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.

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.

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.

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.

Our 13-year-old woke up feeling lousy two days ago. He had a sore throat and sinus pressure, and felt really tired and generally icky. He didn’t look toxic – just a little tired. I gave him a Cold-Eeze zinc lozenge and told him to get ready for school – a method that generally can tease out exactly how bad one of my kids feels. He just sat at the table. We generally adhere to the “unless you have a fever, are actively vomiting, or have blood squirting out of your ears, you can go to school” policy, but there’s been a particularly hard-hitting virus going around the neighborhood, so I figured I’d keep him home – no need to infect others if he was in a particularly germ-effusing state.

He had awakened at 6:30, and by 7 he was back in bed. He slept until 11, and then got up, gargled with salt water, ate a little rice, and worked on a math assignment his teacher had e-mailed to him when we told her he would be out sick that day. Back to sleep by 12:30. He woke up again around 3:30, had some chicken noodle soup, was back in bed within an hour, and woke up again around 7, when he was feeling well enough to join the family at the dinner table (where his 16-year-old and 17-and-three-quarter-year-old brothers joked that we never would have let them stay home without a fever, to which my husband and I smilingly responded that that was obviously because we love the 13-year-old more). He went to bed for the night at 9:30, and woke up yesterday morning feeling completely fine.

He doesn’t normally sleep for 18 hours total in a 24-hour period, so my powerful doctor-sense (or “duh”-sense) tells me his body really needed some rest to fight this thing off. Or maybe it was the zinc lozenge. Or the salt water gargle. Or the chicken soup. Or maybe he would have been perfectly fine by yesterday morning even if I had made him go to school the day before. There’s really no way to “know” for sure – I can’t do a prospective, placebo-controlled trial of each of the possibilities on my child, so my medical decision making was not “evidence-based,” nor is my conclusion that I did the correct thing based on rigorous academic study. It is based on common sense. A generally healthy 13-year-old who felt yucky and exhausted stayed home and slept and felt better the next day. No need for antibiotics or any other “big guns.”

Much of the art of medicine lies in knowing when a little time and rest is needed, and when more is needed. Sometimes, as Voltaire said, “the job of the doctor is to amuse the patient whilst nature takes its course.”

This morning I went for my annual mammogram. It’s not something I generally look forward to. In fact, I mildly dread it.

In my personal experience, mammograms have ranged from quite uncomfortable to downright painful. And then there’s the general unpleasantness of standing topless in a cold room. The first time I had this screening imaging study done, the plate pressed so hard into my sternum that I was almost in tears. Other times, the plates have dug into my ribs or my sides, or my skin has been pulled too tight in various directions. A few times, I needed to repeat a shot or two because I was told that the radiologist needed another picture because the first wasn’t compressed enough.

Last year when I went, I wanted to avoid the need for repeat pictures. The tech told me to let her know when I couldn’t take any more squeezing. So I just gritted my teeth and let her keep tightening. And she kept going. My breasts felt bruised and sore for weeks afterward. And one of the views needed to be repeated anyway.

So I really didn’t want to go today. But I did. Although there is some controversy as to the ideal timing between screening mammograms at different ages, my doctors recommend an annual schedule and from the studies I’ve seen, I agree that that’s a reasonable plan for me.

So I went to my appointment. And when I went into the room with the technician, I followed the advice I give my clients and that I’ve always given my patients. I talked. I voiced my concerns. And I was lucky to have a fantastic person taking care of me.

As she led me to the room, she spoke to one of the nurses about what room we were going to and where we would head afterward so that I would be seen efficiently. I commented on how she really had everything streamlined. When we entered the room, rather than keeping my mouth shut and worrying about being seen as “a complainer,” I told her about my past painful experiences, because I didn’t know how to get the appropriate level of squish without being injured (believe it or not, they don’t teach us that in medical school).

She told me that the re-takes that I had done in the past were likely not because of inadequate compression. She said that when the radiologist sees a little something that doesn’t look quite right, they get another picture to make sure, but so as not to alarm people they tend to say something that indicates the positioning or compression for the film wasn’t good enough, and on the repeat views they generally determine there’s nothing worrisome. She taught me that maximum compression doesn’t mean the best picture – there’s actually an ideal level that you can tell by the firmness of the skin on the compressed breast.

She performed the most comfortable set of breast x-rays I have ever had. And nothing needed to be repeated. And I wasn’t even cold, because instead of having me remove the gown completely, she pulled off one sleeve at a time and tucked the gown into my waistband so that most of me was covered and warm. Did I mention that this person was amazing? 

None of this, by the way, was special treatment or “professional courtesy.” I never told her that I’m a doctor. We simply spoke to each other as we would want others to speak to us. I was honest. She was honest.

I have her card – and I’ll be sure to schedule next year’s appointment when she’s working. I also plan to relate my experience to the people who run the department. Everyone should have a mammography experience like the one I had today, every time. No need to freeze. No need to endure painful squeezing. But someone does still need to work on a lighter adhesive for the nipple markers…