Category Archives: Health and Wellness

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.

 

Ebola Politics

There’s much in the news this week of a nurse who is refusing to stay in quarantine after her return from caring for patients with Ebola in West Africa. So many issues here. Hard to know where to begin.

First, the nurse is correct in her statements that there is no scientific evidence that she should be in quarantine. She has twice tested negative for the virus. She has no symptoms (a forehead temperature registered high at the airport when she first arrived in the United States, but follow-up temperature readings have been normal). The disease is not contagious until people are symptomatic. And again, she has tested negative twice so far.

The fact that she has valid scientific points does not mean that her manner of spurning authority is the most useful strategy or the wisest thing to do in this particular case.

The fear surrounding this particular disease is intense. The vitriol directed toward those who contract the disease when caring for the people afflicted by it is mind-boggling. There is a lack of logic and common sense regarding this disease which is maddening. So adopting a tone that appears belligerent is not necessarily the best way to calm fears, educate people, and work with the scientific community and government officials in a cooperative, productive and helpful way.

Thousands of people have died in West Africa due to this Ebola outbreak – about 5 thousand at this point, out of about 13.5 thousand total cases, in countries whose populations total about 22 million. The medical infrastructure is not present to adequately treat the people there and control the disease. We need more facilities and healthcare personnel to contain the outbreak. The bigger the outbreak becomes, the higher the likelihood that people with the disease will end up in the United States, so even if some people don’t have deaths of people in another area of the world high on their personal radars, the outbreak will have some effect here – it is a global issue. We need people to work together in a smart way.

Ebola is spread through contact with bodily fluids of a person who is actively sick. Casual contact with someone who does not yet show signs of disease has not been shown to transmit the virus. Monitoring people who have come in close contact with actively ill Ebola patients (i.e., healthcare workers, people who are cleaning the bodily fluids of those who are ill, etc.) through the potential incubation period (the time it takes from exposure to disease development, in the case of Ebola 2 to 21 days) is fairly easy to do when there is a small number of people to monitor. When we send large numbers of military personnel to help with the crisis overseas, it will be more difficult to monitor everyone individually on their return, and so a three week quarantine from time of last exposure makes logistical sense.

We are not quarantining every doctor, nurse, lab technician, or custodial worker involved in the care of Ebola patients and their environments. We are monitoring. We are using common sense. We are looking at the data – this is not a new disease, and we have observed the patterns of transmission.

The nurse who is fighting her quarantine has brought in lawyers. She is figuratively kicking and screaming about her rights being violated. The general public is looking at her reaction and saying, “How selfish! What a spoiled brat! How dare she put me at risk?! Three weeks is no big deal. She should err on the side of caution and be done with it!” Her belligerence invokes anger, not understanding or alliance. Her dismissal of people’s fears does not promote an environment of respect and teamwork.

The nurse’s lawyers and the state of Maine’s lawyers are currently trying to work out a compromise. This is beyond ridiculous. Why are lawyers negotiating a public health issue? The state’s public health department has authority here. The federal government, through the CDC (Centers for Disease Control and Prevention), has authority. If the state’s public health department has said “quarantine,” then the quarantine should be respected. If the state has its information wrong, the CDC can step in.

The nurse in this case is well within her rights to cry “foul” to a policy that is grounded in fear rather than scientific reality. But the crying should be done smarter.

She should have called Doctors Without Borders, with whom she’d been volunteering. She should have called WHO (the World Health Organization). She should have called the CDC. After speaking with these organizations and getting official confirmation of appropriate protocols, she should have spoken with the state authorities with whom she disagreed. If they didn’t listen to the advice from WHO and the CDC, the nurse then should have gone to the newspapers and TV networks.

I understand and agree with the stance of not blindly going along with inappropriate policy. When reality/facts/science are ignored, bad things happen. People are ostracized. People are vilified. Already, a child was kept out of school in Connecticut because she had visited Nigeria (not an epicenter of this disease, and she had not come in contact with any sick people) for a family wedding.

The school defended its decision by saying “some of the other parents were scared.” This makes about as much sense as keeping a kid out of school in the Midwest because he had visited his family in Texas, and someone in Texas had Ebola. That school ignored facts and made poor decisions based on ill-informed fears. The nurse in our story is trying to prevent such poor decisions.

If she had just said, “whatever,” and stayed inside for three weeks (or in her original quarantine tent for three weeks) she would have not suffered any long-term negative effects, but she would have been complicit in the propagation of such ridiculous events as transpired in the Connecticut school. She would have been complicit in allowing fear-generated policies to stay in place that would discourage anyone from helping those in desperate need of medical help. She, a healthcare professional, would have been complicit in bad medicine.

But by simply showing defiance and going straight to the lawyers, she, a healthcare professional, says that it’s ok for people to defy public health authorities.

So here’s an alternate unfolding of events:

Nurse gets off plane. She discloses her work with patients with Ebola. Forehead temperature scan reads high. She denies any symptoms. Because of the high temperature reading and an abundance of caution, she goes to the hospital for temporary observation. All subsequent temperature readings are normal and the nurse remains free of symptoms. Lab tests for Ebola are negative. Nurse calls Doctors Without Borders and gets contact information of their infection control experts. Nurse calls CDC and WHO and gets contact information for their Ebola gurus.

Infectious disease team at hospital talks to Ebola gurus from CDC, WHO, and Doctors Without Borders. They reach consensus. They make recommendation to local health department. Local health department makes decision based on evidence, expert consensus, and known data, rather than on TV news sound bites of the fears of random citizens with no science or health background or training. In the meantime, the nurse waits for the appropriate people to deal with the issue. And she abides by the answer.

The media circus was unnecessary. The lawyers were unnecessary. What was needed was communication among all the experts – those on the front lines, those with the epidemiology background, those with the infectious disease expertise. And the government entities needed to listen to those with the knowledge. And a healthcare professional should have recognized the need for this type of communication facilitation, and should have respected the public health entities by working appropriately through the correct channels.

Lastly, keep in mind that tens of thousands of people in the U.S. die from complications of influenza every year. Get a flu vaccine. Measles is one of the world’s most contagious diseases, and it’s contagious from four days before a rash shows up. Get your kids vaccinated. These are issues the media should be headlining in this country right now.

 

Shared Experience, or the Lack Thereof, and Understanding

I just recently attended a meeting where there was a panel discussion on caring for Holocaust survivors. The person who opened the meeting spoke about how she felt inadequate when dealing with this population because she had no personal place of reference – she had no family members who died during the Holocaust, and so she couldn’t truly understand what the survivors went through.

I have a different thought.

Although every experience each of us has helps us to put ourselves in the shoes of others, helps us to empathize, helps us to imagine what others may be going through, each shared experience also puts a potential block between us and the person we are trying to understand.

There’s an old joke: “When two people are having a conversation, one person is talking and the other person is waiting.” We know what we want to say. We are ready with our next speech. We listen to enough of what the other person is saying to tie it in and segue nicely into our “response” to what the other has said. Frequently it’s not truly a response to what the other has said – it’s our response and reaction to the thought as it was first introduced.

If we think we understand someone else, we may fail to listen enough. If we think we don’t understand them, we may listen more carefully. If we think that we cannot understand someone, then we may stop listening altogether. It’s a balance.

I am frequently struck by how differently two people can experience the same event. And I am frequently struck by how similarly two people can respond to disparate events. So alignment of thought, emotion, reaction, and experience is not completely predictable. We need not to presume that we understand someone else. We need to listen and remain open to the possibility that we might not “get” someone that we think we do, or that we might completely “get” someone to whom we had thought we couldn’t relate.

While in many cases having a fundamental experience in common can strongly connect people, the durability of that connection ultimately depends on factors other than that common experience. A genuine caring for the other person, a willingness to hear what that other person has to say (rather than just assuming knowledge of the other person’s story), and the ability to accept differences in the other person enables the relationship to grow and strengthen. When those other factors are present, that shared experience is not necessarily crucial to the interpersonal bond.

Support groups can be very helpful for many people. They pull together individuals who are sharing a specific struggle. The people in these groups can learn from one another, sympathize with one another, gain insights from one another, and support one another. But generally the people who participate in support groups are people who want the support, want to support others, want to connect. There are guidelines in place to protect members’ anonymity (if so desired), and to allow each member the opportunity to tell his or her own story, thus encouraging other members to listen. It’s not simply the shared experience that makes the groups work – it goes far beyond that.

Because I must work very hard to maintain a healthy weight, I can sympathize and empathize with people who struggle with their weight. But if I assume that their experiences and reactions are the same as mine, the counseling and advice I give could very easily not work for them. When I listen, when I get people to tell me their stories, I can combine their situation with what I know from the medical literature, what I know from my own experiences, and what I know from having listened to others’ narratives, to synthesize and formulate a plan with them.

I am not a smoker. I have never felt an overpowering urge for a cigarette. Yet I have been able to help many people quit tobacco use. My lack of sharing in the experience forced me early on in my medical career to take the time to really listen to what my patients had to say about why they smoked, why they wanted or didn’t want to quit, what made it difficult for them to quit, and what seemed to help them and what didn’t. I didn’t come at it with a preconceived notion, with an “oh, I’ve been there, I know what to do” approach – I let my patients teach me.

So while a shared experience certainly can help people understand one another, it is not necessarily so, and a lack of experience-sharing can in some instances lead to better understanding through true listening unhindered by expectations and preconceptions. The key is the willingness to listen. To stop waiting for our turn to talk, and to really listen.  Of course this means that the conversation will take longer, since we need to take the time to formulate a response after fully listening to and hearing what the other person has to say, but the communication that actually takes place during that interaction will be far more fruitful.

The person at the meeting who felt inadequate in counselling a certain population because she hadn’t experienced their trauma still has plenty to offer. If she says “I will never know what you went through, but I care about you and want to understand you. If you will teach me, if you will tell me your story, I will do my best to listen and to learn,” then she will have potentially opened a door to a connection, to trust, to a potentially therapeutic relationship, and ultimately to an understanding that can possibly help her to help the next person whose story she listens to and hears.

 

 

 

What Football and Infectious Disease Control Have in Common

Communication. Such a simple concept. And yet so many ways in which it can fail.

Two examples of communication failures hit the news this past week, both of which have potentially severe medical repercussions, albeit on very different scales.

The first occurred this past Saturday at a Big Ten football game. The quarterback took a hard hit, and his head slammed backwards onto the ground. When he got up, he was so shaken and off-balance that he stumbled and collapsed into his teammate. So obviously, he would be pulled from the game and given medical attention, right? Nope. The coach put him back in for another play, as the crowd booed its displeasure and indignation. No one could believe the coach would show such blatant disregard for his player’s well-being, and there are strict regulations in place regarding head injuries in sports and protecting the athletes when there is any suspicion they have suffered a concussion.

But the coach didn’t pull the player out for a neurological check because he (the coach) hadn’t seen the player’s hit, his head-slam, or his resultant signs of head injury. The coach knew the quarterback was playing on an injured ankle (which had been medically cleared for play), and when he saw him limp back to the sideline, he assumed it was an ankle issue, stuck him in for another play, then had medical personnel check his ankle, and put him in again. Thousands of people in the stadium saw what happened. Millions of people saw on TV. Everyone assumed the coaches saw. But they didn’t – they were monitoring so many different things, planning, talking to people, and assuming important information would get to them. But the information didn’t get to the right people.

The university where this occurred is taking steps to ensure such an event doesn’t happen again. For example, they’re placing medical personnel in the press box for future games and giving them direct communication lines to the coaches. Systems approaches are good. They help. I’m glad they’re putting in extra safety layers to protect their student athletes, and I hope other schools and teams follow this lead. But systems measures can only go so far. We also need individual safety layers, and I cannot overstate the importance of personal advocacy (both self-advocacy and advocacy of others).

If the quarterback had said, “Hey, Coach, I hit my head and don’t feel right,” or, if he was too dazed to speak for himself, if his teammates had told the coach about the injury and their concern, or if anyone who had seen the incident had spoken up and relayed the information to the coach, then the athlete would have been given prompt medical attention and not sent back out on the field to be head slammed again. People need to speak up. And they need to speak up to the people in authority – the decision makers – and not just grumble quietly or complain amongst themselves.

Earlier this week, the news hit that the first person in the U.S. had been diagnosed with the Ebola virus. Ebola requires close contact with someone who is symptomatic with the disease in order to spread. We have good infection control measures in U.S. hospitals. We have quick dissemination of news. We have the CDC (Centers for Disease Control and Prevention). We have state and local health departments. We have a lot of good systems in place. The patient had recently come from Liberia, where there is a current outbreak of Ebola. He developed symptoms, he went to the hospital, and he told some of the medical personnel that he had just recently returned from Liberia. And he was sent home with a prescription for antibiotics. And he continued to be symptomatic, exposing other people for days, until he returned to the hospital and received the correct diagnosis, appropriate medical care, and concomitant infection control measures.

In this case, the patient actually had communicated the important information, but it didn’t get to the correct people. A systems issue, to be sure. But more individual advocacy and strong communication would go a long way here, too.

I was not on the sidelines with the football team, and I was not in the emergency room where the patient first presented, but I have some pretty good ideas as to some of what may have been going on.

Both the sidelines of a football game and an emergency department can be bustling with action. Things are going on in different areas. Different teams (offense, defense, trauma, radiology….) and their respective coordinators (offensive and defensive coaches, head coaches, triage nurses, nurse practitioners, attending doctors, etc.) are functioning within a larger whole, trying to attain their overarching goal (winning a game, getting all the patients taken care of) while trying to maintain the well-being of each individual (the athletes, the patients). With so much going on, communication frequently suffers. And when people are nervous about speaking up, communication suffers.

Players may have been afraid to “argue” with a coach. They may have assumed the coach knew all the facts. The patient or his family or the nurse he originally spoke to may have assumed the ER doctor or Physician’s Assistant or Nurse Practitioner who discharged the patient had read the travel history and considered the possibility of an Ebola infection. Both situations just needed someone, anyone, to say to the decision maker, “Hey, wait a minute. Do you know that (I hit my head and can’t walk straight/the quarterback looks like he has a concussion/this patient was just in a country with an Ebola outbreak/I just flew in on a plane from Liberia)?”

Systems approaches. Individual back-ups. Individual care. Systems back-ups. All necessary to minimize the holes in the information sieve. Don’t skimp on the systems. But also never be afraid to plug the holes in the systems yourself.

 

The Restaurant With the “Unhealthiest Meal” Does a Lot of Things Right – Go, Red Robin!

In general, mine is a family of food snobs.  My eldest son crossed a school off his college list because “Really, Mom, how can I be in a town for four years that doesn’t even have Indian food?” And those of you who know me (or are at least familiar with me through my writing) know my propensity to push healthy food choices. So it may seem somewhat strange that I’m about to extol the virtues of a burger joint. But it’s actually totally consistent.

As far as general food snobbery, most people like a good burger now and then, and Red Robin makes a good burger.

As far as the healthy food choice thing goes, Red Robin makes it a lot easier than many other places to make nutritionally sound picks.

This past summer, one particular combination of items at Red Robin was called out for adding up to 3540 calories. It included a bacon cheeseburger (with lots of other stuff on it, like battered, fried onions and creamy sauces) with an extra meat patty, “bottomless” fries, and a large milkshake (with an extra refill glass). Anyone could tell you that a meal like that will pack a lot of calories. And fat. And refined carbs.

I am not defending that meal. But I am defending the restaurant.

Red Robin has a full array of meal options, has multiple ways to make your lunch or dinner healthier, and tends not to be financially punitive for healthier choices. Rather than ordering a huge milkshake with a refill included, you may order an unsweetened iced tea. As far as the burgers go, you can substitute a ground turkey burger, a veggie burger, or a grilled chicken breast for no extra charge. You can choose a whole grain bun or even a lettuce wrap for the sandwich (which they do quite well, I must say). If you choose not to have their “bottomless” fries, they do not charge you extra to substitute (also “bottomless”) salad, steamed broccoli, or cut-up fruit. And they have many other meal options, all of which they readily tailor to your specific dietary requests.

I cannot tell you how annoyed I become when a restaurant “punishes” me for trying to choose a healthier modification to their meal. A local trendy breakfast place, when I wanted to skip the large pile of fried potatoes that came with my eggs, charged me $2.50 to instead serve me two completely anemic tomato slices. This was several years ago, and I have not gone back there.

So when a major restaurant chain provides me with choices that include vegetables, fruit, and lower fat proteins, and when they don’t up-charge the healthier options, I say, “Bravo!”

I’m fine with the milkshakes remaining on the menu. It is my choice to avoid them most of the time, and I discourage my kids from indulging regularly in them. But every once in a while, it’s ok if we split a mint chocolate shake. Especially if our preceding dinner had sides of broccoli rather than fries.

The person doing the ordering has the power to determine what they will ingest. Use common sense. Eat veggies. Use olive oil. Drink water or unsweetened iced tea. Save the indulgences for rare occasions, and share them so that there is reasonable portion control. And give props to the establishments that make it easy to do so.

 

A Flood of Problems

Wow.  When it rains, it pours!  Yesterday, our area got between 4 and 6 inches of rain in a very short time, which maxed out our local drain system capacity.  With no room for the torrentially downpouring water to go, the drain system (which combines storm run-off with sewer drainage) backed up into most homes in our city and several surrounding ones. Freeways and surface streets were flooded, cars were stranded, people were stranded, and there was and is a lot of general yuckiness.

I have, sadly, heard of one fatality, but so far most of the consequences of the storm are related to stuff, and not to lives.

However, the “stuff yuckiness,” i.e. sewage-contaminated basement flooding, has the potential to cause more people-harm.  So here are some resources:

The Oakland County Health Department has some great information: http://www.oakgov.com/health/Pages/Flood_Safety.aspx, as does the Red Cross: http://www.redcross.org/prepare/disaster/flood.

Beware of electrical hazards. contact your local public safety and public works departments for guidance.  Contact licensed flood/disaster recovery companies.  If local companies are swamped (no pun intended), call companies from other cities a few hours away – they may be willing to travel, especially if you and several neighbors get together and offer them a bunch of customers.

Even if the flood water looks clean, it has a high likelihood of sewage contamination, so everything should be treated as if it is raw sewage (since it likely is, although it may be somewhat diluted raw sewage).  Bleach is an excellent disinfectant, but it can be fatally dangerous if mixed with other chemicals. If you have a little bleach left in a bottle, and a little Lysol, for example, in another bottle, do NOT use them together in the same area – the chemicals can combine to form highly toxic gases.

Wear gloves and protective clothing.  Don’t track the water through your house.  Make sure you and your family have had Hepatitis immunizations.

I know it’s an awful experience to deal with a flood.  Even if people are ok and it’s “only stuff,” the stuff that needs to be thrown away is a flood of memories, and the costs of repair and recovery can lead to an outpouring of money from your bank account.

Let the air flow and remember to breathe.  Let the love flow – help your neighbors and let them help you.  And buy a sump pump or two….

Step on a Crack…

I recently went to an “admitted student day” with my eldest son at the university he plans to attend in the fall.  On our campus tour, our guide pointed out a block on the ground in the center of campus (which incorporates a symbol of the university) that no one steps on because “stepping on it will cause you to fail your first exam.”  In the winter, it is the first spot to be shoveled out after it snows so that no one inadvertently steps on it.

There is no evidence whatsoever that there is any element of truth to the story.  Of course, it’s difficult to do a double-blind, placebo-controlled study, but perhaps it could be done with blindfolded students in thick, rubber-soled shoes, taken in zig-zag-y paths either around or on top of the block, prior to their first exams.  But I would think that only those disinclined to believe such stories in the first place would participate in the study, since no one would want to fail an exam if they stepped where they believe they shouldn’t step.  The not-stepping-on-the-square is different than protecting the symbol from spray paint or other vandalism by rival colleges.  And people wear this symbol on their socks (which get stepped on, obviously) and on the seats of pajama pants (which get sat on), so the not-stepping-on-it isn’t really out of respect for the symbol.  It honestly stems from fear and discomfort arising from a superstitious story.

A remarkable number of otherwise critically-thinking individuals choose to participate in this superstitious behavior.  Many who do so say that even though they don’t really believe the story, “it couldn’t hurt.”

But that kind of thinking and behavior can hurt.  It ingrains a habit of following superstition and kowtowing to irrational fears  Of ignoring fact.  Of ignoring evidence.  Of ignoring science.  And then people make excuses for the superstitious behavior and try to rationalize it: “I just felt like I shouldn’t step on it,” or “I did it out of respect to people who believed it.”

Full disclosure: I hold an undergraduate degree from this particular institution of higher learning.  And I remember walking on the block.  On purpose.  Before my first exam.  Because I did not want to have to worry about having to focus on where I stepped, and I knew that if I gave in to the story at the beginning, then I would end up becoming a slave to the superstitious behavior.  And I did not fail my exam.  But I remember feeling uncomfortable each time I stepped there (which I did frequently over my years in attendance, purposefully).

I want to explore that discomfort.  Again, I really don’t think it’s a “respect for the symbol” issue, as I and my school-mates never had any problem stepping on, sitting on, or eating over any other versions of that symbol.  I have no doubt that if the story were “step on it and you’ll get an ‘A’ on your next exam,” that it would be the most trampled upon spot on campus.  Or that if the “don’t step on” spot were 3 feet to the northeast of the block, that the northeast nondescript area would be avoided.  My unease really was a bit of a sense of fear.  That I was doing something “wrong” that somehow tempted fate.

Never mind the fact that I understood very well that attending classes, doing the reading, doing the problem sets, asking questions when I didn’t understand something, and studying were the factors which would determine my grades on my exams.  These factors have a proven, cause-and-effect correlation with exam performance.  I know that.  And I knew that then.  And yet the unease…

I think some of this unease has to do with a sense of control (or lack thereof).  I can control whether I do the reading, the homework problems, the studying.  But I cannot control what the professor will choose to ask on the test, whether it will focus predominately on subject matter I understand or on subject matter that’s more difficult for me, or how well others do (which affects the grading curve).  Believing a superstitious story (or acting on it) is an acknowledgement that some things are beyond my control, and it’s an action to try to take a bit of control over the uncontrollable.

And yet this lack of ability to control everything is precisely the reason it is dangerous to fall into the superstitious behaviors.  They have the ability to make us feel like we have control when we don’t, and to make us neglect the factors over which we really do have a lot of power.  The superstitious behaviors can indicate that we’re giving up on the provable, the scientific, the rational behaviors.  And we need to remind ourselves not to do that.  We need to make sure that the fear doesn’t take away our power of rational thought and behavior.  We need to remember that although the rational behaviors do not produce infallible results, they are still supremely more reliable than the superstitious, especially when they are not simply “rational,” but also studied and scientifically/factually verified.  We need not to allow a tiny amount of uncertainty or discomfort to outweigh a preponderance of evidence.

Doctors need to remember that their patients frequently feel a lack of control.  And that patients experience fear.  We need to understand the tendency of many people to feel superstitious.  We need to understand the feelings that drive people to seemingly irrational behavior.  We need to remember that once a seed of fear is planted, it can sprout roots and gain hold.  We need not to roll our eyes when people express fears about vaccines, but we need to acknowledge the sense of unease that a human has when he or she feels as if he or she has incomplete control in a situation, and the fear that person has when someone has planted a seed of doubt and suspicion.  The more we understand our patients, the better we can communicate with our patients, the better we can relate to our patients (and our patients to us), and the more likely we are to be heard and our advice followed.

And all of us need to think about what we are afraid of and why.  When there is overwhelming evidence, for example, of the safety of immunizations and the science behind them, we need to think about why we would be afraid of a a repeatedly dis-proven risk, why we would allow the roots of that seed to take hold once we have figured out that it’s a weed, not a flower.  We need to think about why we feel compelled to buy special water with a “memory” of a magic herb and grow suspicious of “western ” or “traditional” medicine.  Or why we are afraid to step on a specific square on the ground.  And we need to force ourselves to step on that square, so that we reinforce our resolve not to become slaves to irrational thinking and behaviors.  The fact that we do not have 100% control does not mean that we should throw up our hands and disregard a preponderance of evidence.

It’s scary not to have complete control.  But every human is faced with such reality.  It is incumbent upon us not to allow that fear to assume de facto control.

 

 

A Little Privacy, Please

Our privacy is eroding. Some of this erosion is our own fault – we post to Facebook, Twitter, and other social media with reckless abandon. Some is the nature of modern communication – electronic trails are just as easy to find as paper trails (if not easier). Some of the privacy erosion really doesn’t bother me so much – if Target knows that I buy a lot of Cheerios, I’m happy to accept their General Mills coupon for $1.50 off my next breakfast cereal purchase. But there are some places where I expect and demand privacy.

Like in a doctor’s office. Or hospital. Or pharmacy.

But business has so inserted itself into so many aspects of life, including medicine, that my expectation of health-related privacy is being slammed into the wall. Although I really couldn’t care less if Target knows my cereal-buying habits, I certainly do care if they share the information when I purchase a pregnancy test. Or athlete’s foot spray, for that matter. Of course the store has no idea if I’m purchasing health-related items for my own family or for someone else, so it’s unlikely that this information will be used for anything other than targeted coupon offers, but it still really bugs me that people look at this information. And yes, I am aware that I can simply use cash when purchasing over-the-counter wart remover if I want complete privacy on that issue. But the fact that I have to consider it really bothers me.

What price convenience? And what price financial savings? I have a Target Red Card. It gives me 5% off the price of everything I buy at Target. It allows me to return items even if I’ve lost a receipt. It gives me coupons for things I buy. But I read an article a couple years ago that talked about a man finding out that his teenage daughter was pregnant because she started receiving store coupons in the mail for diapers and infant formula after she had purchased a pregnancy test and vitamins. This is a breach of privacy. And it could also cause harm aside from breach-of-privacy with its presumptions. For example, while some couples who purchased a pregnancy kit and then started purchasing vitamins may in fact be delightedly experiencing a pregnancy and happy to receive a coupon for a stroller, a couple experiencing fertility difficulty (or who experienced a miscarriage) might not appreciate receiving constant flyers for baby item sales. It’s one thing if someone actively opts-in or signs up to receive notification of promotions of certain types of items, but quite a different thing to have the automaticity and presumptuousness, and it’s a problem.

There are other financial “incentives” that erode our medical privacy. One that bothers me quite a bit is the extra charge for health insurance that many companies currently impose unless you have a yearly health screening and fill out an online, detailed, personal questionnaire about health-and-safety-related issues. Strange that this bothers me, considering what I do for a living. And considering that I am all about people taking responsibility for their health. And considering that I am all about educating people on health-and-safety-related issues and healthy lifestyles. And that I like when there are resources to help people. And that I understand deeply how addressing certain issues can significantly improve a person’s overall health and well-being (and in so doing, how it can have a positive financial impact as well).

But I figured out what it is that bugs me so much. I actually would have no problem with it if there were the same requirement for a yearly check-up with one’s own physician and if the questionnaire were between each individual and that person’s physician. My problem is with the online, one-size-fits-all survey/questionnaire with detailed, personal questions (many of which have nothing to do with modifiable risk factors) that goes to some random computer algorithm and perhaps some random person (who is not a doctor). Seriously, the lifestyle health coaching company does not need to know when someone’s first menstrual period was – they can simply ask if a woman has discussed breast exams and mammograms with her physician. My issue with the current system of monetarily penalizing those who don’t comply with this invasive questioning is the presumptuousness and the intrusion of someone else into my doctor-patient relationship. There are too many people in the exam room.

By all means, the companies should feel free to offer their support services as an option to those who decide they would like to use them, or to those whose doctors feel they would benefit. But if you are not my patient and you were not invited in by my patient, then get out of my office. And if I did not invite you, then get out of my doctor’s office.

Facebook and the Doctor’s Office

I like a lot of things about Facebook. It allows me to see pictures and video of my nephews and niece and of friends’ children, it quickly lets me know when something big (either happy or sad) is going on in people’s lives, it lets me know what people are thinking about, and it gives me the opportunity to share my own news, thoughts, pictures, or occasional videos with others.

But as much as it allows glimpses into other people’s lives, Facebook doesn’t give complete pictures. Each of us has our own public persona, an image we project to others, which is only part of who we are. On social media that persona is even more deliberate and whittled down. We share the highlights, the good stuff, the proud moments, major life events, perhaps some political thoughts, and when we complain about something we often do so in a humorous light. In our reporting, a lot of us tend to skew positive.

I’ve noticed that people tend to do this in their doctors’ offices as well. Appointments are short. There’s frequently only time to cover a few highlights. People don’t want to be seen as complainers or don’t want to “bother” their doctors. So when coming into the office for a check-up or to address a specific issue, the answer to the doc’s “How are you?” is a smile and a friendly “Fine, thanks!” Not that there’s anything wrong with pleasantries, but if it stops there and concerns aren’t voiced, that can be a problem.

When we’re patients, we cannot assume that our doctor will notice a hesitation in our voice or a look on our face, or experience clairvoyance that will enable her to know that something is bugging us. If something worries us, we need to express it. We need to write down our concerns before our appointments so that we don’t forget them or decide that they’re not really that important.

When we’re doctors, we cannot assume that our patients’ friendly smiles and polite answers to “how are you” questions indicate that they have no concerns. We have to dig deeper. We have to read the review-of-systems questionnaires of 500 symptoms with check boxes that we made our patients fill out before their appointments and address what is checked off as “yes.” We need to specifically ask if there is anything else bothering our patients or if there is any other concern they have about their health. We need to remember the facade that people are used to maintaining.

A visit with a doctor requires, from both sides, more than a glance and a click on a “like” button. It requires human interaction. It requires communication. It requires connection. When a patient is in a doctor’s office, it is because that patient needs something beyond a Google search of a symptom. Even when someone healthy is in for “just a check-up,” that person cares enough about their health to be there, and deserves to be encouraged to share any medical concerns. And a doctor deserves information from his patients so that he can do his job as well as possible.

Appointment slots are brief. They can seem a bit like a Facebook encounter (or in some cases, even a Twitter encounter). But a doctor’s visit is not a social media situation. It needs to be deeper. It needs to address the person behind the post. Interact. Communicate. Connect. I “like” that.

 

Keep Calm and Be Methodical – Pretend You’re Working in an ER

There was a brief scare in our neighborhood this past weekend. Our phone rang. Our friend, who lives nearby, asked if her 12-year-old son was at our house. He wasn’t.

The child had been gone for about 15 minutes. Their family had just returned from a shopping trip with a family friend, and that family friend had forgotten one of his items at our neighbors’ house. The child said, “I’ll run it out to him, Mom.” His mother said, “I think he’s already pulled away,” and the kid replied, “I can still catch him.” As the mother was putting away groceries, she realized it had been about 10 minutes, and she hadn’t heard her son come back inside. She called through her house, went outside and looked around, called her family friend (who had not seen the child since he left her house), and then called us. Her husband jumped in his car to look for their son.

All five of us headed outside while the mom called the police. My husband took one car and left to drive an east-west pattern, and our eldest son took another car to drive a north-south pattern. Our two younger sons went on foot to check local parks. Each of us had a cell phone. I walked to our neighbors’ house, and asked my friend for details of everything that had transpired in the past 15 minutes. Their family friend had returned to their house, and he and I went inside to search the house carefully as our friend spoke to the police officers who had just arrived (small city, quick response time).

I did not think that the boy was in the house. But I looked anyway. It’s a doctor thing. Listen carefully to the story. Figure out the most likely cause. Think of the potential life-or-limb-threatening causes. Respond in a systematic way so as not to miss anything important. Being methodical and systematic also helps keep panic from taking over.

From listening to my friend and knowing the child, my assumption was that the kid had just gone to the family friend’s house. My friend did not think so – it was a mile-and-a-half away, and she said he wouldn’t have any idea how to get there. I still thought it was the most likely explanation. The police thought it was most likely that or perhaps he saw a friend and went to hang out with the friend and forgot to call home. My friend was terrified that her son had slipped on ice and was lying unconscious somewhere or that he had been abducted. I’m a mom – I get it. Same thoughts went through my own head.

The first of her fears was not overly likely, since it was the first warm day in a while, lots of people were outside, and someone would have seen him lying unconscious and called the police. The second fear was statistically very improbable. But those were the possibilities that were most threatening, so people started searching immediately. Why search inside the house? I certainly didn’t think he was hiding, but what if our friend hadn’t heard him come back inside and he had fallen on the basement stairs or been reaching for something on a shelf and had something fall on his head? Not super likely, but you wouldn’t want to have a dozen people searching outside while he’s lying unconscious inside. So you’re systematic. You look. Even when you think someone’s chest pain is likely to be benign and coming from his esophagus, you still check an EKG because you don’t want to miss a heart attack. The kid was not inside the house.

I stayed with our friend, reassuring her that she would probably be scolding her child for his disappearance within the next few minutes. The family friend drove back to his house to look – and saw in his mailbox the item the child had run to return to him. He called. And at the same time, one of the police officers swung by to say that another officer had just picked up the kid and that they were on their way back. We called the driving and on-foot searchers, and everyone came home.

The child was missing for less than a half-hour, but it of course felt like hours to us. Our friends’ son learned the importance of telling someone when he’s going somewhere, and of bringing his cell phone with him. Our friends learned that their child could navigate his way around our town a lot better than they had thought. And we all had reinforced the importance of responding quickly, systematically, and appropriately (news crew hadn’t been called, no Amber alerts issued, just as a doctor wouldn’t go straight to a cardiac catheterization for that patient with chest pain without first checking an EKG and some other basic things).

Breathe. Call for help when you need it. Be systematic. Communicate. Ask questions. And remember that the most likely outcome is indeed the most likely outcome, but take necessary steps to address other possibilities.