MRIs as screening tools

I have really come to enjoy the world of blogs! I was doing a little catch-up reading today of several that I enjoy, and I found a disturbing bit of news on one of my favorites, http://thecountrydocreport.wordpress.com/2008/11/23/today-show-plugs-mri-screening-for-brain-tumors/. This show was aired on 11/17. I don't watch the Today Show, as I tend to get my news online and on NPR, and somehow I missed this story.

Briefly, it appears that there is a push to use MRIs as a screening tool for brain tumors. As the Country Doc points out in his excellent discussion, there are no data supporting this type of use of MRIs. I'm just appalled at the Today Show for airing such a piece! I realize that the mobile MRI traveling around NYC was only charging $169, but that is not a realistic price, just like no-money down house financing...

Our health care system is in shambles; we outspend every other country in the world, yet we have worse outcomes than most 1st-world nations. It seems that finally we may get universal health care, but if it is going to work, we need to make some difficult choices. Fortunately, we have established a few evidence-based guidelines we can use to help make decisions, but we need to use them. There are also studies from foreign countries we can use to help guide us. Please don't get me wrong, I am grateful to live in one of the most scientifically innovative and creative societies! And I do worry that if/when we cut health care spending, some of it will come out of research funding. However, we need to take responsibility and use our limited funds wisely. Perhaps if we place more emphasis on preventive care, we'll avoid some of the huge costs of preventable diseases. I know I'm not saying anything remotely new, but I feel strongly that our American mindset needs to change; in other words, we may not be able to save every life regardless of cost, we may not be able to give every single citizen access to the newest, most expensive, and not necessarily the best drugs! As a medical provider, I share in this responsibility, and it is a heavy burden. I went into the medical field because I like to fix things, make people better, but I too need to accept that there are limits.

The Desert

I grew up on the East Coast, and I always loved all the trees, all the green, the lush green lawns. I also remember driving from Flagstaff down to Tucson for the first time, thinking how brown and dreary the desert was. Shortly after arriving in Tucson, I visited the botanical gardens and started my education about the desert. Slowly, I began to learn the names of desert plants, such as creosote, mesquite, and ocotillo. The more I learned, the more variety I started to see in the landscape. Where I'm going with this is that I have come to love the desert and see more colors in it than in the green landscapes of the east.

Last year, on Christmas Eve, we camped out on the dunes of White Sands National Monument, under a full moon. We were the only ones camped in the park and were utterly alone in the vast expanse of the stunning gypsum sand dunes. The silence was deafening, the light was breathtaking, and the air was sharp. Although we were quite cold, it was one of the most incredible camping experiences I have ever had!

I decided to look up some poetry about the desert to share with my readers, hopefully conveying some of it's beauty and loneliness and power. Enjoy!

The desert has many teachings

In the desert,
Turn toward emptiness,
Fleeing the self.

Stand alone,
Ask no one's help,
And your being will be quiet,
Free from the bondage of things.

This is an excerpt from a poem is by Mechthild of Magdeburg, a German mystic from the 13th century. Although she did not live in a desert, and the desert in this poem is likely not a physical desert, I feel that these first two stanzas of this poem captures the spirit of being in a desert.

The following is a poem by Lord Byron which appealed to me as well!

Oh that the desert were my dwelling place,

With only one fair spirit for my minster.

That I might forget the human race,

And hating no one, love her only.

This next poem is by Bernard Howe, a poet who lives in Tucson, which is part of the Sonoran desert, quite different from the Chihuahuan desert where I live. It is lighthearted and quite descriptive of the terrain.

Way out west where the prickly pear grows,

lived an old man who only had 9 toes.

Seems a javelina wanted one for lunch,

when it got the chance it took it with a munch.

Life in the desert is different from the city,

for out in the sonoran no one gives you pity.

With the hot sun beating down upon your head

if you run out of water the next thing is your dead.

The snakes are hiding quietly amongst the desert rocks,

if your not to careful one may bite you through your socks.

And if that ain't enough there's scorpions that will sting,

then there's monsoon storms that always come in spring.

Yes that old sonoran desert that runs through the southwest,

is home for me old sam the old man thats possessed.

The desert cactus that flowers are pretty to your view,

but if you step on one, the thorn goes through your shoe.

It seems everything grows wild within this here desert,

along with the critters that make sure you stay alert.

But there is still beauty in all of this here land,

like the setting of the sun which is always grand.

Many colored wild flowers cover everything in spring,

the splendor of a sunset which makes your heart just sing.

Yes mother nature protects all that she has made,

and all that lives out here knows where to find the shade.

Yes the desert sage may dry up and become a tumbleweed,

and with a dust devil they can pick up lots of speed.

The road runner runs along like the quail with her young,

and our Native American brothers speak another tongue.

All these things live in harmony along with mother earth,

I hope nothing destroys this for it is beyond any worth.

God made this desert land with all its natural beauty

and we must protect its balance because it is our duty.

The final poem is one that I wrote. Now I put it at the end, with the hopes that my readers don't actually get to it...Poetry is not a strength of mine, and I've probably broken every rule/convention in writing it. It is about White Sands National Monument.

Vast and undulating
Glistening and rippled
Interrupted by lone yucca

The power is overwhelming
The silence roars

I am alone in the vastness
My footsteps are my only past
Adjacent dunes are my only future

Connections

I've been a bit slack with blogging through the holiday, enjoying a break from work, then coming back to a flood of phlegm!! You know how it is when you take off of work, you end up paying for it in spades.

I live in a fairly small town in a state that is not known for it's good schools. I myself was fortunate enough to grow up in areas with excellent public schools, and this was primarily due to my parents' choices of where to live; they sacrificed a lot for us to be able to go to good schools. I also enjoyed school and did pretty well.

Sadly, it seems that a lot of the high school teenagers here are not particularly ambitious and don't work very hard. For example, the first year we lived here, there was no valedictorian in the graduating class because no one had fulfilled the requirement of taking at least three honors classes in four years of school. This was stunning to hear. However, this week I had the pleasure of interacting with a junior who I could identify with a little better. She loves school, is taking the hardest classes she can possible take, and wants to go to college. She hates to miss school, and she feels stressed when she gets behind. It was just such a pleasure to chat with her about school and AP classes! When I saw her a couple of days ago, I felt like we really connected. Today, she came in to see me for some mental health issues, and she was really able to articulate her feelings, and so I felt like I could help her in a way that I can't the teens who simply grunt!

Seeing her reminded me that I do enjoy working with teenagers, I love the conversations, I like listening to their thought processes, I like hearing about their plans for the future. Sometimes I lose sight of this when I have less meaningful interactions, but I was pleasantly reminded today with my last patient of the day.

Paying for labs

Last month, we received news at my clinic from "the bosses" that we were to use only one particular lab company for all our labs except for a few types of private insurance. This news came as a surprise, and the medical providers had not been asked for any input on choosing the company. I was very disappointed, as the one that was chosen just happened to be one of the slowest in processing times. When I questioned the administration about the decision, I was told that they offered our organization the best prices for our uninsured patients. End of discussion. Since there was nothing I could do to change the decision, I tried to improve the speed of processing through our customer service representative. Needless to say, nothing has changed on that front either.

So, I went about my business, grateful each time when I had a patient who had the kind of insurance which allowed us to use a different company. But, then, last week, bammm!!! out of the blue, another dictum. This lab company who had contracted to take on the organization's uninsured patients decided that they were losing too much money on us; understandably, they cannot do thousands of labs for free. And our organization decided that we cannot keep losing money by writing off the bad debt. Keep in mind that we are a group of federally-funded community health centers (CHCs), so we provide healthcare for any and all, regardless of insurance status. The policy on labs now has changed, and our patients who don't have health insurance have to pay cash up front for labs. As a provider, I do have the ability to say that a particular lab must be done, regardless of the ability of the patient to pay. However, someone from my staff has to inform the family of the cost of the lab, ask if they can afford to pay, then let me know if they can or can't, and then I need to note in several different places whether the lab is critical or not. I already try not to do unneccesary labs on my patients since for most kids a blood draw is very frightening, so when I order a test, it is generally very important! I suppose I am disappointed because I chose to work for a CHC so that I could provide care to all. I already have to choose medications by whether they are covered or not by each particular Medicaid program, I often have to get prior authorizations for medications and radiologic procedures!

I am very bothered and saddened by this new policy. Many of the families in this community are already struggling to make ends meet. My worry is that they will stop coming in when word gets out about this policy. Fortunately, most of the children I see are covered by Medicaid, but there is a fairly large population of adults who can't afford health insurance. I also understand that our organization cannot continue to provide essentially free care indefinitely. The patients know that we do not send out bill collectors, and some of them have large unpaid bills. However, if they can come in for preventive healthcare, which sometimes includes labs like lipid panels, we end up saving money on them in the long term. I really don't know what the solution is, except that we need to address the healthcare crisis immediately.

Along those lines, I happened to come across the blog of the country doc, Dr. Cohen, discussing President-Elect Obama's choice of Tom Daschle for head of the Department of Health and Human Services, which seemed quite relevant to me, as I continue to struggle with this new policy. I admire Mr. Daschle, but like Dr. Cohen, I am concerned that he may not truly understand what is going on the ground level of healthcare. Both Mr. Daschle and his wife have ties to healthcare firms. Now, I know that healthcare firms are not inherently evil, but they are businesses which want to make money. I'm also not against making money, but I think that sacrifices will have to be made on everyone's part. I am simply hoping that Mr. Daschle will seek input from all participants in our broken healthcare system, including families, primary care physicians, specialists, pharmaceutical companies, and health insurance companies. We need a comprehensive team approach if reform is going to succeed. As a country, we have a lot on our plate right now, and I frankly don't envy Mr. Obama's position one tiny bit!

Brain Power

When I was eleven years old, one of my cousins had an aneurysm which left him a quadriplegic. He had been in medical school, was an avid mountain climber, and an outstanding violist. He had had some non-specific neck pain for a couple of days, and one night, it was bad enough that his mother took him to the hospital. The short story is that he went to the operating room with the hopes that the aneurysm could be repaired but woke up paralyzed, on a ventilator. This really impressed me, as he could speak, but he had to use a computer to write, using his tongue to move a cursor. Ever since then, I have been afraid of a similar thing happening to me, especially after learning about multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) a few years later. Of course, when I was a first year medical student, I had every disease we learned about, including MS and ALS! Fortunately, I survived intact.

For those of you who may not know what ALS is, it is a rapidly progressive and always fatal disease which attacks the nerve cells that control voluntary motor function. Eventually, the upper motor neurons (those in the brain) and the lower motor neurons (those in the spinal cord) stop working, so messages do not get transmitted to muscles, and the muscles eventually shrink and waste away. Oddly enough, most patients retain control of bladder and bowel function, eye muscles, and the senses of smell, taste, hearing, and touch. Usually patients die within three to five years from the onset of the diagnosis, although approximately ten percent live for ten or more years. For more information, I found the website from the National Institute of Neurological Disorders and Stroke to be very informative.

These memories of worrying about various illnesses came back to me last week when I watched the CBS news show, Sixty Minutes. There was a segment called, "Behind the Scenes: Brain Power" (http://www.cbsnews.com/stories/2008/11/04/60minutes/main4570731.shtml) which just blew me away. It focused on a neuroscientist by the name of Scott Mackler from the University of Pennsylvania. He was diagnosed with ALS, and the disease has progressed to where he is ventilator-dependent and unable to speak. However, he is now able to communicate using Brain Computer Interface Technology, which basically allows a person's brain to be connected to a computer using EEG electrodes attached to a cap which is placed on his skull. So, in order to write a letter or to speak, Dr. Mackler looks at a computer screen with flashing letters, and the computer writes the letter that he is thinking of. Absolutely amazing!! The neuroscientist who was "locked in" by his disease now can write journal articles and goes to work in his lab where he conducts research. The story also talks about a woman, Cathy, who suffered a brain stem stroke which left her only able to move her eyes and with some facial expression. She volunteered to participate in a clinical trial where the Braingate system was implanted directly into the motor cortex of her brain. Cathy is able to move a cursor on a computer screen by thinking about how she would move her hand; she is able to turn off lights, for example, using this technology.

Advances in the science like this are always so exciting to me. Yes, I'm a nerd, I know. But the potential for this Braingate technology is limitless, and there are so many people who could benefit from this. Obviously, it would be even better if we could find the causes of neurodegenerative diseases so that we could prevent them, but even if we did, it could be used for stroke victims, accident victims, and many others. I am concerned that with our healthcare system in shambles, along with our economy, that funding for research will be cut, but I hope that our amazing, creative, dedicated science community can continue to thrive somehow.

I'm back! It's been a busy few weeks since I last wrote, between an onslaught of strep throat infections at work and the election, I'm utterly exhausted! Even though the election was decided fairly early on Tuesday evening, I was up too late because I was too stirred up to go to sleep. I was so excited but also apprehensive about our future as a country. Anyway, I'll stop talking about the election, since I have no new and/or amazing insight to add to all the discussion, except that I am very proud of the people of the United States.

On a completely different note, I had a patient this week that reminded me of Stuart from MadTV. For those of you who don't know what I'm talking about, here it is:

http://www.youtube.com/watch?v=U02xbYhhjxQ

My patient was a little younger, fortunately, and I was not thrown out of the window, only because we don't have windows in our exam rooms. But his mother just stood there and watched, then reinforced his behavior by comforting him. She then proceeded to threaten him with a shot if he wasn't good, asking me to back her up on that!! The boy had already dismantled the exam room and managed to pull down almost all the stickers off of our sticker boxes...all this within the first few minutes before I even walked in. The first thing he did, actually, when he arrived at my office, was set off the fire alarm in the patient bathroom. As soon as the alarm went off, I knew he had arrived - it's one of his favorite things to do!

This boy can be well-behaved, I've seen it. When he comes in with his grandmother, he's fine. We've come to an agreement with the physical exam: he holds the stethoscope for me on his chest, I hold it when I listen to his lungs; he holds the otoscope with my hand on his, same goes for the ophthalmoscope. So, needless to say, when I see how he behaves with his mother, it frustrates me. When I ask her about it, she explains to me that his feelings get hurt when she disciplines him, so she's given up. I offered her a session with our social worker to help her understand how she can be her son's friend but also his mother...she was interested, now we just have to see if she shows up; until then, I can only hope that he comes with his grandmother!

We all have our Stuarts, be they children or adults. Sometimes we can work with them, sometimes we can't. They can be difficult to examine, and I always worry about missing something, a murmur for example, when I have one of these wild screaming ones. But, when I'm ready to pull my hair out, I just think about Stuart, and I start to laugh, and think, in his voice, "I can do it...."

ADHD and Nature Walks

I was perusing the NY Times today when I came across an article on Tara Parker-Pope's blog on wellness about a small study conducted at the University of Illinois at Urbana-Champaign about nature walks for children with ADHD.

Here is a quote from her blog which can be found at http://tinyurl.com/5lqqhm

"A small study conducted at the University of Illinois at Urbana-Champaign
looked at how the environment influenced a child’s concentration skills. The
researchers evaluated 17 children with attention deficit hyperactivity disorder,
who all took part in three 20-minute walks in a park, a residential neighborhood
and a downtown area.

After each walk, the children were given a standard
test called Digit Span Backwards, in which a series of numbers are said aloud
and the child recites them backwards. The test is a useful measure of attention
and concentration because practice doesn’t improve the score. The order of the
walks varied for all the children, and the tester wasn’t aware of which walk the
child had just taken.

The study, published online in the August The
Journal of Attention Disorders, found that children were able to focus better
after the “green” walks compared to walks in other settings."

I did not find this discovery to be at all surprising. This was a suggestion given to me when I was diagnosed with ADHD, and it's one I always recommend to parents. Whether a child is on medication or not, I recommend twenty to thirty minutes of outside play immediately after school before homework. Unfortunately, not all parents seem to believe me that it works. I am happy to have a study, be it small, to quote, rather than only my own experience.

For myself, I have learned that I am able to focus much better when I get home when I have gone for a run, once I recover a little...To help motivate myself, I like to sign up for races, it gives me something to work towards; if I don't, then I can come up with one hundred excuses not to exercise on any given day! I cherish my runs outdoors, breathing in the fresh air, having quiet time without interruption, and working my muscles. I also get a mental boost from the sense of accomplishment.

On a different note, I worry about "kids these days," to sound like an old lady. Most of them have such busy schedules, going from school, to soccer, to music, home or out for dinner, then homework. Does anyone play kickball on the street anymore after school? Does this over-scheduling have something to do with the increase in the diagnosis of AHD? I also wonder what happens to some of these kids when they get to college, and suddenly they are in charge of their time after classes. Do they know how to allocate their time wisely? I don't know, but I'd love to hear from some readers!

last debate

Two nights ago, I watched the last debate, more out of curiosity than a notion that I might hear something new; I wanted to see how Sen. McCain behaved in light of his declining popularity. Sure enough, neither candidate said anything particularly new and exciting, and each one responded to the other in much the same way they had in the previous debates, one with an awkward chuckle, the other with utter calm and poise.

However, I, along with Orac, a fellow blogger (see http://tinyurl.com/4a695j), was puzzled by McCain's discussion of autism. Orac, along with others, felt that this was pandering to the "autism-vaccine" people, as well as an attempt to make up for previous incorrect statements about vaccines. I suspect that this is true. But what I found particularly strange was this focus on Gov. Palin's understanding of autism...because she has a child with Trisomy 21? Or does McCain get the two diagnoses confused? They couldn't be more different! I realize that children with autism and with Trisomy 21 both are considered to have special needs but to assume that a parent of one is an expert on the other just doesn't make sense. Maybe he didn't realize that this discussion which he inserted into a statement about reform (and again, how is this related???) would cause a negative stir.

Both as a pediatrician and as a former early interventionist, I am extremely interested in education, including early childhood, special education, and regular education (if you can call it that!). I have been listening carefully to what the candidates have been saying about this. Wednesday night, Sen. McCain proved again to me that he doesn't know much about the topic and that he doesn't really care much about it. Although Sen. Obama hasn't spoken a lot about special education, I am thrilled with his interest/belief in early childhood education. Sadly, with a rotting economy and the "war on terror" to pay for, I don't know how much can truly be done about it, but I think it is a wise investment, even in this economic state. I like Sen. Obama's idea of getting parents more involved, although I don't really know how he can enforce that. But, how can we continue to be a world leader if our educational system is in a similar state to our economy? Certainly, a spending freeze would do nothing for the state of education, it might even diminish Gov. Palin's ability to get early intervention services for her son....Now I'm rambling, so I'll stop. We all know that our future president has an enormous task in front of him (or her, heaven forbid) and will likely not be able to accomplish all his goals, I just hope that the vision of a brighter future will motivate people to go out and VOTE!!!!!

I thought this video from The Onion was quite amusing, helps lower the blood pressure after listening to these debates!!



Latest Poll Reveals 430 New Demographics That Will Decide Election

drug samples in pediatric offices

This morning, as I was catching up on the news in between patients, an article in the NY Times caught my eye: http://tinyurl.com/42ttru. Upon seeing the title, I immediately thought the article would address the issue that drug samples do not come in child-proof containers; however, it actually addresses another serious issue with drug samples which is drug safety.

The pharmaceutical industry gives samples to physicians generally of the latest, "greatest," most expensive drugs. These often have not been tested on pediatric populations yet. This is quite concerning when one considers some of the black box warnings which end up coming out, as happened with Elidel, among others. It is attractive, however, for physicians to use the samples they are given, but difficult for the family if the drug works and they then have large co-pays to cover. I have to admit that, working at a community health center, I don't see much in the way of pharmaceutical representatives, except for those representing immunizations. The majority of my patients have medicaid, so I stick with those formularies as much as possible.

I would like to bring up the point I made earlier, though, and that is patient safety of sample packages. Our pharmacy encourages us to put all samples in child-resistant containers, print out a label like with a regular prescription, which has exact dosing on it, and to print out the drug information to hand the family with the sample. Now, if that sounds like a lot of work, it is, especially when I am the pharmacist dispensing the sample while seeing a full load of patients. Yet, I think it's worth the time to prevent an accidental ingestion. For example, one of the few samples I have is chewable Singulair. This comes in a foil push-out packet (I don't know the official term for this type of packaging). If a child gets a hold of one of these packets, it would be very easy to play with it and pop out one of the yummy pills...chomp chomp. Fortunately, this is not a terrible dangerous drug, but nonetheless... Do most offices dispense samples using this tedious process? Or is there a simpler way of doing it? I am open to suggestions. It just strikes me as odd in this litigious world we live in and especially as safety-conscious pediatricians, we allow this to continue. Perhaps we need to start bugging our friendly pharmaceutical reps! Any takers?

Investing in a turbulent stock market

These are rough, interesting days on the stock market. Up until fairly recently, I was only vaguely aware of what was going on the market but didn't really think it affected me directly. I learned about the history of NYSE when I went to see it in action when I was still in elementary school, and it was still a very busy floor with men in suits running around like chickens with their heads cut off. I hear it's a bit different now with modernized computer systems! Then, as a senior in high school, we "traded" stocks for two weeks in my government class, buying stocks and following them in the newspaper. It was a fun game, or so I thought, again with no real consequences. I also remember Black Monday in 1987, talking about it in government class and seeing adults walking around with furrowed eyebrows. But I was a teenager who was more concerned about college applications and crushes on boys...

Come college, I happily took a variety of classes - there were so many interesting topics to choose from! I took language classes, geography classes, history classes, I even tried music theory, which I absolutely despised. I started off pre-med, so I also enrolled in chemistry and biology classes. I eventually became a French major, having tired of science classes. Did I ever take an economics class? No way. Sounded too boring. Perhaps if the department could have come up with some sexy titles to the courses, I might have, but I'm not even sure then because that was a section of classes in the course guide that I pretty much skipped over.

As you can guess, I eventually ended up in medical school. I attended a school with a very innovative curriculum which included a block at the end of our fourth year with classes relevant to residency, such as medical Spanish, yoga (to help us relax through those grueling intern years), and I honestly don't remember what else. We did have a lecture on paying off our loans which basically gave us the message to pay them off as rapidly as possible, to keep living like a resident after residency in order to make large payments on our loans. Certainly that was sage advice, but that was it for our financial education.

Needless to say, residency was about the same. Our daily noon conferences was excellent medical lectures. Each year we were given a talk on choosing a job which included learning about different types of malpractice, head hunters, and helping involve one's spouse in the decision. Very helpful, but again, not much about how to handle the money we were about to start making. Can you see a theme here?

So, I eventually landed in my first job. I signed on the dotted line to put the maximum amount of money I could into a retirement account because my parents had taught me that saving was a good thing. I chose the default funds to put my money into. For whatever reason, I didn't consult my husband on this choice, I think perhaps because I was overwhelmed by all the paperwork I had to fill out on my first day of work, and I figured that I was being guided in my investment decision by someone who knew more than me. And, as you can gather, I didn't know a whole lot. And my husband would have been an excellent resource.

Happily, the first few years, the economy was still relatively strong, although to an astute observer, there were signs of the current problems. As I started hearing about the stock market losing losing losing, I decided to take a look at my portfolio. Yikes. I had the feeling that this was going to be baptism by fire! The glorious 90s were over. Ignorance was bliss. Since then, I have made the effort to educate myself on the art of investing. I say art, because unless you are completely invested in index funds, there is an art to it. I just finished an informative book my father-in-law sent us called, "The Little Book of Common Sense Investing," by John Bogle, the founder of Vanguard. Although I prefer to read novels in bed after a long day of work, I read this book cover to cover. It was actually pretty interesting and well-written, without too much jargon for a lay person like me. Mr. Bogle focuses on the index fund, his own creation, which has gained many supporters in the financial fields. Basically, this is a fund that owns the entire stock market, thereby minimizing risk, and also, by owning a little bit of everything and not actively buying and selling stocks trying to guess who to invest in, there are low costs associated with it. This is investing for both the non-investor who doesn't have the time and/or skill and/or luck to buy and sell stocks daily, as well as financial wizards like Warren Buffett and John Bogle himself. It is a beautifully simple plan. And the book, although focusing on this particular type of fund, also teaches the reader about other types of investing. I highly recommend it. I obviously still have a long way to go, but I am an active learner now. Honestly, I would still rather read about neurofibromatosis than finances, but I also realize that I would eventually like to retire, preferably before the age of ninety...

The moral of this story is that perhaps some basic classes on investing could be incorporated somewhere into our education. The challenge is that there is just an amazing fount of knowledge we already have to acquire in medical school and residency. Where would this fit in? Maybe we could have quarterly lectures on it during residency or medical school. Many of us become physicians "to do good," not just to make money, and frankly, these days, there are other fields to go into to make money; but there is no reason we shouldn't have the resources to be wise with what we do take home. We work hard for our money, and it should work hard for us.

not too much

Just a quick note from Colorado! I'm at my District VIII meeting, being awed by the work that pediatricians all over my district are doing. It's both inspiring and motivating to be surrounded by leaders in the field. It's also comforting to hear about the struggles they face that I too face, I am not alone!! I'll have lots to report when I get back, new resources, new websites, new ideas. For those of you who may not know what District VIII means, it is a district of the American Academy of Pediatrics, and it includes Alaska, Hawaii, British Columbia, Alberta, Washington, Oregon, Montana, Idaho, Utah, Wyoming, Nevada, Colorado, Arizona, New Mexico, and Uniformed Services West. It's the largest district geographically and obviously quite diverse.

Sorry this is short, but I have limited time!

primary care shortage

All the buzz in the media and on doctor blogs in the past day or two has been the announcement that, according to a survey published in the Journal of American Medical Association, only 2 percent of graduating medical students are going into primary care, primarily due to poor salaries and increased workloads. TWO PERCENT!!!!!! That is just frightening to think about, especially from the viewpoint of an already busy rural pediatrician. We, as primary care physicians, are already pushed to see as many patients as possible by our reimbursement schedules. I know that I am getting busier every season than I was the last. This year, my "slow" period consisted of approximately two weeks of slower days, then we picked right back, last year, my "slow" period lasted closer to one month; this year, I'm already seeing winter time numbers with school having been in session only for a few weeks....I'm afraid things will only get worse.

How about talking about solutions to this problem?! Neither candidate is addressing this specific problems. Then again, nobody is really asking them to. I have a proposal: mandatory one to two year service in primary care medicine prior to specialization. In other countries such as New Zealand, they have general practitioners (GPs) who tend to the primary care needs of their citizens. Perhaps we could do something like that here in the US. I have just recently completed my service time for the National Health Service Corps and although that system is severely flawed, it could be used a loose guide. I am now free to do a fellowship, if I so desire. I've learned a lot from practicing this kind of remote primary care medicine, and I think this type of background would serve me well were I to do further training.

This is by no means a perfect solution, and I'm sure I'm not the first to suggest it, but perhaps it could get people talking if it were put out on the table. I know that we, as physicians, already go through many years of training, and some would groan at an additional two years, but how else will we take care of an increasing population of baby boomers?? We cannot simply rely on foreign medical grads. We cannot rely on the whims of medical students. And, at least at this point, we cannot rely on improved salaries to draw medical students to primary care.

health care

Today, I was reading another physician blog, http://acountrydoctorwrites.wordpress.com/, in between seeing patients (my charts were calling but I ignored them for the moment). One of his recent stories was entitled, "Choices in Swedish Health Care." In it, he discusses the socialized system of medicine in Sweden, a system somewhat similar to other socialized ones. This topic has been on my mind lately, especially with the election looming in November. Perhaps I shouldn't use the word "looming," but I am very concerned that a president will be elected who has not even mentioned the word health care.





I spent one month working at a pediatric clinic/hospital in New Zealand in 2004, another country where everyone has basic health care. It is also somewhat tiered, in that there are some options for faster care through a private-payer system. One of the big problems there, as in Sweden, was waits. There is, however, a fairly strong medical tourism trade with Australia, especially for people needing radiation therapy for cancer; people who can afford to live temporarily in Australia are able to start their therapy more quickly. At the time I was there, these waits were being addressed by the government, so hopefully, things have improved.





However, as we all know in the US, many people go without health care due to lack of health insurance. And, even those with insurance risk bankruptcy with a diagnosis of cancer, or a chronic health problem. We spend the most on health care of any first-world country, yet we have the poorest outcomes. What gives? Is that our technology is so advanced that we try to save those who likely would die in other countries? Is that our fees in health care are completely out-of-line with the rest of the world that we are just simply paying/charging too much? Is it the fault of the drug companies who make enormous profits are drugs that cost too much? I suspect it's a combination of all these and other factors.



The bottom line, for me, is that if we, as a country, feel that health care is a right and not a privilege, we need to be willing to make sacrifices, to change how we as doctors are paid, and to change how we as consumers define health care.

change is in the air

I love this time of year. The sunlight is already beginning to have a fall quality to it, the air smells fresher, and the nights are cooler. Change is definitely in the air!

When I first started this blog, I had plans to start a new job this coming winter, however, due to circumstances largely outside of my control, I will be continuing to practice here for a while. As you may know from reading my previous blogs, I do primarily outpatient care; our local hospital is ill-equipped for inpatient pediatric care. I worked hard as a resident to learn hospital medicine, and I'm afraid I'll lose those skills. So, I've decided to do some prn work as a hospitalist in Albuquerque. I am very excited about this, which is a little surprising to me, since I was very happy to leave the hospital as a resident. However, now that I've been away from that environment for some time, I really miss it! I had an interview last week, and it just brought this fact home to me. I like the challenge of these patients, I love the newborns, and it will be enjoyable to be around other pediatricians and pediatric support staff for a change. I think I'll learn a lot, I will refresh my skills, and I'll bring a unique perspective to the group, coming from a rural setting. I'm ready for this change/challenge.

olympics

I have to admit, I've spent a fair bit of my free time watching the Olympics during the last couple of weeks. I love to watch and dream of being in the shoes of the athletes, pushing myself to get another gold medal. If only I had been a better swimmer or fencer or soccer player, I could just have been there!! Or not!! But I do feel like a kid again when I watch the games. And when I can myself out of bed in the morning to go for a swim before work, I imagine I'm competing, until I notice that I'm the only one in the pool and that I'm not exactly breaking any records. It's still fun though to think there are serious athletes who enjoy doing what I'm doing.


Doing my sprint triathlon a few weeks ago, it was pretty neat knowing that I was doing a miniature version of what an elite group of Olympians was doing on the same day. I was also frustrated when my time was slow...I should be faster, better than this, I thought, yet I didn't exactly train religiously! But, like the athletes, I too have spent some time training heavily to do what I do, and, to do it well, I continue to train reading journals, etc. I also enjoy participating in activities outside of work/training, like spending time with my husband, cooking, reading, traveling, and working out as I continue with my medal dreams! So here's a salute to all the regular working people who compete in their own Olympics every day, walking the balance beam of work and family, running 10000m of errands after work, doing a triathlon at work of seeing patients, completing administrative duties, and completing paperwork, etc...it's a silly analogy, but true if you really start to think about it! Now, if I could just get a set of abs like they all seem to have!!

kids with autism

Last week, I read an interesting article in the newspaper about a family with a child with autism who was asked to stay away from their local church's services. There were a variety of opinions expressed by parents of children with autism regarding this event. Some parents felt that this kind of behavior on the part of the church was discrimination, and particularly galling because of where it was coming from; some felt that it was irresponsible of the family to take their child into a setting which is known to be challenging.

I spent a summer working at a camp for people of all ages and abilities with autism. I also worked in a group home for five men with autism and did some research on the topic. Having experienced the enormous range of abilities or disabilities, I was wondering what I would have done in the above situation. My gut reaction would be to find a church that had a service that was perhaps adapted to my child, and such a church was mentioned. I think I would be hurt that my family was rejected. Then again, some of the behaviors associated with autism can be very challenging to handle in public. And, they are not always predictable. I remember very clearly on a Saturday taking one of the group home residents to see a children's movie, an activity he loved and had worked hard to earn. When we got to the theater, there was a line to buy tickets, and my friend/charge absolutely went ballistic, throwing himself on the ground in the parking lot, swearing (fortunately he was very difficult for most people to understand!), and kicking. This was completely unexpected. I was able to calm him down eventually, get him to come with me to the car, and we came up with another outing where an outburst would not be quite so embarrassing. However, he was allowed to earn another outing to a movie and did quite well. All of us at the group home would have been very sad to take this activity away from him.

I loved my time working with this challenging population of people, and I still enjoy the children with autism that I have in my practice. But I have to admit that it is one of the most difficult diagnoses to deal with as a physician, as an early interventionist, as a caregiver, and I'm sure as a parent.

border medicine

A few weeks ago, I had a new patient in my office for a routine sick visit. I heard a significant murmur that was worrisome to me. When I questioned her mother about it, if it had ever been evaluated before, she said she knew nothing of a murmur in her daughter. The rest of her exam was normal, except that she was a bit small for her age, but both her parents are somewhat short. After doing a chest xray and ECG, I decided to send her to see a pediatric cardiologist for further evaluation. No problem, I thought, since UNM conducts an outreach clinic only 75 miles south of here once or twice a month. I was all set to have this appointment made, when I remembered that I needed to ask the family if they could travel south. You see, there is a border patrol check point between my office and Las Cruces. I don't keep track of which of my patients and/or families are here illegally, but at times like this, I have to be careful. Needless to say, this family did not want to travel south; they would rather travel twice the distance north to avoid the check point. Unfortunately, that isn't always safe either as there is a border patrol station north of as well, although it is only open on rare occasions. Happily, on this occasion, they were able to drive to Albuquerque and back without incident.

What a situation for this family to be in!! Both parents work, and their children go to school and do well in their classes; they are contributing members of society and the economy. But they live in constant fear of being deported and separated from their children who are all legal citizens. Yet, the parents did enter the country illegally, breaking the law. And so, some might say, they deserve to live like this, constantly watching their backs. I have very mixed feelings about the whole immigration issue, and, living here, it is something that is frequently on my mind. There isn't an easy, pretty solution. We rely heavily on this population for the work that they do. Mexico relies on the enormous amounts of money these workers send back home. Our economies are intertwined beyond repair. Will building a wall from California to Texas fix the problem? Doubtful. Do we offer citizenship to all immigrants who have already come here and are working? Not likely to happen. Maybe the official guest worker program that Bush suggested would work, although it too is very complicated, expensive, and unlikely to be adhered to. I really don't know. I do know that Mexico is an incredible country with many natural resources, a strong tourism industry, and a strong textile industry. Perhaps Mexico will continue to try to clean up it's house so that it is a more desirable place for it's citizens to live, so that they will not be willing to undertake the incredible risk and often the incredible financial cost to cross their northern border seeking a better life. We don't see Canadians crossing illegally, do we?

dental care

I have to brag today. I work in a remote area with few healthcare providers. BUT, we have a dental clinic associated with my clinic with two full-time dentists, two hygienists, and a few dental assistants. Because we are a federally-funded community health center, we accept all insurances, all medicaid plans, and we have a sliding fee scale for those without insurance. In addition, our dentists here can refer children to a pediatric dentist 75 miles south for care.

The other day (actually more like a month ago), I had a little girl come in to see me with poor weight gain, decreased appetite, and overall grumpiness. She had indeed gained very little weight in the past year, and I couldn't argue with the mother about the grouchiness! I did a full exam, and the only thing I found was obvious dental caries. On further questioning, she did complain of pain with eating sweets and cold foods. I called the dental clinic, and they worked her in immediately. Two weeks ago, she had dental surgery under anesthesia. I saw her on Monday, and not only had she already gained weight, but she was so happy. Needless to say, her mother was thrilled. And she immediately took the bottle away from the fourteen month old who was still drinking milk at night from it; I had been begging her to do this for months, but to no avail. What a relief! I really feel like I made a difference to one little girl and to her little sister!!

a first for me

I just finished my first triathlon! Hooray! It was a sprint triathlon, but, nonetheless, I did it. I'm proud of myself because I'm not an earlier riser, and I had to train for this before work because of heat and monsoon rains in the afternoon. Not only was it fun, in a painful sort of a way, but I had the chance to talk to some interesting people. The lady in front of me for the swim and also at my bike rack was a 63 year old woman who appeared to be in excellent shape. All I know is she finished before me, as I saw her back multiple times...There was also a kids triathlon before the adult event, which was a blast to watch. Oh, the race faces they put on, so intense and focused, I would have loved to take any one of those little athletes home with me. I may see if we can arrange for one of those around here next summer to give the kids a goal to work towards; I know that helps motivate me.
Anyway, I'm pretty tired, and I think I'm still a bit dehydrated, so off I go to my water bottle and to dreams of faster races...

physician responsibility

Today, I was reading Dr. Rob's blog, Musings of a Distractable Mind (http://distractible.org/2008/07/30/do-you-trust-your-doctor/) concerning the doctor-patient relationship and trust. I agree that there are many components to this relationship, it is definitely not as simple as I think it used to be! We, as physicians, are under time and insurance constraints, we worry about malpractice, and we worry about keeping up with the most recent advances. As patients, we look up information on the internet, we worry about costs of our visits (co-pays, deductibles, etc.), we worry about our illness of course, and we often have to wait to be seen which can make us grumpy. Doctors no longer are the all-knowing father or mother figure. I think this is a positive change! I like to get input from families when I come up with a plan, of course, only if they agree with me! No, seriously speaking, I do try to review my plan of action with the parent(s), especially when I don't know what illness I am dealing with. I also make it clear that I don't know, I don't try to hide that fact.

All this aside, it still hits me when I realize the trust that parents do place in me. I had young parents in this week with their two year old who they worried had west nile virus. After carefully listening to their concerns (she had vomited a few times the previous day and had a decreased appetite) and carefully examining the child, I reassured them that it was unlikely that she had this disease; they left my office clearly relieved. The little girl was happy, playful, afebrile with a completely normal physical exam, and did have a few mosquito bites. I am very grateful that her parents trust me, but as usual, I worry at 3 am about my conclusion that she was OK. What gives me the "power" to say, "I think your child is fine, I think she has the same viral illness that many of her friends have right now, and she has a few mosquito bites on top of this?" Yes, I know, four years of medical school, three years of residency, and a few years of practical experience. But, wow, that's a big responsibility we have as physicians! It's just something I didn't really think about during residency because there was always an attending backing me up or correcting me, now I'm it! It's a tremendous honor to do this work, yet it's also a burden/challenge/constant worry. Perhaps I can relax with a few more years of experience under my belt....we'll see!

healthcare costs

Yesterday, I saw two patients and received a phone call about a third one with mosquito bites. No fever, no pain, just itching, no concern for WNV. The parents wanted me to fix the problem. I was a little bit confused about how to fix it, as I am not an exterminator. I recommended kid-safe bug repellent and topical vinegar for the itching. Recently, I had a pre-teen come in with a pimple on her face. One pimple. I saw another child who had sneezed a few times, really. But doc, she doesn't usually sneeze. Of course, I can come up with zebras that these problems may hide as. I also know I am not alone in seeing such patients. But something all of these patients have in common, and I could give many more examples, is that they do not have co-pays for office visits, they have medicaid. Our taxes pay for me to see the 11 year old with the pimple. At least she didn't go to the emergency room.

I may be crucified for saying this, but I really believe that all patients should have to pay a co-pay, even if it's only 2 or 3 dollars (less than a pack of cigs or a bucket of soda from the local convenience store). Perhaps this will make some people stop for a few seconds and consider if their child really has a problem that needs to be addressed by a physician. A two dollar co-pay is still a bargain, and certainly less than people with private health insurance have to pay. Our health-care costs in the USA are spiralling out of control, and we are not doing much to address this problem. These small co-pays could perhaps help, even just a little, with reducing our costs, and these days, every little bit helps. Such visits are a waste of time, money, paper, and gas for the family to get to the office! I know that what I think is scary may not be scary to parents and vice versa, but really. Mosquito bites, zits, a few sneezes, a fleeting moment of achiness, I say YARRRGGGHHHH (but I can't say that to my patients!).

obesity weighs heavily on my mind

I was reading the NY Times online today, catching up on news of the world around me. In the past 10 days or so, there has been a series of articles about doctors counseling patients about weight loss (http://tinyurl.com/63d9zh). I was definitely intrigued by the headlines, as I was recently told that I was mean to my overweight patients; I am honest with my patients. What was more interesting to me than the articles themselves were the comments. The basic idea is that overweight and obese people know they are overweight and don't need another lecture. I can see that, although in my office it tends to be the parents who already know their children are overweight, and are often overweight themselves. But I still feel that it is important to show the child (depending on the child) and the parent(s) the growth chart with the BMI plotted. Maybe in doing so, I am being too harsh. Yet, I feel that if my concern is health, I need to address the topic in a frank way. I do ask families how I can help, and I try to refer them to a nutritionist, if available; when necessary, I check a lipid profile. I can think of other things I would like to do, like change school lunch menus, get kids in daily physical education classes from kindergarten through 12th grade, and teach parents how to cook in a healthful way, but we don't have the resources. I do as much as I can to offer solutions, like cutting out the ramen noodles and flaming hot cheetos! But I also ask parents not to keep unhealthy snacks in the house. Just the other day, I had a parent tell me that it makes her 107 pound five year old son sad when she goes to the grocery store and doesn't come home with ramen noodles, and I suggested that that was OK that he was sad, that she could perhaps just make them as a treat once in a while. My patients know though that I am their loudest cheerleader when they start exercising and watching what they eat, even if they don't lose weight right away.

transparency

Well, I'm back after a bit of hiatus, due to weather. Yes, weather. It's monsoon season in the Southwest, and often during these bouts of turbulent weather, we lose our internet service. We're also getting a Walmart, and the construction has frequently interfered with our internet service, our phone lines, and our power. Today, for example, I nearly fell onto an infant because the lights went out right as I was walking into an exam room where an infant was sleeping peacefully in his car seat on the floor. One of my colleagues, a dentist, was drilling in a tooth when the lights went out! Bummer! I'm really glad I was not her patient at that moment.

I've been enjoying reading another blog, http://www.ruraldoctoring.com/, written by a family physician in rural northern California. I find her posts interesting and relevant to my work. Recently, she discussed transparency, as it pertains both to medicine and to blogging. Every time I write a post, I think about HIPAA and about my own privacy; I know that I feel like I am exposing myself, my thoughts, etc. But Dr. Chan makes an important point in her writings: "The goal of transparency is a greater common understanding of how processes work, so that special interests and self-promotion cannot corrupt the system." I agree that by writing about medicine and how it affects our lives, we are not only promoting understanding, but we are promoting our humanity. One of my colleagues here who is a physician's assistant told me that I always seem confident when I talk about my patients or when I answer her questions about pediatric patients. This surprised me, as I am most definitely not always confident; I worry about my patients, often waking up at 3am thinking about one or two particular kids, second-guessing myself. I know I'm not alone in this. I am acutely aware of my responsibility practicing in a rural area, however, because if I miss something, it's a really long way to a proper hospital facility. I have learned to be honest with my families, and I frequently ask them to come the next day and the next day and so on if I am unsure of where an illness is going. They too, I think, understand that when I do that, I'm trying to do the best for their child, either by closely monitoring therapy, or by following a fever to determine whether an antibiotic is needed or can be avoided. I sincerely hope that the patients whom I serve feel that I practice in a "transparent" fashion, just as I try to write these posts with candor!

Immunization Alliance

Yesterday, I posted about the AAP's current focus on parent education on immunizations, since it was voted the No. 1 resolution at the ALF in March. Today, I opened my AAPNews for July, and what's on the first page? A great story about the development of the Immunization Alliance. For those of you who haven't seen the article or who don't receive the magazine, I'll sum it up. This is a working group of fifteen members, including people from the AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Public Health Association, the Association of State and Territorial Health Officials, Easter Seals, Every Child by Two, the Immunization Coalition, the March of Dimes Foundation, the National Foundation for Infectious Diseases, the National Vaccine Program, Parents of Kids with Infectious Diseases, Rotary International, and Voices for Vaccines. They hope to come up with an effective media campaign that addresses parent fears and increases confidence in vaccines. This team is aware that the campaign needs to address a parent population that is comfortable using the Internet as an important source of information and that time is of the essence. I now that I, for one, will be eagerly awaiting their media campaign, especially now that Guardasil is in the news too!

The Onion: Sources Warn Miley Cyrus Will Be Depleted by 2013

Silly!

Hannah Montana

A few months ago, it feels like years ago, I had the privilege of attending the Annual Leadership Forum of the AAP. For those of you unfamiliar with this, this is the yearly planning session where leaders from chapters, sections, and councils get together and come up with goals for the AAP Board of Directors to consider. (That is a very basic summary of what the ALF is; for more info, contact your chapter!) It was a fascinating and tiring few days. There were many resolutions, arguments, and, of course, lots of voting. Topics ranged from RSV prophylaxis to ATV regulations; some seemed nit-picky, others seemed very relevant.

One of the most important discussions, from my perspective, revolved around how the AAP is going to address the apparent increasing resistance to vaccines. Do we need a celebrity, like Hannah Montana (this was suggested by one of the participants), to help us with our cause? Or do we need to show parents scary videos of what the diseases are that we are protecting their kids against? More pamphlets? Less Oprah? How do we, as pediatricians on the front lines, tackle this issue?

When I was in residency, I took care of a teenager who died of subacute sclerosing panencephalitis from measles that he contracted when he was nine months old, most likely from an un-immunized person. This was one of the most heartbreaking deaths I dealt with during my training for many reasons, but mostly because it was potentially preventable. I also participated in the care of a little boy with disseminated HIB. In my practice, I use these examples when I talk to parents. I spend a lot of time discussing the fact that un-immunized children are a danger to others, not just themselves. Unfortunately, as we all know, some parents will simply not be swayed; I have them sign consent that they refuse vaccinations after receiving education and VIS sheets on each vaccine they refuse and re-visit the issue at the next visit.

What is the best approach for us as individuals and as an organization? I don't know. But I do know that I keep plugging away at the resistance I encounter, and I keep hoping that I can maybe get through to one family!

And, just as an aside, I found a funny story in The Onion about Hannah Montana, which I couldn't resist attaching just to lighten things up a bit!

Musical MDs

I've decided to have a theme each week, at least for a little while, to see how that goes. So, since my first post of this week had to do with Mozart, I'll continue with music.

When I decided to go into medicine, I had always imagined I would join a doctor's orchestra. There are several in the United States, including Houston, Los Angeles, Boston, New York, Washington, DC and Philadelphia, based on a google search. They are extremely common and well-respected in Europe. I did wonder, though, whether rehearsal would sound more like a symphony of pagers going off than Beethoven!

I feel that medicine and music fit well together, and I can understand why it is a common hobby among doctors. Both require attention to detail, looking ahead, and a good ear. I think I had an easier time learning to auscultate in medical school because I was used to attentive listening and to blocking out noise around me. I also think memorizing music throughout my childhood helped me academically. I also learned the discipline I needed to stay focused in medical school. As a ten year old, this discipline came by the command of my parents; usually, I would have preferred to stay outside and keep playing kickball rather than go in and practice, but I didn't exactly have a choice.

I am attaching a video, I hope, of one of my favorite cellists, Pablo Casals, playing one of my favorite pieces of chamber music, Beethoven's Piano Trio No. 7 in B flat major, opus 97, 1st movement. How cool is that that it is posted on YouTube!!

Pediatricians and guns

I was listening to NPR the other morning as I was getting ready for work, and I heard about the Supreme Court decision regarding Washington DC's gun restrictions. I immediately started thinking about the AAP reaction to this news, and sure enough, there was already an email news alert waiting for me in my inbox when I got to work.

I live in an area where many, if not most, people have guns at home; in fact, I suspect my entire AAP district, district VIII, has a fairly high gun ownership rate, as it includes Wyoming, Montana, Alaska, Washington, Oregon, Idaho, Utah, Nevada, Colorado, Arizona, New Mexico, and Hawaii (although I honestly know little about gun ownership there). Some of my patients hunt regularly with their parents, and other families keep guns for protection. I address the topic daily, using any teachable moment I can to ascertain which families are aware of gun safety, and which are not. I cringe when I hear about the loaded gun under the pillow. Any gun in the home is a potential weapon, a tool for suicide, altogether a danger.

During medical school and residency, I took care of several children who were the victims of accidental shootings. One teenager in particular comes to mind. He and his brother, who were well-versed in gun safety and had various guns of their own, decided to clean their dad's shotgun as a surprise to him. Unfortunately, there was a shell in the chamber, and in the process of cleaning, the one brother accidentally shot his brother's eye out, nearly killing him in the process. Their parents were horrified at the carelessness of the one boy because they had taught them about gun safety, but they were home alone, unsupervised.

This was a tragic accident. I feel strongly that, even with "trained" children at home, guns should be kept in a safe that only the adults have access to. In other words, we should try to eliminate access to guns in unsupervised situations, although I am aware that accidents also happen when an adult is present. I also believe that there are types of guns that should not be sold to private citizens. However, what irks me about this whole issue is that children are exposed to many dangers all the time, and we don't have that knee jerk reaction that we have with guns. We've all had parents tell us that they would never have a gun in the home because it's not safe, yet they smoke in the home and allow their children to get out of their carseat because "they just won't stay in;" these are all potentially detrimental to the health of their child, and I try to make that point with the families.

I suppose that my point is that we, as adults, need to protect our children by putting them in car seats, by locking up guns, by feeding them healthful foods, by locking up the bleach, by immunizing them, etc. I know nobody disagrees on this point, I just wish that we would put as much effort into some of the less obvious dangers that they face as well!

physician health

As I discussed in my last post, I've been spending a fair bit of time reading other blogs, some pertinent to medicine, others not. It is quite striking to me the number of doctors who discuss having ADHD themselves and how they've learned to cope with it. With this in mind, I did some research to try to find the incidence and prevalence of ADHD in physicians, to no avail. There is a wealth of information available on the internet for parents of kids with ADHD, for physicians who make the diagnosis or treat patients who've been diagnosed by another medical/mental health professional, for adults with the diagnosis, etc. Even on pubmed, there is nothing that I could find.


However, that point aside, there is very interesting information on doctors as patients. We are taught early on that our job, as physicians, is to take care of other people, not to become sick ourselves. We refer patients to mental health professionals, but we don't go ourselves; if we have back pain, we tend to take some ibuprofen and keep going, perhaps not always the best approach! There is a book, "When Doctors Become Patients," written by a psychiatrist from Columbia University Medical Center, Dr. Robert Klitzman, discussed in a NY Times blog from February, 2008: http://tinyurl.com/5d8h4d. I haven't read the book yet, but I would definitely like to. He discusses what he learned himself from illness, not just the misery of waiting for several hours to see the doctor, as many patients do, but communicating with the doctor, and especially, accepting the he himself was not invincible. I know that for myself, I try to do my own "doctoring" when possible, rather than to go see someone. Part of that is that I don't want to accept that I too become sick, and part of it has to do with living in a small town where I feel I need to go out-of-town for care for privacy issues. It's just interesting to think about this topic, that maybe we need become better patients ourselves to become better doctors. I am not suggesting we wallow in our times of illness, but to be aware that we can learn from these experiences and use them to improve ourselves professionally.


Please excuse me while I go on a hunt for this book! And, thanks to Andy for the hint of the shortened URLs!!

As I'm new to this world of blogging, I'm learning a lot, which absolutely thrills me. There are lots of blogs by physicians out there; however, there is one in particular I enjoy reading: http://scienceblogs.com/insolence/2008/06/when_psychics_attack_autistic_children.php#more
The author is an eloquent surgeon and his ramblings are fascinating. Needless to say, I feel as though my posts are rather childish and mundane compared to his.

He posted a story today about a mother who was reported to "the authorities" for concern for possible abuse, based on a report by a psychic that the adolescent's educational assistant had gone to see the night before. Yes, a psychic. Do check out the site, as the full story is unbelievable! Now, we've all heard that psychics/astrologists and the like have apparently been consulted by various occupants of the White House, but to base a report to child authorities on this seems absolutely insane. I understand that we live in a world where harm can come to children, unfortunately, and all of us who work with children, be it as teachers, doctors, school bus drivers, whoever, need to be vigilant, but we must use our common sense. This particular story had a happy ending for the family, but I imagine that that is not always the case when a false report gets filed. I worry about both ends of the spectrum - missing a case of non-accidental trauma or sexual abuse AND giving a false, or what turns out to be false, report. Obviously, the latter is preferable in the long run for the child but can be devastating to a family. Anyway, I'm not saying anything people don't know, so I will stop.

I am thrilled to be part of this blogging community. I'm looking forward to seeing how other people's minds work and to becoming another rambling physician....

Father's Day

Today is Father's Day, a day where families across the US are celebrating with cook-outs, watching the NBA finals, or just relaxing. These days, unfortunately, I only get to reminisce about the fantastic father I had. He was an extremely intelligent, well-educated, well-spoken man who was a loving father and husband. Although he was a nuclear physicist, he knew classical music very well, and he loved geography and history. He survived multiple harrowing experiences in WWII but then had tremendous opportunities after the war. He spent time in the Sahara Desert doing research, as well as two trips to the North Pole. After meeting my mother, he did work at several particle accelerators both in Europe and the US.

But on Father's Day, and nearly every other day, I remember him as a caring father who, despite being the traditional man who ruled the roost, encouraged his three daughters to become anything they wanted to, there were no limits for what we could do. It's kind of funny, but he preferred my mother not to work but to pursue the old-fashioned role of a mother, a la June Cleaver, but for his daughters, he was different! He taught us how to chop wood, change tires, mow the lawn, etc... All of us loved to help him in his woodshop when he was building furniture for our family.

English was not his first language, and he always struggled with idioms, a problem that he passed on to me. He loved to discuss one of his favorite books, Nothing Doing on the West Side, aka All Quiet on the Western Front. He also bragged about having quit smoking "dead duck." We were always amused by his sayings, although, as I mentioned, I learned well from him and can't get an idiom straight myself. He kept his charming accent throughout his life, along with his ability to speak multiple languages.

Today, I celebrate what he passed on to me, a love of nature and the outdoors, a love of music and literature, and a strong will (which when I was a teenager he called pigheadedness!). Even though he died nearly six years ago, I think of him nearly every day, and I will always miss him. He was a wonderful role model, and I wish I could have shared him with more kids!

dealing with parents

I just read an interesting article in the NYTimes, http://www.nytimes.com/2008/06/10/health/views/10case.html?ex=1213761600&en=ef2909e401d524f0&ei=5070&emc=eta1. I think all of us have families with challenging members. I know which families are non-compliant, which ones go to the local emergency room to get the antibiotics that I wouldn't prescribe for their colds, which ones treat themselves first with medicines from across the border, and which ones just plain don't like me. These relationships can be difficult because I come to dread the visits - I see their names on my schedule, and I immediately feel on the edge. But I have also had the wonderful opportunity to see some of these interactions change for the better. I work hard to communicate, to explain my thinking behind my actions, and my office staff also works very hard at it. The author talks about the mother not believing in preventive care, which is our middle name, and that interfering with his relationship with her. Would he fire families who don't immunize? I doubt it. This group of patients frustrate me no end, but I encourage them to keep coming to see me, so that at least their children are getting care when they're sick. I wouldn't dream of "firing" them, even though their beliefs are so opposite mine.

Sadly for my patients, I'm all they've got; if they don't like me, then they have to drive 75 miles up or down the interstate to find another pediatrician. And with that in mind, I would not feel right for taking the author's position and firing the patient because I don't like his mother; if they fire me despite my efforts to establish rapport, so be it, you can't please everyone!

ADHD

Oh how these four little letters can stir up so much debate!! Speaking of debate, I won't address politics anymore; it made me feel too weird. Next time I am lacking ideas, I'll simply talk about the weather or nail polish colors.

So, do you think this kid in the cartoon was actually listening to Dad reading the story, or thinking about the DVD he watched, the new video game he learned, etc.? But he clearly has a skill, even if it's one his parent doesn't have!

As a pediatrician, I get lots of questions from families, friends, and patients about ADHD. Having worked in early intervention in the 90s when the diagnosis was becoming quite fashionable, I had a non-medical perspective, one that was more influenced by families and preschool/daycare teachers. From this view point, I saw children who were quite intelligent, but parents and teachers had a hard time working with them due their distractability and/or inattention. These children were often in classrooms with many children, some typically-developing, some with special needs. The challenge in the classroom was huge. As an early interventionist, I would try to work with the teachers and the child in the classroom to help them learn to work together. Often, I would request that a child be put in a smaller class or a different center all together. However, this was not always an option.

Then, I went to medical school. In my pharmacy class, I learned how the different stimulants affect the brain and the body; I obediently learned the different dosing schedules, half-lives, metabolites, etc. I was exposed to pediatricians who felt that the diagnosis was a farce, an excuse for poor parenting and teaching, as well as pediatricians who were committed to the diagnosis. During residency, I worked with one pediatrician who felt that pharmacotherapy was most indicated when a child's self-esteem was affected by the ADHD - this has really stuck with me, and I continue to use it as a guideline in my practice.

Now I am a pediatrician, simply with a background in early intervention and special education. I was also diagnosed with ADHD during medical school, in case you hadn't guessed already! I love taking care of these patients who tend to be quite imaginative and often questioning of authority; it is incredibly rewarding, yet quite frustrating at times. I spend a lot of time discussing non-pharmacologic ways of dealing with ADHD, including regular exercise, good sleep hygiene, healthful diet, and strength-based learning, as illustrated by the cartoon at the top of this blog. However, as we all know, these strategies don't always work; parents do not always have the option of putting their child in a private/charter/alternative school, and homeschooling can be difficult as often the parents have ADHD themselves. And incredible results can be obtained sometimes with the right medication, in conjunction with everything else. Ultimately, my goal is to teach kids how to cope with school and ideally to excel in school, how to live with rules, and how to navigate in a tremendously busy world with many distractions. Unfortunately, I know that some will try self-medicating, some will struggle with depression, but I remind myself that with help, many can be successful, bright, innovative leaders.

There are lots and lots of resources out there for ADHD, but here is a website that I find is a good place to start: http://www.help4adhd.org/index.cfm?varLang=en.

politics

I am just not feeling very inspired, so I'm stuck writing about something that has had me fired up for several months now, even if it is political.

Is anybody else confused and annoyed by the presidential campaign of Hillary Clinton? Maureen Dowd, in yesterday's NY Times, wrote an excellent op-ed column on the subject. Then I heard on NPR this morning that she and Bill will host a party on Saturday night in Washington, DC, which will officially "suspend" her campaign. What does that mean? Does it mean that she'll be ready to go in case Obama changes his mind and decides that he doesn't want to be president after all? I agree with the democrats that they need to focus on unifying the party to improve the chances of not only winning the presidency, but also winning seats in both houses. McCain has had the full support of his party for several months now, and even though the race between Clinton and Obama has somewhat overshadowed his campaign, he has been able to focus on his and his party's ultimate goal.

Anyway, now that I've discussed my political views with my readers, I feel better. Maybe this post will prompt some discussion!

overcoming loneliness

It is an amazing, if at times, terrifying, experience to move to a rural practice after residency in a major children's hospital. My first few months here were spent studying for the boards, getting to know my organization, the paperwork, etc. However, after about six months, the loneliness set in. Not personal, but professional. I would attend meetings at our local hospital and with the whole organization I work for, and I'd be looked upon as a bit of an oddball, which I might be, but you know what I mean! Why would I want to work with kids and their annoying parents? What was wrong with me? Of course, I look upon all of them and wonder the same thing! Obviously, my readers likely understand why I chose pediatrics. Who else gets feathers and interesting stones from five year old boys? Who else gets to dance around the office with a giggling two year old? But that's beside the point!

I make it a point to attend CME meetings, rather than only online CMEs. This is gratifying because I feel energized after a meeting, and it's pleasant hanging around with other pediatricians for a few days. I have also been fortunate enough to have another opportunity come up. As a member of the Section on Young Physicians, the SOYP, I received an email that the section was looking for people to run for the executive committee. The election was to be by district. I jumped at the chance, and to my great surprise, I was elected to the post.

I now am involved with the AAP on a national level, as well as at a district level and state. My first task was to attend the District VIII District Meeting. What a great experience! My district is the largest in country, and it includes NM, CO, UT, AZ, WY, MT, ID, OR, WA, NV, Hawaii, Alberta, BC, AK, and Uniformed Services West, so the district meeting brings to gather a variety of pediatricians from all types of settings. They discussed resolutions, chapter triumphs and challenges, and we had the opportunity to meet the candidates for AAP president. What an incredible treat! I felt so much more connected after the meeting. The SOYP executive committee itself is an inspiring group of docs, and I feel honored to be a part of them.

The bottom line is, I now I have a group of pediatricians across the country that I feel I am a part of. I also feel that I am an active member of the AAP, not just one who pays dues and gets monthly journals. This is something that I hope to keep up with, even when I get too old for the SOYP (which is sooner than I care to think), and even when I eventually leave TorC to join a practice with other pediatricians and professional loneliness is not such an issue.

For any of you who are not familiar with the SOYP, we are the largest section in the AAP, and we are composed of members who are in their first five years of practice and/or under 40. Here is a link to our website: http://aap.org/ypn/yp.

off the subject

When people come visit New Mexico, it seems they often go straight to Santa Fe and/or Taos. These towns have a lot of to offer in terms of history, culture, interesting architecture, and much more. However, the state has much more to offer the interested traveler, especially the pueblos of the Native Americans. I bring this up because I went to a gallery in the northern area of Albuquerque, the Bien Mur Indian Market Center in the Sandia Pueblo. Their website, www.bienmur.com, is a good starting point. I bring this up not to advertise for this market, but to tell you about an experience I had there. Periodically, there are artists who come to the gallery and work on their art as people stroll through. This particular Memorial Day weekend, a Navajo artist by the name of Hosteen Etsitty was there. He does sand painting, an art form I had never been particularly enchanted by. However, I was drawn to the table where he was working so quietly and methodically on a complex painting with an incredible array of colors. His son was next to him, also working on a sand painting, though much simpler in content. We started talking to Mr. Etsitty about his work, and he explained the symbolism most eloquently. He talked about the spirituality of the world and our spirituality. He talked about interesting art shows he has done with Buddhist monks who also do a form of sand painting called mandala; he talked of his journey as an artist, starting with training from his elders starting at 17. Rarely have I heard an artist be able to describe the spirit of a work, not just the symbolism behind it (Wynton Marsalis is an example of one who has that gift). However, what struck me most, was the incredible attention his son gave to his father while he was speaking with us. I am sure he has heard his father address the topic of his art and spirituality before, but the obvious respect in his expression was incredible. I grew up being told to respect my elders, but on Monday I saw that in action like I never have before.

The image of the father and son together has stuck with me and inspired me to work on becoming a better listener and to listen beyond the spoken word. I would also love to be able to impress on the teenagers in my practice that their parents may have much more to offer them if they can just listen. I suspect all of this sounds trite, but in the high-speed world we live in, I think it is relevant to think about.

we're off!!

Thanks for the comments! It's pretty exciting to see that some people have found the blog. Then again, it is somewhat obvious on the PedJobs website! Please do understand that everything in this blog is just my opinion, so I can enjoy saying things like, "Go Red Wings!!!" I'll try to stay away from politics, although as the election draws near, I may not be able resist making some comments.

In my days here in TorC, I take care of children of different ethnicities and widely varying home lives. My staff and I have some frustrating days when people don't show up for appointments, or when phone numbers given on one day have been disconnected the next, but we have learned together to laugh about as much as we can. We also share stories with each other which allows us to blow off steam or to celebrate happy events. I have started to write down some of the funnier ones, so that I can go back and look at them and laugh or cry. One of the reasons my husband and I chose to move here was that we felt it would be the most interesting place to serve my time, and it hasn't disappointed.

I want to share one of the more amusing stories in particular with you. It was during my first few months here. A fifteen year old girl came in with respiratory complaints. Since this was my first time meeting her, I asked if she was a smoker, which she was, about a pack a day. I asked if her parents smoked, which they did, then I asked if her siblings smoked as well, which, of course, they did. Then, being a smart alec, I asked facetiously, "does your dog smoke too?" to which she responded, "she eats the butts we throw on the ground." Yikes. I guess that's what I get for trying to be funny!

Well, I need to stop for the day. I am still getting used to the idea of this blog. Next time, I'll have more to say about some job issues which are quite relevant to me at this stage of my life.

Hello!

So, here we go! My first blog post ever. Big, deep breath. I feel like I'm on a first date or a job interview. At least when I'm writing, you can't hear the nervous wobble I get in my voice or see my kneecaps quiver (I didn't know that was anatomically possible until I gave my first presentation at a conference).

Let me give you a little background into my life. I am currently working in Truth or Consequences, NM, as the first and only pediatrician they've ever had in the county. And yes, it really is called that, although locals just call it TorC. It was named after a gameshow in the 50s hosted by Ralph Edwards - the producers put out a challenge to the country that they will film an episode in any town that is willing to change their name to Truth or Consequences, so Hot Springs jumped at the chance. Needless to say, we have a lot of people drive through town just to say they've been here. We also have a large psychiatric population, with some patients telling me they settled here because, "it was time to accept the truth or face the consequences." When I hear this, I think it might be time to go back to the old name. Check out the town website: http://www.truthorconsequencesnm.net/

Anyway, I digress. I came here because I am a National Health Service Corps scholar, and I had limited job options due to their restrictions. This area qualifies as severely underserved. As such, I have had an amazing, interesting, and at times, quite frustrating experience here. I trained at Primary Children's Medical Center in Salt Lake City, a lovely hospital with lots of pediatricians, all types of specialists, and an incredible staff trained in pediatrics. Then I came here, the only pediatrician for miles and miles, with the nearest pediatric specialists being 150 miles north in Albuquerque, and some specialists 75 miles south in Las Cruces. It's been baptism by fire. Thank goodness for the PALS line at UNM, the internet, and my sister who is a pediatric intensivist at Oakland Children's and who has answered a few desperate phone calls with questions on sick kids!

That's my introduction. I have lots more to say, but I suppose I shall do this in installments, like Hemingway did with his novels in Esquire magazine, not that I am even remotely comparing myself to Papa, ever.

Looking forward to next time!