Dr. Fix-It

by Rob on March 24, 2009 · Comments

in Being a Doctor, Personal Musings

(+4 rating, 4 votes)

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Sometimes I wonder if I am really helping people.

Patients come to me wanting me to treat their pain, relieve their depression, improve their focus, and generally to take away the hard things in their lives. They want me to find out what is “wrong” and do something to “fix” them. That’s my job, after all, to make people better, cure diseases, and take away pain. Right?

I am not sure that is always the case. I used to think there were very few reasons to withhold an antidepressant from someone who asked me for one. I figured that they knew how they felt better than I did; and who was I to force them to continue to feel that way? It’s always worse to feel bad than not to feel bad. Right? As time went on, however, I noticed several things:

I can never totally take away someone’s pain. There are always negatives in life – good things are jaded with the fact that they must end. Aside from total sedation, I can’t remove all pain.
Some people define bad things much differently than I do. Some parents are upset when their child gets B’s; some people want medication for a respiratory infection immediately; some people want pain medications when they pull a muscle in their back. What constitutes enough pain or a bad enough situation to merit intervention?
Seriously bad things in life often result in significant good. The struggles I’ve had trouble overcoming have made me far more empathetic to patients who struggle themselves. Cancer patients often say that the disease made them realize what stupid things they spent their lives worrying about.

I had attention deficit/hyperactivity as a kid – there is no doubt about it. My grades weren’t great – I got mostly B’s, some C’s and some A’s. I never “reached my potential” because I was too interested in messing around with my friends and too easily taken off task. I sometimes wonder what would have happened if I was medicated. It certainly would have given me far more success in academics. I probably would have gotten into a better college and probably a better medical school. I wouldn’t have developed the self-doubt that has followed me throughout my childhood and into adulthood. That’s good. Right?

But self-doubt is a very important thing. It keeps me from running off at a diagnosis rashly by forcing me to second-guess myself. I have seen enough failure that I don’t take success for granted. I am much more grateful for what I have, not thinking that I somehow deserve it. I really think that many of the lessons I learned from failures are exactly the things that make me successful as an adult. I wasn’t treated for ADHD, but I am now a successful physician who writes an inexplicably popular blog. Hindsight says that medicating me would have been a mistake.

This makes me wonder how many kids I am treating are like me. Am I keeping them from learning the important lessons that struggles can teach? It’s impossible to know, but I suspect that some would probably be better left untreated.

Another example of the desire for quick fixes is the use of cough/cold medications in children. As some of you know, I was really annoyed when the FDA discouraged the use of them in children under 3. I have done pediatrics for over 18 years and have not even seen a hint of harm from these medications. I have four children and all of them got cough/cold medications – it made them feel better. It made me feel better to treat them. I thought the FDA was just silly to take them off the shelves.

But I was wrong. It’s been a year since we stopped giving kids these meds, and I have seen no significant problems. Parents seem content with the explanation: “They just need to have their body fight this off.” The kids seem no worse for the wear, and the parents are actually more accepting of sickness as normal. Just because you can do something doesn’t mean you should.

One of the hardest things for many parents to accept is that it is not only OK for their kids to get sick, it is important. If we put a bubble around a child and prevented exposure to all contagious diseases for the first 18 years of their life, we wouldn’t them strong; we’d weaken them. This is a dangerous world we are in, and our bodies have to be good at dealing with that adversity.

The same could probably be said with emotional hardships. Do we really do kids well by protecting them from struggles and even failure? Maybe we are just surrounding them with a bubble.

Obviously I am not suggesting that disease, depression, or ADD should not be treated. I do treat it and feel I am doing good for many of my patients. But I do struggle with those in the gray zone – ones who would have never been considered for any treatment a decade ago. Everyone is getting a diagnosis and is being treated. Everyone has something broken that needs fixing. Is there such thing as a normal person? It’s far easier for us to hear that we have something that needs to be treated than to be forced to face hardship.

This is a very difficult line to draw, and I suspet it will only get harder.

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Josh

Dr. Rob,
I'm a parent of a handful of rugrats, and I, too, have a child that could probably be diagnosed ADD/ADHD, but have chosen to not get him diagnosed or medicated. Having seen other children medicated for this, I feel that it takes away from their personality, and I kind of like his. Also, as an amateur student of history, I think that if most of the geniuses of the past had grown up in today's society they would have been medicated out of most of their more amazing discoveries - Einstein and Mozart come to mind.

On the subject of children's medication, I know that a cold will go away in a week to week-and-a-half when treated or 7-10 days when not, so wasn't too upset about the change in recommendations and availability. I've also seen that certain illnesses are necessary for development of immune systems, physical coordination, and even mental ability. We even have a name for such critters - we call it "the FUO (sounds like flu): Fever of Unknown Origin" and only when it's severe do we run to the pediatrician.

Dr. Smak

Dr. Rob,

Great post. A lot of us struggle with this....isn't life full of a normal amount of pain, be it physical or emotional? I think that we as a society, largely through the entertainment industry, get the impression that a perfect life exists out there, and if we don't have it, something is wrong. Happiness is about expectations, and if yours are set too high, you are bound to be disappointed.

Depression and anxiety are real and debilitating illnesses. But as with ADHD, I feel that I treat people who likely are just going through some ennui. Is it helping them, or hurting them?

Smak

Rob

Tara: I think your perspective on this is probably clearer than mine. I do think that seeing hard things in our own lives makes it a little harder to stomach some of the demands for borderline problems.

Liz D

Great post, Dr. Rob.

Now I am a grandmother and I'm working with other folk's kids who struggle in school.

Relative to your comments about cough/cold medication: one thing I notice is that today's parents lack practical nursing skills. In other words, they don't know how to reduce a sick child's discomfort without medication. Instead of using petroleum jelly (or similar) to prevent a runny-nosed chid's nose from chapping, they want a medication to stop the nose from running. They don't have a clue about keeping a feverish and congested kid well hydrated. Examples abound.

Relative to your comments about ADD/ADHD: I'm for medication when it is in the best interest of the child, but the demands placed on the child also need to be examined. My oldest kid was in 5th grade 20 years ago. The demands placed on most 5th graders today, in terms of executive function, were similar to the demands placed on 9th graders 20 years ago. Yes, some kids can meet the demands, but (IMAO) we are setting kids up to fail (and to perhaps earn a label/diagnosis) because school is asking them to perform management skills beyond their developmental means. I'm not talking about academic content (although I have complaints there, too) I'm talking about mere "stuff". Keep track of these papers. Have these materials with you. Shift focus smoothly and efficiently. Stay seated. Respond to open-ended, undefined queries.

Children and the need for failure/discomfort -- my sig line used to bear the maxim: Success -- fall down six, get up seven. Failure is an essential part of the learning process. Toddlers know this instinctively as they struggle to master the new skill of walking. Somehow this has been processed out of modern approaches to childhood.

The first of the Four Noble Truths of Buddhism is often translated as "Life means suffering". The other three can be interpreted as a way of saying, "you can control how you respond to the things that happen to you, in such a way that your equanimity isn't controlled by outside events."

Back to ADD/ADHD (and other conditions) -- some fortunate folk learn how to "do" executive function on the fly. Others need more explicit, direct instruction, with lots of opportunity for guided practice For some, the explicit, direct instruction is enough -- others need both medication and explicit, direct instruction. Medication alone is rarely the answer.

peggikaye

The same could probably be said with emotional hardships. Do we really do kids well by protecting them from struggles and even failure? Maybe we are just surrounding them with a bubble.

My sons both have TS/OCD.
My oldest, when learning about them at 8 years of age (now 19) exclaimed "I'm normal in my abnormalities!"

That's been our family motto ever since. They are normal for 2 kids with tourettes. They act like kids with OCD.
I'm normal for someone with my issues (ok, as normal as I can be)
My husband is normal for someone with his.

It's NORMAL for a child with TS to make weird noises and move their heads. (yes, they were both treated for a while, neither are now, when it interferred with life processes, we treated, now it doesn't, we don't)

It's NORMAL for a child with OCD to do things over, repeat things till they sound right, want to wash their hands (we treated one child with meds (not now) and the other with cognitive behavioral therapy).

Some things in life are just NORMAL and we've gotten spoiled as people thinking we're supposed to be comfortable.

grindcm

You are asking questions and pondering ideas that many of us fail to even ask ourselves due to the demands of daily life. Our society has become one of the "microwave mentality," in which we want things or solutions as quickly as possible so that we may return to or 'enjoy' further or daily lives. In doing this it would seem that we have become a society of individuals. In this emergence of the individualistic society and our new found mentality we fail to understand the consequences of our daily decisions. We consider "normality" to be the ability to carry on our daily routine and when something interferes with the routine, whether disease or what, it then becomes abnormal and in need of a solution. I believe that many in our society apply the term abnormal too broadly and then search for a solution to an imaginary or partially fabricated problem. I do believe that ADD/ADHD are issues but, I think the term is to often applied to children without investigating the source. Its easier to fill a prescription than it is to look into our personal lives. Needless to say, I truly believe your on the right path and on another note Failure, in many ways, is an integral part of success.

some dude named steevo

You forgot about the New ADD - Bipolar Disorder. ADD and Bipolar disorder are incredibly over-diagnosed. I am a family practice doctor, but I no longer prescribe stimulants to any children (or adults). I also tell a lot of patients they don't have bipolar disorder. For those who do, I insist they see a psychiatrist to confirm diagnosis and initiate treatment, and a psychologist for cognitive therapy.

Sometimes I wish I was a radiologist...

AnnR

I like to blame schools for the over-do on ADD. Any little problem and they're telling you to have your child evaluated.
Maybe shoving a bunch of sit-at-your-desk-for-hours work on a young child is part of the problem. Maybe your boy gets in trouble in the lunch room because he's sat still all morning and hardly gets a chance to blow off a little steam with a nice hard game of dodge ball or pick-up soccer.

That's not to say that all children shouldn't be taught important things like reading and math. Just that I think schools are quick to push you off in search of medication.

ducky

I wouldn’t have developed the self-doubt that has followed me throughout my childhood and into adulthood. That’s good. Right?...But self-doubt is a very important thing. It keeps me from running off at a diagnosis rashly by forcing me to second-guess myself...This makes me wonder how many kids I am treating are like me. Am I keeping them from learning the important lessons that struggles can teach? It’s impossible to know, but I suspect that some would probably be better left untreated.

I believe that you are confusing two different, though related concepts in this post. There is a difference between trying, failing, and learning from your failures, and trying, failing, and feeling that you are a failure. Learning to second-guess ones actions, and develop a healthy understanding of the limits of ones initial judgments is important, but I don't necessarily think that treating a child for a learning disability would prevent that.

There are several biases in the general "conversation" about ADHD that impact these issues. There is a bias towards looking only at the behavioral impact of hyperactive behavior, and using hyperactivity or classroom disruption as the yardstick for measuring childhood ADHD. This obscures the serious difficulties faced by those who have inattentive ADHD, and can, in some cases, harm their ability to get treatment. There is also a bias towards having ADHD solely diagnosed and treated by physicians (often at the request of teachers), rather then psychologists or psychiatrists. This contributes to a culture of over-diagnosis, and a tendency to medicate first and seek non-pharmaceutical treatment second-or never. Adding to this cloud of stuff is the tendency of modern parents to want to protect their kids, and to come up with quick fixes when something is wrong (see your cold medicine example).

For every adult like Dr. Rob, who succeeded without treatment and intervention (and now wonders if that success would have been possible had they been medicated) you have several people who were diagnosed as adults and how look back wondering how many years of pain and suffering they could have been spared if they had received diagnosis sooner. While I am unsure of my views on medicating children (particularly elementary school aged kids), I believe that having a diagnosis is important, because it allows you to understand the underlying causes of your behavior and work around them. I'm old enough that ADHD wasn't a fad diagnosis when I was in elementary school, and young enough that some of my peers were diagnosed as children. Many of them received therapy and learned strategies for how to manage their symptoms without medication. Though some took medication as kids, many feel that they have learned skills that allow them to function without it as adults.

The learning skills part is what I want to emphasize. Because Dr. Rob got where he is today because he learned (non-destructive) skills that allowed him to cope with his ADHD without requireing medication. And skill-building is what is often left out in the rush to medicate kids who are diagnosed with ADHD by a non-shrink Dr.

Sorry if this post sounds disjointed. This is an issue I have been struggling with myself after being diagnosed and begining both theraputic and medical treatment. I spent years feeling like a worthless failure (despite some successes), and though my feelings of worthlessness ultimately led me to participate in a lot of positive-outcome service-oriented activities, I still look back at the years I spent hurting myself, or wanting to die and wonder if am a better person for having lived through that pain, or if I would still be who I am today without it.

some dude named steevo

"There is also a bias towards having ADHD solely diagnosed and treated by physicians (often at the request of teachers), rather then psychologists or psychiatrists. This contributes to a culture of over-diagnosis, and a tendency to medicate first and seek non-pharmaceutical treatment second-or never."

First of all, psychiatrists are physicians. Second of all, psychologist can't prescribe medications. And third, psychiatrists and psychologist are just as likely to overdiagnose as primary care physicians, if not more so (e.g. bipolar disorder - see above). I think you are vastly over-generalizing in this statement. I see many children nowadays with the diagnosis of ADD or ADHD without proper initial investigation or ongoing re-evaluation. The "standard of care" for ADD treatment is really sub-standard across the board.

"I believe that having a diagnosis is important, because it allows you to understand the underlying causes of your behavior and work around them."

It is good to have a diagnosis, and it seems to have worked well for you. However, it doesn't help you understand anything about the process or illness, it is just a label.

If you know nothing about cars, and your mechanic tells you your car broke down due to a fuel injector block, would that help you understand the proper functioning of a fuel injector and how it provides a fuel/air mixture to the combustion chamber? I don't think it would, and the human mind is nearly infinitely more complicated than a car engine.

Rob

Ducky: I don't disagree with anything you wrote. I do reject those who say people should not be treated "because pain is good." I do medicate both children and adults, although at a lower rate than I did initially as a physician. We do have an "automatically medicate" culture, and it is against those expectations that I have to decide who to treat medically and who to recommend otherwise. There are people who are obvious on both sides, but the gray zone is the trouble.

I admit that one of the things that allowed me to survive was the incredibly steady environment my parents established at home. My ability to get B's despite ADHD play into it as well. Not everyone has the advantages I had.

There is no easy answer. This post is a lament of one who face those difficult choices and make a decision. The other docs who responded agree.

Colloidal Silver

Great points, very well written.

Diane

Hi, I accidentally found this blog and it is remarkable that it should address the issue that I am facing for the first time in my 60 years. I'm a female poet, wife, and knitter. I've had lots of problems and have dealt with them well enough (some very well). I've had a little acclaim and have friends and a wonderful husband, So?". . .I've had too many years of therapy trying to understand my quick prone to the blues mind (I'm weary of blaming my poet talent). Those popular disorders with initials have not been found to apply to me. Except for now-- a recent psychologist is convinced I am ADHD-1. Inattentive, of course, not hyperactive at all. After much talking, tests, history-taking, etc., and more self-honesty, I believe she's accurate. Like 'Ducky' I have regrets about a lifetime of quiet pain amidst even good stuff and it's not your average moodiness. So will I take the medication she recommends? (I have taken anti-depressants in the past to no avail.) I don't think so because I have reservations about the serious and profound medical impact of such rx., but at the same time I wonder if I'm foolishly conservative (I don't smoke by the way and stopped drinking 23 years ago.). I still blame and notice sadly all my erratic chaos despite knowing better. Thanks for all the info in the essay and e-mails that followed. They give me more insight.