerable (people undergoing chemotherapy, people on immunosuppressive medications, babies too young to be immunized, people with immune deficiencies, people who are too frail or ill for their bodies’ immune responses to function properly, etc.) are at risk. And because the vaccines are not 100% effective, even those healthy folks who are fully immunized are at higher risk because of the decrease in herd immunity. So clumps of folks refusing to immunize will affect other people, not just their own families.

And because we are human, even if the herd immunity issue were not in play (although it most definitely is), many who understand the science and the importance of immunizing and the benefits versus the risks to the individual (putting aside, for the moment, the community as a whole) would still be frustrated by the failure of groups of people to vaccinate their children. Because even if (again, ignoring the public health risk for the sake of this argument) we could say to ourselves, “if they don’t want to immunize themselves that’s their problem – they can suffer from and potentially die from preventable diseases if they so choose,” (which I personally have a hard time saying), we still care about the welfare of their children.

And there’s the rub.

Because that is also what motivates the vociferousness of some of the people who loudly oppose vaccines. Not all of them, but some of them.

And understanding motivation is essential to understanding and communicating with people.

What doesn’t motivate people is calling them stupid.

At this time, I will not speak to the few people within the official medical establishment (M.D.s and D.O.s) who speak against, discourage, or otherwise buck the positions of the American Medical Association, American Osteopathic Association, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Academy of Pediatrics, American College of Physicians, etc. My opinion and analysis of these people will be a topic for another day.

I will also not speak at this time to people who have not undergone the rigors of scientific medical training who hold themselves out to the public to be healthcare practitioners and give advice contrary to scientific medical consensus. This will also be a topic for another day.

What I will speak to right now is the vaccine resistance (and vigorous promotion of this resistance) that is found within small proportions of the general population.

The people I am speaking about certainly love their children. They are motivated to protect their children. They are motivated to protect other people’s children. They are motivated by fear. Deep fear.

I understand fear. And I understand fear of vaccines.

Most of our immunizations are done by injection. A needle is stuck into us (or our child) as the vaccine is injected into our muscle. It hurts.

We have evolved to resist being stuck and injected – we reflexively try to avoid bees and wasps. That resistance for most of us is easily overcome with our intellectual understanding of immunization, but we are definitely actively resisting a natural impulse when we allow ourselves to be injected. Sometimes fears can be too strong to overcome with our own intellectualizing and we need a little help.

Frequently, young children will cry when given injections. It’s awful to see your child in pain. Yes, that pain is to protect him from something that would cause much greater discomfort and could cause grave harm or even death, but the injection pain is right here, right now, and real, while that disease potential is not right in our face and we don’t frequently see the awful diseases that we once used to (due mainly to vaccination).

A child will frequently be fussy after vaccinations – her leg or arm hurts where she was poked. She may have a fever for a couple days. She may sleep poorly while she feels icky. And a parent feels awful, because the parent gave permission to someone to do this to her. This ickiness of vaccination is right in front of the parent, while the disease being inoculated against is not in front of the parent.

Although severe vaccine side effects are exceedingly rare, a parent may still worry about the potential.

We look for confirmation. We look for validation. We look for reassurance. We take it where we get it.

While most of us are able to intellectualize and rationalize the extreme benefit of vaccination, some of us have more difficulty overcoming the fears. When we’re having difficulty, the reactions of others can make all the difference in the world.

Who listens to our fears with empathy? Who rolls their eyes? Who sighs with exasperation? Who ridicules our fears? Who explains and educates? Who gives us time?

Although correlation does not imply causation, our tendency is to infer causation from correlation. We are suggestible. Although large scale data gives us significantly more information than a few anecdotes, we tend to remember and hang on to stories. When we are given some information we know to be correct, we are more inclined to believe accompanying information from the same source, whether or not that accompanying information is valid.

These tendencies, coupled with who is responding to a person’s fears (and how they are responding), will influence whether someone who is afraid will go in one direction or the other.

There was a recent study  that looked at information intervention to see how it affected parental attitudes on the MMR vaccine. For this study, parents were given a questionnaire which included questions on how likely they were to have their future children vaccinated with the MMR vaccine, whether they thought certain vaccines caused autism, and how likely they thought it was that someone would suffer serious side effects from the MMR vaccine. They were then randomly assigned to five groups. One group received information (from the CDC) explaining the lack of evidence that the MMR vaccine causes autism. The second group received text from the official Vaccine Information Sheets explaining the dangers of the diseases against which the MMR vaccine protects. The third group received pictures of children with measles, mumps, or rubella. The fourth group received a dramatic story (from the CDC) about an infant who almost died from measles. The fifth group was the control group – they received no vaccine information intervention materials, but were instead given reading on the costs and benefits of bird feeding. The parents were then given a second questionnaire which included the three specific questions mentioned above.

The results of this study showed that none of the interventions increased a parent’s likelihood of having a future child immunized with the MMR vaccine. The autism-vaccine corrective information did decrease the respondents’ beliefs that there was a link between vaccines and autism, but it also decreased the respondents’ future likelihood to vaccinate (mostly in the group of parents who originally held the least favorable view of vaccines). The dramatic story of the infant with measles increased the perception that the MMR vaccine has serious side effects. The pictures of ill children increased the parents’ likelihood of saying that some vaccines cause autism.

I don’t find the above results surprising, nor do I find them particularly discouraging, although headlines in response to its publication were generally along the lines of “You Can’t Change an Anti-vaxxer’s Mind” (that one was from the Mother Jones blog). The above study looked at four different “spot” information interventions. It did not look at comprehensive education, communication techniques, nor empathy of information providers – it simply provided limited, unifocal written materials. It is not fair to say, from the results of this study, that people scared of immunization cannot be reached.

If I had been a parent in this study given a story to read of a sick child, or had been given alarming pictures of children with measles, mumps, and rubella, I might then go to my computer and do a quick search on those diseases. While doing so, I would very likely come across websites promulgating false information about dangers of the MMR vaccine or quoting the (fully discredited) study linking the MMR vaccine to autism. I also might have thought, “Why are they trying to scare me about these diseases? Maybe they think they need to scare me because the vaccine is dangerous.” I wasn’t given information on the safety of the vaccines. I wasn’t told details about potential side effects. I wasn’t given an opportunity to ask questions.

Communication is critical. Comprehensive communication is critical. Empathy is critical.

The costs would likely be prohibitive, but it would be nice to set up a study (with the same questions looked at in the above study) where people with negative attitudes towards immunization were identified, where they were randomized to an intervention group where a doctor listened to their fears, addressed their concerns, quantified the risks and benefits of vaccination versus the diseases themselves, provided trustworthy further sources, and explained which sources were not scientifically trustworthy and why, all while maintaining an empathetic demeanor; a group where the above was done in an arrogant/ridiculing manner; and a control group where a doctor discussed the benefits of wearing a bicycle helmet. How might people respond then?

The anti-immunization community (both physical and internet) provides empathy. They tend to be comprehensive in their information (albeit false). They define the enemy (enemies). They pull people into their fold, making them feel a part of a valued and cared-for community.

Calling people names will not pull people back from a group that’s making them feel welcome and supported.

Again, the majority in this country understands the science behind immunizations, trusts the medical and science establishments, and immunizes their children against dangerous communicable diseases. People who are wary of immunizations are not trusting the overwhelming consensus of physicians. If they are already pulling away in some thoughts from the medical world, why would anyone think that insulting them would help pull them back?

A piecemeal approach of a written form here, a scary story there, or some random disease photo is also not likely to pull anyone back, nor is an internet meme with a snarky comment or comparison.

Memes make points or sum up arguments with a picture and just a few words, frequently with an element of humor. I frequently appreciate the humor and the analogies made when the memes are pro-vaccine. But when I look at those of the anti-vaccination type, it hammers home just how lacking a meme is. It may pack punch, but it lacks depth. It lacks nuance. It lacks explanation that addresses questions or concerns.

This is not to say that the memes are useless. They generally serve to support/confirm/validate what people on one side or the other already understand or believe. They also, by serving as an indicator of what someone posting the meme thinks, contribute to defining norms. So it is helpful for Facebook to have a preponderance of pro-vaccine posts, since it helps cement immunization as the acceptable/preferable thing to do, and it is possible to do this with humor, with analogies, and with respect. It is helpful for people to respond to/refute anti-vaccine posts in a respectful, empathetic, honest, respectful, non-condescending manner.

Here is my official, as-a-doctor stance on vaccination:

Vaccines save lives. Vaccines are not perfect, but the ones that we have now have been proven overall safe and effective. We’ve come a long way since the first documented attempts to immunize. Variolation for smallpox – rubbing material from smallpox sores into people’s skin to induce a cutaneous case of the disease which was milder than the normal variant and conferred immunity to the more severe infection – has evidence of being performed in China 1000 (yes, one thousand) years ago, and was practiced in Asia, Africa and Europe from the 1600s through the 1700s (see historyofvaccines.org). Our vaccines and their manufacturing process have been refined and improved remarkably over the past two centuries. All of our present-day science overwhelmingly indicates that the benefits of our current vaccines vastly outweigh the risks. This does not mean that the risks of vaccination are zero, but they are ever so much lower than the risks of not vaccinating.

Choosing not to vaccinate has risks not only to those who refuse to vaccinate but to others in the community as well. Doctors and medical researchers read studies, discuss findings, analyze quality of research, and continually ask questions to direct further lines of inquiry. As new information becomes available and as better methods evolve, we update recommendations and practices accordingly. All of our best available current information leads me to recommend immunization.

Immunize yourselves. Immunize your kids. And if you still have concerns or questions about vaccines, ask them of your physician. If you feel you are not being answered respectfully by your doctor, calmly and respectfully point this out, and ask again.

If you are a doctor and there seem to be multiple patients in your practice with similar vaccine concerns, hold a few group talks to openly address the concerns and share your knowledge with multiple people at once. Make a video addressing common concerns, make it comprehensive, include analogies, show appreciation for concerns as you discuss them, and put it on your website. No matter how exasperated you may be with the whole anti-vaccination issue, show empathy, kindness, and compassion to those with fears. Teach your patients, and don’t chase them away with outward manifestations of your frustrations.

Let’s live beyond the memes.

 

Following the Trails

Our family loves to hike. Traveling the trails is a deeply happy place for us. In fact, I don’t think there’s ever been a time when one of us suggested taking a hike and everyone didn’t unanimously and enthusiastically agree. A few weeks ago, my family took a lovely hike in a state park in Massachusetts. It was a gorgeous day – temperature in the upper 40s, blue skies, no wind. The hub of trails started at a large, beautiful pond. There were large hills in every direction (which we really miss in general since we live in a fairly flat region in the Midwest), and the trails were dry since we hadn’t had rain in a couple days.

We checked out the big map at the trail head and picked up a small folded guide to bring along with us, as there were so many choices and branchings of paths along the way. Both the large wooden and the small paper maps said, as pretty much all maps/guides in any hiking area say, to stay on designated trails both for personal safety and for protection of the land.

We started out along the perimeter of the pond, where most people were walking, and then headed away from the water on a path to see some cliffs. After a short while, we noticed that the path was not well-marked. It was easy enough to follow at the beginning as the cut through the trees was fairly obvious, but as the trees thinned it became more difficult to discern exactly where the trail was. A thick carpet of leaves was everywhere, and since it was early winter there were no ferns or other greenery growing where the trail wasn’t.

All five of us are good with maps and with judging relative distances. The guide we had showed various bodies of water as well as contour lines of changing elevation. With some work, we managed to figure out how to get to each subsequent destination along the trails on our afternoon’s journey in spite of the lack of trail markings. It was a lovely little adventure and a delight to be out in the woods.

But I couldn’t help but think about how disconcerting this could be to someone who wasn’t a seasoned hiker, who wasn’t familiar with topographical maps, and who was travelling alone or with young children. The signs said to say on the trails, but the sign-makers neglected to mark said trails. When you tell someone to stay on a trail, you can’t assume that someone will know where the trail is. You need to provide trail markers.

People frequently use the phrase “blaze a trail” metaphorically to indicate that someone is the first person to do something and that others will follow. However, the actual meaning of “blazing” a path is that someone is providing markers to be used by others to follow that path. It’s not just finding and knowing the way, but helping others find the way as well.

This is the case in medicine. Doctors can’t just tell their patients to do something without explaining in detail the hows, whys, whats, wheres, and whens. A doctor might know what a general piece of advice entails, but a patient could be figuratively lost in the woods without a mark in sight on any tree in any direction.

“Cut down on your sodium intake.” “Take this medication twice a day.” These concepts may be clear and precise to the doctor, but may be vague and unclear to the patient.

Doctors must describe the setting – the situation and what’s happening. They need to describe the different paths, landmarks along the way, and tips for getting through/over/around the difficult parts. They need to describe what to do if their patient wanders off the path – how they can find their way back if they can and how to reach help if they can’t do it themselves.

“Sodium is an element in salt that causes your body to hold onto more water than it needs, and because you have early heart failure it’s important for you to make sure that your body doesn’t have too much fluid. The medications you’re taking help, but your diet is important, too. For the next two weeks, try to prepare all your meals at home – I know you and your wife love to cook together! Don’t add salt to anything. Here’s an example of a nutrition label – see where it says “sodium”? Try to make sure that the total amount of sodium on anything packaged that you eat throughout an entire day doesn’t add up to more than 1500 mg. This is hard to do, and it will probably force you to avoid a lot of pre-packaged foods. If you have difficulty with this, I’ll help you set up an appointment with a medical nutritionist. Feel free to call me with any questions, and I’ll see you back here in two weeks.” Blaze the trail well.

Patients need to make sure they have detailed maps with them, an understanding of how to read those maps, knowledge of what the trail markers look like, hiking partners, and ways to reach help when needed. If their doctors have not been clear and comprehensive, they need to ask for clarity and comprehensiveness.

“When you say to take this medication two times each day, does that mean exactly 12 hours apart? If not, what is the rough window of time that’s ok? Should I take it with food or on an empty stomach? Are there any side effects I should watch for? Do I take the medication all the time, or only when I feel like I need it? Is there anything specific I should or should not do while taking this medication? Should I direct further questions to you or to my pharmacist?” When people point out that a trail is not well-marked, the park rangers will improve the trail blazing.

Maps. Markers. Trails. Skills. Partners. Guides. Communication. Enjoy your hiking!

 

 

A Little Less Zen in the Shoveling but Still Good

The coolness of the crisp, clean air, the beauty of the blanket of fresh snow, the quiet of the early morning, and the satisfaction of having cleared my own family’s and my neighbors’ walks and driveways.

The soreness of my shoulders, the frozenness of my fingers and toes, and the overall tiredness of me.

The timing of our last two snowfalls were such that I was the only one around to shovel. I love to shovel snow, actually. I find it peaceful and satisfying. In fact, one of my very first posts was about shoveling snow (Zen Shoveling). But sometimes I get a little grumpy. Like when the plow pushes that heavy stuff over the end of the just-shoveled driveway. And when it’s really cold.

I’m a couple years older than when I wrote the first piece. I tolerate the uber-frigid temps a bit more grudgingly. I now follow a bit more the advice I’d give my patients – bending at the knees, not reaching/leaning when lifting, dumping rather than throwing the snow, taking frequent rests, just generally listening to my body.

It turns out that my body has plenty to say. Like, “Put your hood up, Dummy.” Amazing how much warmer a hood or a hat makes you.

And “You’d better start shoveling on the other side, or this arm is going to fall off.” Gotta remember the balance.

And “Yes, you’re in a groove, but it’s been over two hours and if you don’t stop soon you’ll regret it later.” Right. Later. I forgot about later.

A warm bowl of oatmeal post-shoveling. A hot shower. Some slow stretches.

Some mild soreness for a day or two – a reminder of the workout.

Beautiful views outside my windows of the white blanket of snow, marked with the footprints of rabbits, birds, squirrels, and some larger animals whose prints I can’t identify.

Enjoying, but wouldn’t complain if spring came on the early side this year…..

 

An Appalling and Alarming Devaluation of Life

I received an email earlier this fall from someone very close to me – a psychiatrist, in her mid-60s, extremely intelligent, level-headed, non-reactionary, balanced, rational, and even. She tends to be somewhat progressive and mildly left-of-center on social issues. She sent me the link to Ezekiel Emanuel’s article in the Atlantic, “Why I Hope to Die at 75”, and she expressed significant concern.

I also tend to be somewhat progressive and left-of-center on social matters, reasonably level-headed, and non-reactionary. I found the article to be chilling.

I provide the brief background on our personalities and social-issue political leanings very deliberately. You need to know who is alarmed here, because my article is about to sound like it was written by a right-wing pundit with paranoid tendencies. It was not.

The piece in The Atlantic invokes fears far beyond those of death panels (which, as unacceptable as such a concept is, at least imply that there are some decisions to be made as far as who might merit the resources to have life-saving treatment). Dr. Emanuel’s article sets the stage for an expectation that people’s health is not something for which society should pay at all once they have reached a specified age (the specific age he chose is 75). No need for a death panel – you just need access to a person’s date of birth. He repeatedly uses the term, “American Immortal,” to imply that the idea of living healthily into old age is unrealistic, selfish, and greedy. He steps so far over the line with his stated “personal” preferences that the rest of us won’t be able to help but view the government as magnanimous when it generously allows Medicare to cover an antibiotic for a 76-year-old. I am afraid that Dr. Emanuel aims to be so outrageous in his arguments that a slight step back will be viewed as reasonable.

His points of persuasion reminded me of an Onion article from the late 1990s, when Dr. Kevorkian was frequently making headlines (“‘Vehicular Manslaughter Doctor’ Assists in 23rd Doctor-Assisted Vehicular Manslaughter”). The Onion writers are able to make anything funny – even a subject such as assisted suicide. Their satire in this particular article goes over the top in its farcical quotes depicting the suffering of people (for example, having to put on a special pair of glasses just to read) whom they are putting out of their misery by running over with a car. Dr. Emanuel’s depictions of the infirmities of those 75 and older are frequently as preposterous as those of The Onion (for example, one of his instances of something horrible to be enshrined in the memories of someone’s children or grandchildren is that person’s having to ask what someone else said – seriously, he implies that it’s better for a person not to have a memory of a grandparent who has some hearing loss). To be fair, Dr. Emanuel does not advocate direct homicide of those 75 and older, but he most certainly promotes shoving them out of the healthcare world onto a proverbial ice floe. And rather than being funny, the seriousness of his dissertation is simply horrifying.

His position is coldly utilitarian. He establishes any loss of functionality, productivity, or creativity as making the world smaller, of being no way to live or to be remembered. So he recommends that people die first, before losing any functionality, productivity, or creativity. I certainly would not want to be the in-any-way-less-than-perfect family member of this guy.

Dr. Emanuel puts forth that those 75 and older already have grandkids or even great-grandkids, and their continued existence overshadows the next generation down. I would put forth that a little therapy would go a long way towards resolving such psychological issues for someone who feels he is not able to achieve his rightful position as patriarch, and I would put forth that such therapy would be significantly preferable to killing off one’s parents.

Speaking of killing people off, it also shocked me that a physician would take the medically unsound (from a population/public health standpoint) stance that after a certain age he would refuse a flu vaccine. Is this so he can pass influenza along to infants, other elderly people, and those with weakened immune systems, so as to efficiently thin the herd and more quickly reduce their financial burden on society? There are creepy parallels to both The Giver and Children of the Corn.

On Ezekiel Emanuel’s website, there is a big quote screaming from the homepage (www.ezekielemanuel.com): “Zeke Emanuel is a force of nature. Author, ethicist, cook, medic, policymaker: he makes other over-achievers look lazy and inadequate. There are very few policy experts – in health care or any other field – with Zeke’s smarts, political antenna and persuasive powers.” This man is a member of the academic and political elite. One of the architects of the Affordable Care Act (ACA or “Obamacare”), he is in the healthcare policy inner circle. His words do not die on the page. People in positions of power are listening to this man.

He sets up a false choice of being a sickly immortal-wannabe or forgoing all medical care at a predetermined age. He puts forth what is either his own fear of not being at his peak or what is his politically calculated and expedient depiction of old age as a universal “succumbing to that slow constriction of activities and aspirations,” and thereby devalues any life that is not at his defined “peak.”

This man is an ethicist. His ethics are unnerving.

I asked my youngest son to read the article and tell me what he thought about it. He is still two months shy of turning 14. I’ll stipulate that he is a smart 13-year-old (he has two smart older brothers to learn from), but still – he’s 13. Here’s his response:

“There’s a lot of wrong stuff in that article. He makes it sound like getting old is bad and that life is less worth living when you’re old. He’s wrong. As you get older, you know more and more about life, so you live it more clearly. You’re wiser. So what if you slow down a little? And what’s wrong with listening to books and doing puzzles? He said it was bad for people to have memories of someone older or weaker. He sounds like he just wants to shove old people out on an ice floe.” So I wasn’t the only one who had that ice floe image. “And that thing he said about older people overshadowing younger ones – that’s just messed up.”

I then asked my son if it sounded like the author was just stating his own personal opinion. He answered, “Actually, it sounds like he’s trying to convince other people of what he’s saying under the guise of it’s being his own opinion.” Out of the mouths of babes. He’s a high school freshman and he wasn’t fooled.

My son asked who this author is. I told him that he’s a very influential doctor involved in healthcare policy. He replied, “that’s scary.”

Listen to the kid.

Because Ezekiel Emanuel is a member of the political elite, he will have the prerogative to “change his mind” and access healthcare when he’s older than 75. But when his words have been enacted into policy, the rest of us won’t have that option. This man’s words and his position of influence combine to seriously threaten our right to life, liberty, and pursuit of happiness. Do not let him force anyone to go gentle into that good night before they’re damn good and ready.

I cannot dismiss his article as the musings of a madman. His words appear to be the cold, calculated attempt at the social engineering required to decrease our country’s medical bills in a deeply disturbing manner. They are a set-up to “well, if Ezekiel Emanuel is totally healthy and strong and climbing mountains in his late 50’s and declares that he should be dead in less than 20 years and not using up money for healthcare, then who is someone with (arthritis, diabetes, any ailment of any kind) to demand care? Why should we give a new hip to a 70-year-old? Why should we treat cancer in someone in their 60s?” I hope every member of the AARP (and every one of their family members, and anyone who is in or someday plans to be in that demographic) reads Dr. Ezekiel’s article. And I hope they read mine.

Do not let this man have the last word. Do not let him smile sweetly and innocently as he sets the stage for a “there will be no coverage for chemotherapy (or dialysis, or ICU care, or hip-replacement surgery, or medications other than painkillers…) after age (whatever seems like a number likely not to cause a huge outcry)” policy enactment. Let the outcry be heard now. Let it be huge. Keep your eyes and ears open. Follow what policy makers and policy influencers are saying and know who your elected officials are listening to. Keep reading what Ezekiel Emanuel writes. Keep up the outcry as necessary and keep it loud. Do not underestimate the power and influence of his words, or the power and influence of your own.

 

Exponential Ire

I was invited to a “networking party.” I went. I was horrified by what transpired there. And disgusted. And felt blindsided. And angry. And blown away by the prevalence of what I couldn’t decide was greed, ignorance, or an unseemly combination of the two. And what magnified the intensity of my repulsion was the fact that a large proportion of the people involved have the title, “doctor” (although none of them were MDs, DOs, or PhDs). I felt mortified.

The evening began like any other business networking event. We walked around, munching on some hors d’oeuvres and shmoozing informally. Then we all gathered for the formal part of the evening, where we all took turns introducing ourselves to the group with a brief “elevator pitch” (quick spiel) of what we did for a living, and if we were a visitor we told the group whose guest we were that evening. And then, the presenter began. And I almost fell over.

This was not a networking thing. This was a pyramid scheme.

The presenter had a board with little velcro hearts and rainbow-colored umbrellas arranged in a triangle shape with the apex at the bottom. There were four layers, so above the one cute little velcro item on the bottom there were two on the layer on top of it, four in the next layer, and six (with two empty spaces) at the top. The presenter then explained how each little symbol represented a person in this wonderful system, and how each new member was added to the top layer when they paid a “gift” of $1,000 to the person at the bottom. She added two symbols to the top to complete the row of eight and to then demonstrate that when the person on the bottom had received her $8,000 in “gifts,” having originally only payed in a gift of $1,000, thereby netting $7,000, the pyramid above split into two, and each of the people who had been in that next layer above the recipient would now be the recipient of the $1,000 from each new member in the next layer of people who joined, with this pattern repeating so that each person would end up netting $7,000.

There were multiple assurances from the presenter and confirming enthusiastic shouts from people in the room that this was all perfectly legal, since it was all in the form of “gifts,” and that it was not at all a “pyramid scheme.” A pyramid scheme is a model in which members make money solely by recruiting new members to pay into a program, and new members pay in with the expectation that they will have a turn as a money recipient. This was absolutely a pyramid scheme.

Pyramid schemes are unsustainable. They implode. The people who start them and get in on them early will make money off the many people who will lose their money when they join later.

In the room that evening, people bragged that they were on their second time through. They spoke of how wonderful it was to be able to “help” the person on the bottom who only invested $1,000 but now was on her way to receiving many times that amount. And they spoke of how noble it was to help the people in this group, who each had reasons for needing to grow their money – tuition for their children’s college, seed money for starting their own businesses, etc.

What they neglected to discuss was the basic math involved. The concept of exponential or geometric growth. The one person who started the program needed to recruit 14 other people to fill in that first triangle cycle with the top layer of people each paying in $1,000. For each of those 8 payers to receive their $8,000 and split the triangle in two for the people in the next layer up, they needed to recruit one hundred and twelve people (sixteen to pay the two people in the original second layer, thirty-two to pay the four people in the original third layer, and sixty-four for those eight people in the original 4th layer). For those sixty-four who paid in to the original fourth layer of eight people to receive their own payout requires recruiting eight hundred and ninety-six more people. This is because each layer of people must double three times for the payout to be complete. Within about 9 of these complete cycles you’ve covered the population of the United States, and in less than two more full cycles after that you’ve covered the population of Earth.

Obviously this contrivance collapses fairly quickly. A lot of people will lose their money, since the number of people buying into the game plan is finite. The system is designed to have a lot of people lose their money. This particular scheme tries to make it ok by describing the buy-in as a “gift,” thereby trying to excuse themselves from being obligated to each person buying in.

How scuzzy. How unethical. Or, if giving some of the people involved the benefit of the doubt, how ignorant.

And as I mentioned above, several of the people who were a part of this scheme (not people who were brought in as guests to this “networking party”) were members of professions in which they have patients and people call them “doctor.” They are not MDs or DOs, but they refer to themselves as “primary care doctors.” They are practitioners of “alternative medicine.” And here at this event they were actively taking part in a scheme that showed they either lacked a basic understanding of high school math or they understood it quite well and were willing (and hoping) to exploit the ignorance of others for their own financial gain. Either possibility is frightening in members of professions that purport to care for the health and physical well-being of others.

Members of these particular professions frequently speak against conventional medicine. They speak of “toxins” in vaccines. They promote homeopathic “remedies” and “preventions.” Do practitioners in these fields not understand the math involved when each person with measles in an un-immunized population infects 12 to 18 others, how quickly that number explodes, and how 2 out of every thousand people infected will die (significantly more, up to 10%, in areas where people are malnourished and don’t have access to adequate medical care) and how many will suffer blindness, encephalitis, or pneumonia secondary to a measles infection? Do they not understand the comparison of those numbers to the one person in a million who will suffer a severe allergic reaction to the vaccine? Do they not understand that a homeopathic remedy, which is created when an herb or a poison (yes, a poison) is diluted multiple times (so that there is exponentially less of the substance with each step), leads to a solution in which there is no detectable active ingredient (which is actually a good thing in the case of the poisons) – the opposite of exponential growth? Or do they understand these concepts well enough but are willing to exploit the ignorance of others for their own financial gain, even if that exploitation is not just financial but is at the expense of the health and well-being of those whom they purport to “heal?”

I do not presume that every alternative medicine practitioner participates in predatory Ponzi schemes. But each of us, especially when we make a point of announcing our profession and describing what we do, is a representative of our profession. If there had been a group of financial planners taking part in that pyramid racket, what would you think of that profession? What if there had been a large contingent of lawyers? Or teachers? What would that do to your trust of that profession as a whole? I know that there are chiropractors who treat back pain and don’t talk their patients out of vaccinations or into useless remedies or out of appropriate medical care. But I have to try harder now to remind myself of that. And I find it easier to understand when the general public complains that “doctors” are just looking to make money when I find “naturopaths” who call themselves “doctor” trying to recruit people into a pyramid financial arrangement that will find their recruits each out a thousand dollars as their “gift system” collapses.

It’s been almost two months since the “networking party.” Rather than continuing to fume, I am stepping back, taking a deep breath, and trying to transform my indigestion and raised blood pressure into helpful words. Think about what you do. Think about what you promote. Think about the consequences of what you do and promote, both to yourself and to others. Ask yourself if you are acting out of greed only, with a disregard for the well-being of others, or out of a sincere desire to make the world a better place. When someone is handing you a line, figure out if they are doing it out of greed (and a disregard for the well-being of others). Go back to basic math, to basic science, and to basic ethics. And when you are making a decision about your health or the health of someone you love, work with a doctor who understands and respects these basics.

Housecleaning and Doctor Visits

I spent this past week worrying that my in-laws were going to divorce me. For sure. No getting out of it this time.

I do not keep a neat house. There are piles everywhere. Piles of books. Piles of papers. Piles of clean-but-unfolded laundry. Piles of mail. Piles of music. Piles (believe it or not) of instruments. Piles of shoes. Piles of coats (it’s cold these days, but varying degrees of cold). There’s a drum set in the living room (because that’s where the piano is). Did I mention the books?

My parents-in-law keep an immaculate house. I don’t think I’ve ever seen a pile of anything in it. Ever. And they’re arriving this afternoon for a weekend visit.

They get that we’re busy. They get that we suck at housekeeping. They have never, in twenty-one years of marriage or the dating years prior to that, criticized us. They focus on our strengths rather than weaknesses. But we all have our limits.

Normally, it’s possible to move the piles around a bit, tidy up around them, and keep a reasonable level of cleanliness in between the occasional deep-clean. But it’s been quite some time since the last deep-clean, and there’s only so much you can do with the touch-ups.

My house epitomizes the problem with the state of medicine today. Stay with me on this.

We’re busy in my family. You should see our Google calendar – so many overlapping color-coded blocks that it actually looks beautiful if you step back and let your eyes go a little fuzzy. So aside from regularly taking out the trash and recycling, cleaning the toilets, and doing dishes and food clean-up, other stuff gets relegated to an as-needed basis. When something gets really gross, we clean it. When something breaks, we fix it. When the toothpaste spatter around the sink reaches a critical radius, we wipe it. But when that goes on for too long without a no-one’s-going-anywhere-until-this-entire-place-is-company-ready cleaning frenzy, it can get really bad.

Bad enough that a visit from your parents-in-law, whom you love deeply, actually frightens you.

A similar phenomenon has been happening in medicine. And, like my house, it’s been getting worse. There’s no time to spend with patients. There’s more and more on the schedule. There are more billing issues to focus on. More regulations. More pressure to see a greater number of patients. More hoops to jump through to maintain board certification. Doctors have time to swab a throat here, adjust a blood pressure medication there, give a quick reminder that someone’s due for a colonoscopy, tell a patient that it would be in his best health interest to lose a little weight. It’s like cleaning around the piles. It can sort of work for a short while, but the dirt builds up.

Every so often, a doctor’s got to sit with her patient and do the equivalent of a deep housecleaning. Find out what’s going on in the patient’s life. Listen to the fact that her son’s been out of work for a year. Maybe that’ll give you the clue that perhaps the reason you’ve had to increase her insulin prescription so much recently is that she’s been giving half of it to her son, who also has diabetes.

My husband and I have spent 8-and-a-half hours so far today straightening and cleaning. We’ve got a little over an hour to finish whatever we’re able before his parents arrive.

It’ll be ok. The bathrooms with which they’ll have contact are thoroughly clean. There is no dust and there are no piles of clothing in the room where they’ll be sleeping. And much of the rest of the house is a heck of a lot better than it was. We’ve done a pretty good job. Not the ideal, whole-house deep clean, but targeted deep clean with broad adequate cleaning. Kind of like a doctor’s visit that focuses on diabetes, high blood pressure, smoking cessation, headaches, ways to reduce stress, healthy eating advice, and ways to fit exercise into a daily routine, The next visit will address the need for a screening colonoscopy, and will describe the preparation for it.

That prep would be the equivalent of our cleaning out our basement. Maybe I’ll wait until I’m 50.