My latest podcast on breastfeeding is up at http://housecalldoctor.quickanddirtytips.com and in iTunes.  My bottom line is that breastfeeding is the best way for babies to be fed.

When I was discussing this with Dr. Gwen, we got into an interesting discussion.  The dilemma pediatricians face is that if we strongly push nursing, we are criticizing anyone who chooses otherwise.  How strongly do we push breastfeeding when a large number of parents in our practice choose to nurse.  Beyond that, the advances in the quality of the formulas available have been great.  We have lots of bottle-fed babies in our practices and very few of them seem to suffer from it.

Doing the research for this podcast has swayed me back toward pushing breast milk more.  The studies I cite are fairly convincing to me that babies who are breastfed are at an advantage over those who are not.  At the very least, breastfeeding early in the baby’s life is a very good idea.

This underlines one of the basic things I have learned about being a parent: you can’t always do what is best.  There are lots of choices we make when raising kids: whether they should participate in sports or take music lessons, public or private schools, spending more time working to support them or spending more time at home.  It is rarely black and white.  Parenthood is full of second-guessing and can be burdened with lots of “if I had only done x” in retrospect.  Adding more guilt trips to an already self-conscious group may not be constructive.

I just think that telling parents the facts – in this case that breastfeeding is more advantageous than bottle-feeding – is the best I can do.  The choice is not always straightforward, so I won’t criticize parents who do otherwise.  I do think, however, that some parents don’t really know the facts.  I didn’t even know all of the facts before researching this podcast.  As long as we give good information and communicate it clearly, the parents are the one who need to make the decision in the end.  I need to state the case for breastfeeding and then back off.

A lot of the work I do as a pediatrician involves undoing the damage done by others.  Parents are assaulted constantly by barbs thrown from people who either are ignorant or should know better.  Many of these are even thrown by my colleagues.  It’s hard enough to have these independent little critters running around as your living report cards; having clueless or mean-spirited people doing the grading can cause serious mental harm.

If you are a parent, you’ve been on the receiving end of this and have undoubtedly developed related insecurities.  If you are not a parent, you are probably thinking and saying really dumb things about other people’s kids.  If you are a parent and are thinking and saying these things, then you either have a very bad memory, or you are evil.

Don’t believe me?  Here are some examples of what parents face:

1.  Fear of Looking Stupid

Jimmy has been sick for five days.  His fevers have gone over 103 and he’s looked like a wet-rag at times.  His cough is keeping him up all night.  But stepping into the exam room of the doctor causes a supernatural change in the child.  He not only stops having a fever, but the cough suddenly vanishes and the child smiles and is playful.  It happens all the time.

At home, parents of sick kids are caught between two worries: either they are overreacting to a minor problem, or they are endangering their child by not seeking help soon enough.  It’s really hard to know when a kid is “sick enough” to bring to the doctor.  Either extreme can make the parent feel stupid.

Some doctors make matters worse by telling the parents: “There’s nothing wrong.”   I said this kind of thing before I had kids.  Now I hang my head in shame over what I said before I knew better.  Now when I see parents in this situation, I try to say something like, “It looks like there is nothing we need to treat, but it’s good to make sure.”

2.  Busy-Bodies

Other people always seem to know how parents should parent more than the parents themselves.  Grandparents are often the worst in this area, but at least they have an excuse.  Unsolicited advice is given about what kids should eat, how they dress, how to discipline, and what to do about medical problems.

I face this a lot with bad medical advice.  Grandparents remember what their pediatricians told them and assume I am falling down on the job.  Babies are given solids at 2-months of age and feet turning in are fretted over despite my best reassurances that there is no need for treatment.  I’ve had many parents say that they are not worried, but grandma won’t leave them alone about this.

Its even worse when someone in a restaurant plays the role of “expert,” suggesting that the appropriately chubby 6-month old is becoming obese.  Parents can ignore these people easier than their family, but it still casts a seed of doubt that I end up dealing with.

3.  The Hairy Eyeball

An 18-Month old is rolling around on the floor screaming at Wal-Mart as the mother futilely tries to calm the cacophony.  That’s just what 18-month old children do.  It’s developmentally appropriate.

But the looks cast by the other shoppers give say otherwise.  They are derisive looks that label the mother as a lousy parent that is going to raise delinquent children.  There are even comments like, “If I had ten minutes with that child, they wouldn’t be doing that.”  It’s hell for the mother.

I tell parents of children around this age that this is when they are paid back for all the bad thoughts they have had about other peoples’ kids.  They grin knowingly.  I remember when my oldest was a pleasant 4-month old, we had dinner with friends who had a 15-month old son.  The boy spent a good part of the meal screaming, resistant to any attempt to pacify.  When we were driving home, my wife and I agreed that our kids would never scream like that.

What a stupid thing to say.

If you have not had a child, be aware that any judgmental thoughts you are having will come back to haunt you.  I believe that the gods of toddlers are especially alert to people who speak and think judgmentally and pay them back ten-fold for their ignorance.  Don’t tempt these gods.

If you are the parent of an 18-month old, you should just stay out of Wal-Mart.

4.  Misleading Simplifications

The word “just” should not be allowed when it comes to parenting.  “Just do X and your child will eat right.”  “Just discipline like Y and your children will obey.”  These statements should be subject to stiff fines and possibly jail time for those who utter them.

Parenting is hard.  Some principles are straightforward, but their application is extremely difficult.  Many parenting techniques claim that applying simple principles can make parenting easy.  This is like saying, “We just need to eliminate poverty,” or “The Israelis and Palestinians should just get along.”  The advice may be based on sound ideas, but their simplification of a difficult task can cause big problems, inculding:

• Guilt – parents will inevitably have a hard time applying these principles and so will feel like they are ruining their children.
• Desire for Quick-Fixes – the idea that the right technique will have quick results makes parents impatient.  They try X and it does not work, so they change to Y.  If one discipline technique doesn’t yield immediate results, it is abandoned for something else.  But there are no quick fixes.  Lasting change takes persistence and patience.  Kids are stubborn and require the parents to out-stubborn them for change to occur.
• Rules over Love – in my view, the best way to get “good kids” is to love them.  We all make a gazillion mistakes in parenting, as did our parents, but the kids I have seen turn out good have been the ones whose parents gave a rip about them.  Techniques treat kids as objects to be managed, and this tends to look at the world from the parents’ perspective.  The best parents I have seen, however, are the ones who put their kids’ needs over their own.  The best way to wreck your kids is to be selfish, no matter what technique you use.

So if you are a parent, you have my deepest sympathy.  It’s great, but some of what makes it so good is its difficulty.  It is unfair that this difficult task has to be done with these added troubles.

If you are not a parent, please take these things to heart.  You have absolutely no idea what it is to have kids.  If you have bad thoughts towards other people’s kids, just keep them to yourself.

I have a mental picture of my pediatrician growing up.  Very nice, quiet, reserved, and wearing a white coat.  The exam rooms smelled strongly of rubbing alcohol.  I remember getting shots, gagging on the stick, and him looking in my eyes with the ophthalmoscope.

It’s not a bad memory.  I don’t remember having a whole lot of fear, but I don’t remember liking my pediatrician either.  He didn’t influence me to go into pediatrics, but he didn’t scare me away from it either.  I just have those translucent memories of childhood.  A few snapshots in the memories of my life.

Every once in a while it strikes me that I am what a bunch of children picture when they think of a doctor.  Doctors are goofy and tickle.  Doctors have beards and wear sandals.  For some reason, this idea hits me hardest when I hear them say my name.  It happened today, when a very sweet 2-year-old responded to his mother’s question: “who is he?” while she pointed at me.

“Doctow Wambuts.”

My heart melted.  It always does.  Something about hearing a little child say my name just hits me like an arrow.  I have to pause and take a deep breath.

One child who especially liked me could never get my name right.  To her I was “Mr. Ladder.”

Another child, probably around five years of age, had me at the very top of her list.  I can hear her voice in my head still.  I was walking into a room and she caught sight of me and shouted: “I love you Dr. Lamberts!”

It is strange to think that I am their mental picture of a doctor.  I am just a normal guy who practices medicine.  I am just a goofball who likes to mess around with kids and adores infants.  I am me.

But not to them.  To them I am the man in the strange place that smells like rubbing alcohol (not as much as my doctor’s, I hope).  I am the person who looks in their eyes with the bright light and puts the stick in their mouth.  I am the scary guy with the beard, or the beloved silly guy that doesn’t act like a doctor.

To them I am “Doctow Wambuts.”

It gets me every time.

I have never seen a case of epiglottitis.  I remember the stories I heard as a medical student: a young child comes to the ER with fever, drooling, and muffled voice – not just sick; a ticking time bomb.  I was told that if the child was disturbed – even something as small as putting a tongue depressor in their mouth – the airway could suddenly close and the child could die in minutes.

It scared me then.

Now, thanks to the fear-mongers for immunizations, I may get to see it.  Today I got the following from the American Academy of Pediatrics:

Hib Alert: 5 Cases, 1 Death

The U.S. Centers for Disease Control and Prevention (CDC) today announced that five cases of Haemophilus influenzae, type b (Hib), invasive disease (meningitis, pneumonia and epiglottitis) were confirmed in 2008 in Minnesota. This is the highest number of cases of this vaccine-preventable disease in children under 5 years of age that Minnesota has seen since 1991.

Three patients had received no vaccinations due to parent or guardian deferral or refusal of vaccinations. One of the unimmunized patients, a 7-month-old infant, died of Hib disease. Two of the remaining children received age-appropriate immunizations. One child, a 5-month-old, had received two Hib immunizations. The other child was 15 months old and was fully vaccinated for age but, subsequent to Hib infection, was diagnosed with an immune deficiency (hypogammaglobulinemia).

Even in the conservative south I am having more parents falling prey to the immunization fear-mongers.  People are questioning them – even ones that don’t have the feared autism association.  To my knowledge, HIB has never been a specific target of the anti-vaccination crowd (if you know otherwise, please tell me).

These parents probably thought “what’s the harm?  Why can’t we just wait to do the immunizations until the risk is less?”  A 7-month-old infant died from this logic.

As a pediatrician I work to keep children from unnecessary harm.  I am expected to pick out the very sick child – the child with life-threatening disease – from the routine illnesses.  It can be extremely difficult sometimes.  Catching disease early can save the life of the child.  Parents trust me to recognize this.  They expect me to have the training and wisdom to know what to do to keep their child from harm.

But there are some who would suggest that I am deluded.  I am brainwashed by the vaccine manufacturers, drug reps, or narrow-minded training.  Yes, I can be trusted to rescue their child from the brink of death, but can I be counted on when I recommend vaccines?  They trust me with the life of their baby when death is stalking, but what about when it is only a threat?

Horrible diseases have been prevented by immunizing children.  Is it worth the “risk?”

Ask the parents of this 7-month-old baby.

Credit

Trust me.

I don’t regret the fact that I have never seen epiglottitis.  I don’t want to.  Trust me.

Please, trust me.

entropy
noun Physics

• a thermodynamic quantity representing the unavailability of a system’s thermal energy for conversion into mechanical work, often interpreted as the degree of disorder or randomness in the system. (Symbol: S)
• figurative lack of order or predictability; gradual decline into disorder : a marketplace where entropy reigns supreme.

We fight it constantly.  It is actually one of the main things we do as physicians – forestalling the effects of the tendency of a system to get more disordered.   People who are well get sick.  People who are alive die.  Do doctors save lives?  To some extent; but more accurately, we extend lives.

Credit

Why am I saying this?  This season of the year is typically the most disordered time in many people’s lives, and it is also the start of “sick season.”  Emotional stress is very high – I have seen several people today who are bent to the point of breaking by the additional stress of the holidiays.  People who have suffered loss of a loved one or who have gone through divorce are reminded that the new “normal” is not the normal that they want.

The additional number of patients along with the increase in anxiety and depression takes its toll on my staff and me personally.  I have less time to do more.  Add to that the fact that we are all humans going through the same struggles and illnesses that our patients are facing, and you end up with a predictable outcome: disorder.  Sometimes it is even chaos.

So much of the talk about how things “should” be in healthcare don’t take into consideration how things are.  I can’t do as good of a job as I want because I have too much to do.  I can’t do as good of a job as I want because I am stressed out.  I can’t do as good of a job as I want because my patients are anxious, depressed, self-destructive, and basically frail.  It would be great if I could fix things, but I can’t.  I can put duct tape on the problem, but all fixes are temporary.

What can be done?  The advice that I have given to several of my patients today is this:

• You can only do what you can do.  Don’t live under the condemnation of “should.”  If you live your life under the expectations you think others are putting on you – how you “should” be.  Most of the time these expectations are not put on us by others, but rather by ourselves.  We feel we the expectations we think others are putting on us – but they aren’t expectations we ourselves put on others.  You can only do your best.
• Simplify.  This is an offshoot of #1.  We do too much because we “should.”  Who cares if you have lights up?  Who cares if you send cards?  Do it only if you do.  You can turn anyone into a failure if you expect enough of them.  Most of the time we do this to ourselves.
• Enjoy the good.  Yes, there is trouble, sickness, pain, and even death.  Even as those things exist, there is also laughter, peace, joy, and birth.  They don’t cancel out, they coexist.  You can find some joy amidst trouble.  That doesn’t erase the bad, but just puts it in perspective.
• Vent.  What do you think I am doing right now?  It helps me to get this stuff down because it reminds me of the truth.
• Laugh.  If things are too serious, then find something to laugh at.  “I laugh because I am crying inside” may not be pathological.  It may be survival.  If you can’t think of things to laugh about, just picture stampede of llamas rampaging through Washington DC – through the White House, the Capitol, and the Supreme court.   These llamas are staging a coup, you see….take it from there.

Yes, I am in a introspective mood right now – I tend to do that at times.  Being in my shoes has a tendency of causing me to do that.  That is why I am glad I have this blog.  There is much joy in it, and much learning.

I haven’t done this for a while, but I have to step into the fray.  I first saw it on White Coat’s blog, then Grunt Doc weighed in; and not to be outdone by some ER docs, I had to see what kind of blogger I am.  So I went over to the Typealyzer, and typed in my blog URL:

ESTP – The Doers

The active and play-ful type. They are especially attuned to people and things around them and often full of energy, talking, joking and engaging in physical out-door activities.

The Doers are happiest with action-filled work which craves their full attention and focus. They might be very impulsive and more keen on starting something new than following it through. They might have a problem with sitting still or remaining inactive for any period of time.

I won’t comment that they used a hyphen in the word playful (I guess I just did), but I have to say that this is fairly accurate.   The analysis now turns to my brain:

Analysis

This show what parts of the brain that were dominant during writing.

So this is where the whole thing falls apart.  Logic and order over intuition and feeling?  Me…Practical???

Oh well.  At least I am giving in to peer pressure.

So this takes me to the award section: Bronnie Thompson of the HealthSkills blog gave me the Kreativ Award, calling me (gasp) nutty!  Well, if you look at the diagram of my brain, nuttiness does not seem to be on there.  I am also not sure why the word is spelled Kreativ, but since it is unlikely that I will be nominated for an Emmy, I will take this award with great thanks (despite the “nutty” comment).

In accepting the award, however, I had to figure out exactly what Kreativ meant.  So I went to Wikipedia, and looked up the word.  It turns out, it is not an English word at all.  But when I looked it up on the Norwegian Wikipedia, this is the explanation I got:

Kreativitet er skapende evne eller virksomhet, det vil si si oppfinnsomhet, idérikdom og det å lage eller finne på noe nytt. Kreativitet er avgjørende for å løse problemer og utfordringer innen alle fag og i alle situasjoner og for å skape forandring og fornyelse. Kreativitet blir særlig forbundet med oppfinnelser og vitenskap, kunst og håndverk, men også næringsliv og markedsføring der utøverne gjennom fantasi og forestillingsevne tenker annerledes og nytt, skaper noe originalt eller setter noe kjent sammen på nye måter. Den mentale prosessen bak kreativitet er komplisert, og det er ingen entydige forklaringsmodeller eller definisjoner. Kreativitet kan være en medfødt egenskap, men kan også læres og utøves gjennom praktiske teknikker. Det fins derfor en rekke kurs og bøker for å lære bort kreativitet.

3 eggs
3/4 cup sugar
2/3 cup whipping cream
2/3 cup 35 percent fat sour cream
3 cups flour
2 T. baking powder
1 tsp. cardamom
2 T. melted butter
shortening or oil for fryingBeat eggs and sugar until light and lemon-colored.
Whip cream and sour cream lightly together.
Sift the dry ingredients. Add alternately with melted butter and both creams to the egg mixture. Mix lightly together. Refrigerate overnight.
Roll the dough out and cut doughnuts. Re-roll again to cut remainder.
Heat the shortening or oil to 180 degrees C (350 degrees F). Deep fry, a few at a time, until golden, three to four minutes.

Note: The Caption Contest is still going on…I am in the process of increasing the allowance of securing the judges.

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It’s a hard world for kids; they come into the world completely helpless to parents who don’t know much about how to raise them.  Some parents have a better idea than others, but as a parent of four children I can say that the mystery far outweighs the understood.  As a parent you are in constant fear that somehow what you are doing is going to cause some unexpected harm for you children down the road.  I have no doubt that many of the things I have done will cause such harm.

But as many know, the world is far harder for some kids than the rest.  These kids don’t simply have frail and fallible parents, they have parents who don’t care or are even emotionally antagonistic toward them.  Perhaps these parents had similar examples when they were kids – I can’t compare my relatively good childhood experience to theirs – but regardless of the reason, many parents’ attitudes cause significant harm.  I see it regularly.

Since my job is to maximize the overall health of children, I see somehow helping this situation as of high priority.  But how do you communicate this?  How do you get people to see that they are harming their child with their attitude?  How do you avoid coming across as judgmental or patronizing?  My goal is not to preach a sermon and feel better myself, but to actually affect change.

My current approach to this problem is simple: I say nice things.  From the very start of a child’s life I do whatever I can to get the parents thinking as highly of the child as possible.  Whenever they come in for a visit I comment on how cute, advanced, or smart the child is.  I use words like “perfect,” “wonderful,” and “beautiful.”  I want the parents to know what a great gift they have as a child – and perhaps that feeling of pride they get will cause them to pay more positive attention.  You take better care of treasure than trash, and part of my job is to convince parents that they have a treasure.  I believe they all do.

This does not stop when kids get older.  Much of a child’s success depends on what the child thinks about him/herself.  A sense of helplessness, hopelessness, or predictable failure will cause them to seek comfort in drugs, sex, or overachievement; or worse, it will cause them to be full of bitterness and anger toward the world.  It is my job to be a positive voice in their life.  I do what I can to emphasize their success, using words like “smart,” “successful,” and “terrific.”  I want the child to believe that they are valuable in who they are – not in what they need to become.

Now, I don’t buy into the modern mantra of “you can accomplish anything you want as long as you believe in it.”  That is simply not true.  I could have never been a professional baseball player (too klutzy), or a neurosurgeon (too distractible).  That type of mindset sets kids up for shame – a lack of success in what they do will simply be evidence that they didn’t try hard or believe enough.  You are who you are – with unique strengths and weaknesses.  I think it is the job of us adults to encourage children to be themselves and embrace who they are.

Belief in yourself should focus more on yourself, and less on belief.  It is not the strength of the belief, but the object of it.  Believe in who you are and not who you would be better off being.  I think one of the keys to both happiness and success is to like the person who wears your skin.  Self-contempt does not push people toward improving themselves, it stifles ambition.  Self-belief – the realization that you as a person have value as you are – is, in my opinion, the best predictor of a truly successful and happy person.

I can’t change the world; but it is nice to be able to put in a few good words and perhaps make a parent believe in a child, and a child believe that they are truly worth having in this world.

At the start of next year, the drug companies will no longer be giving pens and pads of paper to doctors.  The rules regarding pharmaceutical sales practices have grown progressively more stringent over the past few years.  The FDA already regulates what the reps say to physicians (they may only assert what is in the PI, or package insert).  Now they will be very limited on other contact with physicians.

Thank goodness.  Those pens and pads of paper were sending subliminal messages to me.  I hear them talking to me in my sleep.  I just have an insatiable need to prescribe unnecessary medications because of a ballpoint.  It will be good to get out of this marketing hell these reps have put me in.

Citizens are worried about the influence these companies are having over us physicians, wondering if their efforts to influence are driving up the cost of care.  One online petition site states:

Drug marketing is out of control. Help send a message to Congress.
Support the Physician Payments Sunshine Act, which will require drug companies to publicly report their gifts and payments to doctors.
Drug companies spend at least $25 billion each year marketing to doctors. We pay for that with every drug we buy. And studies prove that marketing causes doctors to prescribe higher-cost drugs. Some new drugs also have safety risks (like Vioxx). By increasing transparency, the Sunshine Act will help protect patients and help counter the skyrocketing costs of drugs.

Congress is also getting involved:

While it’s no secret that pharmaceutical companies lavish gifts on doctors — everything from free notepads and pens to meals to the more extravagant paid trips or seminars — most patients are in the dark about who, exactly, is courting their physicians. But Congress may be finally acknowledging this relationship, one important step toward creating a national gift registry so patients can track the perks Big Pharma is giving to their doctors.

In June, the nonprofit government watchdog Public Citizen testified before the Senate Special Committee on Aging in favor of federal legislation that would require drug companies to disclose payments to doctors. But the group urged lawmakers, before jumping on the proposal, to examine a Petri dish of existing disclosure laws. Although four states and the District of Columbia already have disclosure laws on the books, the group says they are “inadequate” and do not give patients a clear picture of how money is changing hands.

I do understand this concern.  Advertising works, and there are definite financial reasons for the drug industry’s aggressive marketing to doctors.  The pressure seems to be working, as witnessed by the pen and paper ban.

I guess it is appropriate congress is getting involved, since they are very familiar with the influence the drug companies can have over people and their behavior.  From the Wall Street Journal:

Health Industry Pours Money Into Democratic Convention

The health-care industry has a lot at stake in Washington these days. Maybe that’s why the list of the Democratic convention’s host-committee sponsors is so full of big players from the health sector.

Among them: Merck, Amgen, Pfizer, AstraZeneca, Novartis, Mylan, Medtronic — (pause for breath) — Abbott, Walgreen, UnitedHealth, Eli Lilly and Anthem Blue Cross Blue Shield.

Nor are the companies letting the money do the talking. The CEOs of Pfizer, AstraZeneca, Eli Lilly, Amgen and Merck are all making appearances in Denver this week, reports FDA Legislative Watch.

And Pfizer was among the million-dollar donors that landed skyboxes at Invesco Field for Obama’s big speech Thursday, the Dallas Morning News reports.

As we noted earlier this year, the sector has shifted to favor Democrats over Republicans recently. But that doesn’t mean the Democrats are getting everything: There will be plenty of industry money sloshing around Minneapolis – St. Paul next week for the Republican convention.

Hmm….  I smell hypocrisy here.  Isn’t this problem of at least equal importance to the short-skirted drug reps and gawking doctors?  Is the lack of pens and paper in my office (which will boost the local economy as we go to Staples to buy it for ourselves) such a great accomplishment when Pharma (and every other industry) is buying influence with our government?

I don’t really care about the pens, but it seems a much bigger issue to me that corporate America has bought our legislators and are trying to influence our President.  These are the people who are going to reform healthcare?  These are the people who have a vision of how things need to be?

I’ve got an idea: let’s start a petition to prohibit them from giving pens and pads of paper to politicians.

OK, it is time to put on your nostalgia caps and remember back to the cold war.  Those were the days, weren’t they?  “Nuclear Winter” was being thrown around like “Global Warming” is now.  Life went on like normal, but life was always lived with an underlying dis-ease that the end of everything was just a button-push away.

One term frequently used at that time was “Mutually-Assured Destruction” (MAD) which described the stalemate of two huge stockpiles of nuclear weapons that could destroy the world many times over.   The thing that kept the fingers off of the button was the surety that the destruction of one side would result in the end of life for both sides.  It wasn’t a comforting thing to have to trust the rationality of two sides that had created the stockpiles in the first place, but perhaps there was some truth to the idea of MAD causing restraint to occur even in the least rational of all people: our leaders.  Who knows?  We’re not really out of those woods yet.

But this is not a post about nuclear weapons.

I was listening to the NPR Science Friday podcast, and there was a very interesting story about a journalist who had studied and befriended people with Lesch-Nyhan syndrome, a condition where people have a single nucleotide substituted in their DNA that causes them to engage in grotesque self-mutilation.  The degree to which people with this disease harm themselves is quite disturbing (don’t look at pictures of it unless you are prepared), even resulting in these patients chewing off their fingers.  Very disturbing.

On the podcast (I highly recommend it), the journalist makes the statement: “There’s a little of Lesch-Nyhan in all of us.”  Some people chew their fingernails and others bite their cuticles, even when they know they shouldn’t.  Lesch-Nyhan is just the extreme of this type of behavior.

Yes, there is a little of Lesch-Nyhan in all of us.  Smokers smoke despite their emphysema, alcoholics would do anything to get away from the destruction of drinking but keep drinking to their own harm, compulsive gamblers gamble away all of their money, and people with credit cards spent to the limit somehow find a way to keep spending.  Last week I picked at a callus on my foot so much that it hurt to walk.  I kept telling myself to stop, but my hand would somehow end up on my heel without before I could think to pull it away.

My job depends on this irrationality.  I once posed the question: what impacts my income more, human frailty or human stupidity?  Self-destructive behavior causes a significant percentage of my visits – whether it be subtle: noncompliance with medications or tests ordered; obvious: alcohol, smoking, or overeating; or overt; anorexia nervosa, people staying in abusive relationships, or people “cutting” themselves.  Is this stupidity?  It certainly is irrational – people feel like they can’t stop themselves in this kind of behavior and sometimes even feel a pleasure in the self-harm.  Yet there is also a degree of rationality to it, as it puts pain in our own control rather than in the hands of others.  The draw to it is moth/flame-like.  The more irrational the behavior seems, the stronger the gravity of the need it is filling.

Credit.

This is a mystery to me.  I see it every day in my patients and I see it in myself.  I sometimes tell my patients that one of the best parts of being a doctor is that you get to see that everyone is as screwed up as you are.  If I could push a button or prescribe a drug to help with this behavior, I would.  I doubt there will be a button or drug to fix this, however, as history tells us that this kind of self-assured destruction (SAD) is not new to our time and culture.

This is probably the main reason I don’t feel I can judge my patients for their self-destructive behavior.  It is too common.  I see it in the mirror every morning.  That is not to say that the behavior itself is not wrong or bad, but to make the jump to say that I wouldn’t do the same in their shoes belies the fact that I engage in my own form of SAD.

Too many people see SAD as inevitable and too many physicians just treat the consequences of this behavior.  My hope for both myself and my patients is that somehow this cycle can be broken and the legacy of self-destruction can be interrupted.  As any recovering alcoholic can tell you, this is not easy at all.  But life would be a lot happier for all of us without that dis-ease of the finger close to the button.

As one of my favorite musicians once put it:

The man who twirled with rose in teeth
Has his tongue tied up in thorns
His once expanded sense of time and
Space all shot and torn
See him wander hat in hand -
“Look at me, I’m so forlorn -
Ask anyone who can recall
It’s horrible to be born!”

Life is hard.  But it is far harder when we forget that, despite the appearances, we are all human.

Being a parent is scary.

I remember when my first son was born I looked at him and was overwhelmed.  This person was my responsibility.  Even as a pediatrician, I felt a sense of being lost in the sea.  Remembering this feeling makes me have much more compassion on my patients.

The incredible fear the can carry into the office is palpable.  I think you have to be a parent to understand.  Most of the time I can find ways to diffuse the fear – through reassurance, diagnosis, or making a plan to come to a diagnosis.  This is true in about 99% of the pediatric cases I see.  Most kids aren’t really that sick, and those who are can be treated easily.

There is one type of visit, however, that stops me in my tracks.  It is called an Apparent life-threatening event or ALTE.  UpToDate defines an ALTE as:

ALTE is the abbreviation for "apparent life-threatening event", a poorly defined term to describe an acute, unexpected change in an infant’s breathing behavior that was frightening to the infant’s caretaker and that included some combination of the following features:

• Apnea — usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)
• Color change — usually cyanotic or pallid, but occasionally erythematous or plethoric
• Marked change in muscle tone (usually limpness or rarely rigidity)
• Choking or gagging

Unfortunately, an ALTE is only observed by the parent at the time of the event.  They present either to the office or the Emergency room understandably panicked.  Their baby has stopped breathing, turned blue, went limp, or choked.  If a parent is not upset, I get really worried.

So the reaction of the parent is extreme.  But what really happened?  Nobody knows.  Did the child really stop breathing, or is it an over-reaction to something that was a little scary?  How do you reassure a mom when you don’t know what really happened?

The good news is that there is no clear relationship of ALTE and SIDS (Sudden Infant Death Syndrome).  The bad news is that it is very difficult to figure out what to do.  Studies show that about 50% of the time, a diagnosis can be reached through exam and a careful history.  The most common cause of apnea-like symptoms is reflux (that happens in nearly 75% of babies).

Even with a child who refluxes, however, there is often doubt in the back of your mind as a doctor that you are taking a risk at calling it "just reflux."  So more studies are usually ordered.  Here is a list of possible tests from UpToDate:

In one review of test results from a consecutive series of 243 infants admitted to a tertiary center with ALTE, 3776 tests were ordered, of which 18 percent were positive and only 6 percent contributed to the diagnosis

In the consecutive series of 243 infants with ALTE described above, among 171 infants in whom a particlar diagnosis was suggested by the history and examination, the following tests contributed to establishing the diagnosis:

• Blood counts, chemistries, and cultures
• CSF fluid analysis and cultures
• Metabolic screening
• Screening for respiratory pathogens
• Screening for gastroesophageal reflux
• Chest radiograph
• Brain neuroimaging
• Skeletal survey
• Electroencephalogram
• Echocardiogram
• Polysomnography

Among the 72 infants in whom the history and examination were noncontributory, only the following tests contributed to establishing the diagnosis:

• White blood cell count
• Screening for gastroesophageal reflux
• Urine analysis and culture
• Brain neuroimaging
• Chest radiograph
• Polysomnography

This means that there is an average of more than 10 tests ordered per child, with only 6% of them actually helping.  Great.

Most of the time, the kids do great.  Sometimes you put the baby on an apnea monitor – a device that lets out a shrill sound when the breathing rate goes down or the heart rate goes too high or low.  The vast majority of alarms on these devices are false-alarms and can make an already anxious parent become even more anxious.  But what else can you do?

I have never had a bad outcome with an ALTE.  Most of the time the child does just fine.  So when will the good luck end?  It just puts a bad feeling in the pit of your stomach.