Thursday, July 31, 2008

physician responsibility

Today, I was reading Dr. Rob's blog, Musings of a Distractable Mind ( 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!

Wednesday, July 23, 2008

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!).

Friday, July 18, 2008

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 ( 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.

Thursday, July 17, 2008


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,, 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!

Thursday, July 10, 2008

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!

Wednesday, July 9, 2008

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


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!

Thursday, July 3, 2008

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!!