Thanksgiving

Sometimes I wonder what I’d be like if I was born in 1800.  I’d be crippled, since I have an arthritis requiring regular medication.  Once the arthritis affected my eyes and without medication, I might’ve become blind.  Then one time a mosquito bite on my calf got infected, my knee swelled up, and it took surgery and a month of antibiotics to clean up.  In 1800 the cure for this infection, to save the patient’s life, was a mid-thigh amputation.  Without anesthesia.

Modern medicine gives me lots to be thankful for, not being a one-legged, blind, crippled guy.  In the late 1800s anesthesia was invented, so patients didn’t have to be strapped down and shriek through their operations.  Also at that time aseptic technique was discovered, so that patients wouldn’t get infected during surgery.  Before that, surgery was a last ditch effort to save people, since many died from bacteria introduced in surgery.  Then in the 1930s, antibiotics were invented, another breakthrough that made today’s whole Scott possible.  Finally, the 20th century brought anti-inflammatory and non-narcotic pain medication.  In the 1800s the only pain medications available were opioids like laudanum, which was opium dissolved in alcohol.  That would’ve made me a one-legged, blind, crippled narcotic addict.

My pediatric patients have lots to be thankful for as well.  When I was a kid, if a child developed leukemia, the most common pediatric cancer, he was certain to die within months of diagnosis.  Today, leukemia has cure rates above 90%.  The majority of my cohorts who had cystic fibrosis, sickle cell disease, congenital heart defects, extreme prematurity, were dead by the time I had my fifteenth birthday.  Today most of these kids will live into old age.

Finally, in 1900, one in ten babies died before their first birthday due to infections like diphtheria, tetanus, and, pertussis.  One in three were dead before age 5. Thanks to improved living conditions and vaccinations, these deaths are rare.  During my own 26 year career, the invention of  meningococcus, pneumococcus, and H. Flu vaccines have emptied pediatric wards that were once filled with kids with meningitis and blood infections.  Modern medicine has kept me whole, and countless of my own patients.

What if there was an apocalypse, and technology reverted back to the way things were in, say, 1800?  The best-selling book, Station Eleven, explores what life might be like if a flu epidemic wiped out the majority of the world’s population, and civilization collapsed.  The book jacket come-on asks, “What would you miss most?”  Coffee?  Electric lights at night?  Recorded music?  Air-conditioning?

If this sounds like science fiction, don’t get too comfortable in that thought.  In 1919 the Spanish Flu epidemic was unimaginably huge.  One in four people on the planet got sick.  Millions and millions died.  In some towns, so many were sick that there weren’t enough able-bodied to bury the dead.  Today, when things go bad with water supplies after hurricanes in parts of the world, there are still cholera and typhoid epidemics.  One bad virus could turn the whole world into post-Katrina New Orleans, with few left to keep the lights on, bury the dead, and maintain order.

The movie Contagion, with an all-star cast including Gwyneth Paltrow, Laurence Fishburne, and Matt Damon, tells a more likely scenario.  In this film, the flu epidemic wipes out a lot of people and whole cities are quarantined, with resulting movie mayhem.  However, the CDC and government keep a lid on things while struggling to isolate the virus and develop a vaccine.

So this Thanksgiving, be thankful for the good things modern medicine has given us.  Like we discussed above, medical advances have kept so many more children alive than a hundred years ago- kids with infections, cancers, sickle cell disease, cystic fibrosis, and extreme prematurity.  Don’t let thanksgiving become complacency either. Though we rarely see kids with diseases we vaccinate against- meningitis, pertussis, polio- doesn’t mean they’re not out there, waiting.  Make sure your kids have their vaccines.

When I worked in the Philippines in 1998, where many don’t have the luxury of vaccination, I saw two kids die of tetanus.  One was an un-vaccinated teenager from a rural village.  He had stepped on a sewing needle, which inoculated him through his foot.  He died a slow death by asphyxiation, as his chest wall muscles spasmed and wouldn’t allow him to breath.

Be thankful for vaccination! 

Is There A Doctor In The House?

This week’s guest columnist is Dr. Meighan Anderson, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

She’s 10 years old.  She has asthma and eczema, but hasn’t seen her regular doctor in a year- her pediatrician retired and mom hasn’t found a new doctor yet- life’s so busy!  Yet the girl has had several asthma flares requiring Emergency Department visits. The itching from her eczema is also making life miserable, with sleepless nights and scaly skin.  Visits to walk-in clinics have yielded treatments that haven’t worked.

Many kids don’t visit their regular doctor enough.  When they get sick, Urgent Care clinics are so convenient.  Sometimes the family’s moved and not found a new doctor locally.  Sometimes their doctor has retired, or doesn’t take the family’s new insurance.  We also hear a lot of “he’s never sick, he hasn’t needed a doctor,” in the ER.

Having your own doctor is more important than many realize, especially for kids with chronic conditons like our 10 year-old asthmatic.  For kids with these issues, only their doctor has reliable records of what has already been tried, what worked and what hasn’t.  Office-based doctors are better trained and more experienced with these conditions too, rather than Urgent Care or ER providers, whose focus is acute illness.    Finally, office doctors are where to go for vaccinations, school physicals, and specialist referrals.

The first step to find a doctor is your insurance.  If your child has medicaid, only certain practices accept that, though most pediatricians take some medicaid patients.  If you have private insurance, that company will provide a list of accepting doctors.  Office location is important too- shorter trips from your home are helpful with busy lives.  Then you need to decide what kind of doctor to pick.  If your child is newborn through teenage years, a board-certified pediatrician is best.  If your kid is a late teen, soon to be 18 years-old, a Family Practice or Internal Medicine doctor is better, since they can take care of him into his adult years.  They take care of parents too!

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul.  Although the two cannot be separated.” -Plato

Though Plato wrote this over 2000 years ago, it’s still relevant.  Above we discussed finding your child a doctor- insurance accepted, location, and specialty (Pediatrics, Family Practice, Internal Medicine).  But is the physician right for your child’s body and soul?  And your soul too?

Cultivating the doctor-patient relationship is important to successful care.  One of the  determinants in this is a practice style called “shared decision making.”  This is where you and a doctor negotiate what is possible for care, rather than the doctor dictating what you should do, and you being expected to follow blindly.

What does shared decision making look like?  In some cases, there isn’t much sharing.  Technical issues are decided by the expert- the doctor.  For example, your child has a sore throat.  It could be a virus and resolve in a few days, or strep throat, requiring an antibiotic.  A strep test is done, it’s negative, and the doctor doesn’t prescribe an antibiotic, because it won’t help and may have side effects.

But what if your child always has a sore throat and it seems allergic?  With chronic illness like allergy, where lifestyle affects your kid’s illness, shared decision making is a must.  Should you go to an allergist, or would this be too much trouble, or does the thought of skin pin-prick allergy testing freak you both out?  Should you try some anti-allergy medication first?  Which one- inhaled, sprayed in the nose, or swallowed liquid, or a pill?  Which will your kid tolerate, and which is most effective?  Can you afford to tear up your carpet and put in hardwood floors for better dust control, and what about the smokers in the house?  Will they quit, can they quit?

All these questions should be explored with your doctor.  What is doable, what is best for your child, what can you and your kid tolerate, to optimize your child’s care?  Together you all decide on realistic goals and expectations.  In the old days, the doctor was always the boss.  These days, to deliver the most effective care, sometimes she’s boss, sometimes you are, often you’re co-captains of the team 

Trusting Science, When It’s Convenient

Every once in a bad while, I diagnose a child with a brain tumor.  Usually she’s had some progressing coordination trouble, and worsening fussiness.  We do a CT scan, there it is, and I have to break bad news to the parents.  A common first parent reaction is denial.  ”It can’t be!” or, “Tell me you’re wrong!” are some first things I’ve heard from parents when faced with such trauma.  To help them past this denial, I show them the CT scan. It’s all there in black and white.

It’s easy to trust science when the facts are plain to see.  People also are glad to listen when it’s good news.  A glass of red wine is good for you?  Drink away! There’s going to be a cool eclipse?  Let’s go see! But when the news is bad, believing is harder, especially when denial is a basic human response.  Denial is even stronger when you can’t see the evidence for yourself, like on a CT scan.

That’s why denial is easy when it comes to issues like global warming or the benefits of vaccines. The evidence of these is wrapped up in reams of numbers and statistical analysis. Belief in vaccines or global warming comes down to trusting professionals who “live the data.”  Like vaccine researchers, environmental scientists are university professors or government employees, earnest and sincere, whose career success depends on generating good data that survives the scrutiny of their peers. Science is a self-regulating profession.  If your data sucks, you’ll hear it from your colleagues, as they publicly take apart your numbers, looking for faults.

So I trust the environmental scientists just like I trust my colleagues in the vaccine field.  However, it’s easier for me to trust the vaccine guys, since being in the profession I understand their data, and have actually met some of them.  Doctors are certain of vaccine benefits because part of our years of training and experience involve learning how to acquire data, interpret it, and use it.  We can be trusted to talk with authority on vaccines, because we also live the data.

However, I know of at least one doctor who doesn’t believe in global warming.  While doctors trust their own science, they may not trust others.  We’re only humans ourselves, subject to the same denial response as anyone.  Recently one of my residents was printing out climate studies.  I asked if she didn’t believe in global warming.  She did, but another of her professors didn’t, and he wanted to see some proof.  My resident further explained that this professor thought environmental science was involved in a conspiracy. He believed that climate scientists were being secretly paid by renewable energy companies to generate data that supported their industry.

As we discussed above, trusting science is hard when the news is bad and we just want to deny it.  It’s also hard when the data is wrapped up in sheets of numbers and statistics that we don’t understand.  It’s even harder when we actively decide not to believe- to take an end-run around science with conspiracy theories.

Trust in doctors, and in the medical profession, has taken a hit in the past few decades.  In 1966, 73% of Americans had great confidence in medicine as an institution.  In 2012, only 34% felt that way.  This follows erosion of public trust of other institutions like government, the church, the press, and other sciences.  This makes doctors have to work harder to keep individual patient’s and parent’s trust.

Many older doctors lament the good ol’ days when people took what they said as gospel and didn’t question them.  However, I trained in an era where some patient skepticism was viewed as a healthy thing, that patients and parents should be engaged in decision-making.  After all, it’s their bodies.

To maintain their patient’s and parent’s trust, doctors now are being pro-active.  They’re being more careful to be friendly and open-minded with patients and parents, to not deride their beliefs and denials, but work with them. After all, people rarely respond well when being told they’re stupid.  Rather, doctors should be positive and understanding, gain trust, to then better explain the science when it’s time.  This effort often works well for doctors, showing families that they care enough to meet them half-way, and the families become more inclined to trust when it counts.