April 16th, 2009 by Stacy Stryer, M.D. in Health Tips
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By Stacy Beller Stryer, M.D.
Those middle school years …
As a parent, we often think these are years to be feared. Years that we wish we could just blink away. We hear horror stories from our friends and look at book titles, such as “Parenting 911,” and “The Roller Coaster Years,” with trepidation. If only we could run away … just for awhile.
But, if we did run away we would be missing out on some of the most rewarding and exciting times we will have with our children. Sure, I am not going to deny that middle-school age children(referred to as “middlers” by authors Charlene Giannetti and Margaret Sagarese) are emotional, moody and, at times, unreliable. But, as someone once told me, almost every negative attribute can be turned into a positive one. I guess that means that maybe, instead of being emotional and unreliable, our middlers are actually passionate and spontaneous.
Developmentally, they are expanding their horizons in many ways. This is when they develop abstract reasoning, a complex sense of humor (beyond the potty jokes), and the knowledge that there is an entire world out there for them to conquer. This is when they begin to develop strong interests, likes and dislikes, and when they begin to take greater risks – in a positive way.
Personally, I love being with my middler (8th grade) and my almost middler (5th grade) girls. They are interesting, exciting, and a blast to be with. When my 8th grader becomes passionate about something, particularly some social injustice, she can talk a mile a minute. My 5th grader can be very intense when she practices viola or writes original music for her instrument. She often performs for me while I am preparing dinner. Both are becoming much more adventurous – last month we went to an Asian supermarket and bought several canned fruits we had never heard of so we could have taste tests.
I have been thinking about these middle years recently, not only because my children are this age, but also because I have been preparing for a lecture on this topic for parents at a local school. Although I have been counseling patients for years, I have recently read several additional books on the topic in preparation for the talk. They have been helpful, although my basic parenting principles remain unchanged. They seem to be important for children and teens of all ages. I think (“Parenting, according to Dr. Stacy”) that the six key elements of being a good parent of any age child include:
1. Open communication
2. Respect and consistent discipline
3. Compassion
4. Sensitivity
5. Awareness
6. Being a role model
Although the principles remain the same over time, the way we express them varies, depending on the child’s age. For middlers, there should be a strong emphasis on sensitivity and awareness. Children in this age range tend to be very emotional and sensitive, and we need to understand and respect this. For example, they may not want to be kissed or hugged in public anymore. Or, they may need some private time after school or in the evening. We should allow them to retreat to their rooms for a certain time period before bombarding them with questions or making other demands. Respecting their needs ultimately improves communication. We should also be particularly aware of sudden or extreme changes in our middlers’ behavior, as depression, eating disorders and other problems can appear during these years.
Adapting these six basic parenting skills will certainly not ensure a problem-free middle school experience for you or your child, but it will make it much more likely that he or she will come to you in times of need and will strengthen the relationship that you have with each other. Consequently, your middler will be less likely to engage in high risk behaviors or succumb to peer pressure which occurs during these years.
April 15th, 2009 by DrRich in Better Health Network
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DrRich thanks the Cockroach Catcher (his favorite retired child psychologist) for pointing him to an article (by Mark Wicclair, a bioethicist) and an accompanying editorial (by Deborah Kirklin, a primary care physician) in the peer-reviewed medical journal, Medical Humanities, which deconstruct the television show “House MD.”
A TV show may at first glance seem a strange subject for a medical journal, but this is, after all, a journal whose subject is the “softer” side of medical science. (DrRich hopes his friend the Cockroach Catcher will take no offense at this characterization, and directs him, in the way of an apology, to the recent swipes DrRich has taken at his own cardiology colleagues for their recent sorry efforts at “hard” medical science.) Besides, the Medical Humanities authors use the premise and the popularity of “House MD” to ask important questions about medical ethics, and the consequent expectations of our society.
DrRich does not watch many television shows, and in particular and out of general principles he avoids medical shows. But he has seen commercials for House, and has heard plenty about it from friends, so he has the gist of it. The editorial by Dr. Kirklin summarizes:
“[House] is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary.”
Given such a premise, the great popularity of “House MD” raises an obvious question. Dr. Kirklin:
“… why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House?”
Indeed. While it has not always been the case, maintaining the autonomy of the individual patient has become the primary principle of medical ethics. And medical paternalism, whereby the physician knows best and should rightly make the important medical decisions for his or her patient, is a thing of the past.
It has been formally agreed, all over the world, that patients have a nearly absolute right to determine their own medical destiny. In particular, unless the patient is incapacitated, the doctor must (after taking every step necessary to inform the patient of all the available options, and the potential risks and benefits of each one) defer to the final decision of the patient – even if the doctor strongly disagrees with that decision. Hence, the kind of behavior which is the modus operandi of Dr. House should be universally castigated.
So, the question is: Given that House extravagantly violates his patients’ autonomy whenever he finds an opportunity to do so, joyfully proclaiming his great contempt for their individual rights, then why is his story so popular? And what does that popularity say about us?
To DrRich, the answer seems quite apparent.
The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy – or to put it in more familiar terms, individual freedom – is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.
So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. Of course, most think, this ought to be the governing principle of medical ethics.
But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy – the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit – and minimize the harm – to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge – always and without exception – to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is caustic and abrasive about expressing it). DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence – that is, through medical paternalism – are plain for all to see.
Obviously the principles of beneficence and of individual autonomy will sometimes be in conflict. When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our case, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.
DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. Indeed, he espouses a time-honored precept of medical ethics, which until quite recently was THE precept of medical ethics. There is much to be said for beneficence. Making the “right” medical decision often requires having deep and sophisticated knowledge about the options, knowledge which is often beyond the reach of many patients. And even sophisticated patients who are well and truly medically literate will often become lost when they are ill, distraught and afraid, and their capacity to make difficult decisions is diminished. Perhaps, some (like House) would say that their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor indeed has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.
It is instructive to consider how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior – generally involving medical “research” on Jewish prisoners – that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which under the Nazis were extreme but which were by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or the beneficence of their own doctors to protect them from abuse at the hands of authority. Thusly was the ethical precept which asks patients ultimately to rely on the beneficence of others starkly revealed to be wholly inadequate. The precept of individual autonomy, therefore, won by default.
Subsequently, the Nuremberg Code formally declared individual autonomy to be the predominant precept in medical ethics, and beneficence, while also important, to be of secondary concern. Where a conflict occurs, the patient’s autonomy is to win out. It is important to note that this declaration was not a positive statement about how honoring the autonomy of the individual represents the peak of human ethical behavior, but rather, it was a negative statement. Under duress, the Nuremberg Code admitted, societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.
DrRich will take this one step further. When our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement. From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority – kings, clergy, heroes and philosophers – and individuals were eventually trampled under by them all. For this reason our founders declared individual liberty to be the bedrock of our new culture – because everything else had been tried, and had failed. In the spirit of the enlightenment they agreed to try something new.
There is an inherent problem with relying on individual autonomy as the chief ethical principle of medicine, namely, autonomous patients not infrequently make very bad decisions for themselves, and then have to pay the consequences. The same occurs when we rely on individual autonomy as the chief operating principle of our civil life. The capacity of individuals to fend for themselves – to succeed in a competitive culture – is not equal, and so the outcomes are decidedly unequal. Autonomous individuals often fail – either because of inherent personal limitations, bad decisions, or bad luck.
So whether we’re talking about medicine or society at large, despite our foundational principles we will always have the tendency to return to a posture of dependence – of relying on the beneficence of some authority, in the hope of achieving more overall security or fairness – at the sacrifice of our individual autonomy. In DrRich’s estimation the popularity of “House MD” is entirely consistent with this tendency. (Indeed, the writers almost have to make Dr. House as unattractive a person as he is, just to temper our enthusiasm for an authority figure who always knows what is best for us and acts on that knowledge, come hell or high water.)
Those of us who defend the principle of individual autonomy – and the economic system of capitalism that flows from it – all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend it. We – and our founders – did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world over the past century, is even more true today.
Individual autonomy will always be a very imperfect organizing principle, both for healthcare and for society at large. Making it an acceptable principle takes perpetual hard work, to find ways of smoothing out the stark inequities, without ceding too much corrupting power to some central authority. This is the great American experiment.
Those of us who have the privilege of being Americans today, of all days, find ourselves greatly challenged. But earlier generations of Americans faced challenges that were every bit as difficult. If we continually remind ourselves what’s at stake, and that while our system is not perfect or even perfectable, it remains far better than any other system that has ever been tried, and that we can continue to improve on it without ceding our destiny – medical or civil – to a corruptible central authority, then perhaps we can keep that great American experiment going, and eventually hand it off intact to yet another generation, to face yet another generation’s challenges.
*This blog post was originally published at the Covert Rationing Blog.*
April 15th, 2009 by AlanDappenMD in Primary Care Wednesdays
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The most revolutionary tool in primary health care, for almost all out patient care for that matter, is something so common, so mundane, so overlooked that it’s like the nose on your face, you never see it. This tool is not the computer, the internet or a killer software application.
It’s the phone. Why? The answer is equally as simple: The phone allows for 24/7 communication between a doctor and patient who know each other. Likewise, the patient can access the health system with an expert from anywhere and most of the time get what they need.
The American Telemedicine Association (ATA) estimates that 70% of medical problems can be resolved with phones. Almost everyone thinks phone medicine is reserved for an arctic explorer or a poor citizens living in Timbuktu. This assumption ignores how life transforming it would be for every American citizen to pick up a phone, and expect to speak to their doctor anytime from anywhere, at work, on the metro, even on travel, or vacation and expect to resolve their issue instantaneously! No wait, no hassle, no waiting room, no bureaucracy. At least 70% of the time it should be that easy!
Telephone medicine is not to be misconstrued for talking to a stranger. It is not impersonal, nor meant to avoid seeing patients. In reality, it is simply one way of many to get good health care. Sometimes you need a hospital, an emergency room, a specialist, an office visit. However, more than half the time you only need a phone visit, preferably with a doctor or medical practice you know and trust. Even emails are appropriate at times.
That telephones could so easily replace more than 50% of all office visits is so unexamined, so foreign, so shocking, that a predictable series of objections arise:
1. If it was so safe why isn’t it being done already? Of course this begs the reality that our health care system doesn’t pay — or underpays — a doctor to do this. It’s as simple as following the money. Right now the money is in seeing you, so an office visit it must be.
Doctors also answer phones on weekends and night. In fact more than half of the week they are practicing “free telemedicine care,” and that means phone medicine has more real time, more experience in any week than office visit time. It’s just been always deemed “free.” No money means no mission. The doctor, saying, “We’ll schedule you an office visit,” is code for, “Come on in so I can get paid.” That’s a business fact!
2. Isn’t the doctor afraid that he/she’ll miss something? First, office visits miss things all the time. For the sake of not missing something, shouldn’t it mean every problem needs doing a full body scan, complete blood work, and parading every medical problem in front of three separate specialists. If each problem was hospitalized too, maybe that would mean not missing something.
The answer of course, is that to every problem there is a season of reasoning; a triage of appropriateness. Many problems arise where physical exam is irrelevant. If you or the doctor thinks you should be seen, then a face-to-face visit should be arranged but when both people agree what’s going on and that an office visit is not needed, then a phone visit makes sense, which is true over 50% of the time.
3. Isn’t it dangerous for a doctor to answer the phone? To which no one asks the converse question: What’s the experience when the doctor doesn’t answer the phone? If this occurs, then the most knowledgeable person about healthcare, becomes the LAST person to know. This means exposure to the Hippocrates business model of care: long delays, hassled waits, rushed visits. Illness is not a static problem but evolves. The reality of how you feel this minute in front of the doctor often is rendered irrelevant tomorrow when something dramatically changes “Waiting and communicating change” is critical to medical decision making and treatment. Most doctors bring you back in to “see how you’re doing” and make sure they get paid again. It’s not the doctors’ fault, It’s the way the system pays them.
4. Telemedicine, doesn’t that mean higher chances for malpractice? You’ll love the answer to this, but that will need to wait ‘til next week.
Until next time, I remain yours in primary care,
Alan Dappen, MD
April 14th, 2009 by Dr. Val Jones in Book Reviews
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I recently met the author (Dr. Jill Grimes) of Seductive Delusions: How Everyday People Catch STDs at the AMA’s 29th Annual Medical Communications Conference in Albuquerque, New Mexico. Jill is a family physician in Austin, Texas, with a kind and down-to-earth demeanor. Jill is the type of doctor you like immediately – she makes you feel at ease because of her unpretentiousness.
Jill told me that she wrote Seductive Delusions out of sadness and frustration with her inability to protect young people from STDs. Jill saw new cases of sexually transmitted diseases in her patients every week, and wanted very badly to reverse this trend. No amount of counseling “after the fact” had a sufficient effect on new cases, so she decided to launch a preemptive strike: an educational book targeting those who never thought they could contract an STD.
Seductive Delusions uses a “case based learning” approach to educating readers about STDs. Each chapter begins with two true life stories about young people who succumb to STDs. Characters are based upon the lives of patients whom Jill has treated over the years, but stories are blended to protect anonymity. The story-telling format (followed by fact-based summaries) makes the content more entertaining and engaging to read. I doubt that a textbook could hold readers’ attention as effectively as Seductive Delusions does.
I chose to read Seductive Delusions cover-to-cover in 2 sittings, and such a concentrated dose of horror stories made me feel hesitant about ever having sex again. I can also say that there was one uncomfortable moment in an airplane (I read the book on the way back from Albuquerque) when the man sitting next to me glanced at the cover and gave me a very shifty look, and spent the rest of the flight leaning noticeably towards the seat on the opposite side.
That being said, I did enjoy the book. Jill’s characters have an innocent quality to them – like the cast from “Leave It To Beaver.” And I think that was exactly her point – you’d never expect the Cleaver family to be touched by STDs, and yet the truth is that they are succumbing to them in record numbers. Part of the danger of being one of those supposedly “low risk” individuals is that sufficient precautions against STDs are not taken due to a false sense of security.
I had assumed from the title of the book that “everyday people” would include a wider range of characters than were presented. I have been concerned about the reemergence of STDs, for example, in the retiree community in Florida, and thought that Seductive Delusions might touch on that unexpected risk group. However, the target demographic for the book is the late teen to thirty-something heterosexual male and female. I agree with Jill that there’s an educational gap there – but I would have enjoyed her casting a wider net.
The other potential short coming of the book is that the narratives describing how the various characters contracted an STD are so engaging that the reader is left disappointed at never hearing about the long-term outcomes for these individuals. I became emotionally invested in the story (for example) of how Evan contracted HIV from his very first girlfriend (a woman who had been with a man who used IV drugs prior to dating Evan). I felt as if I were there with Evan when he received the devastating news about being HIV positive, and then he drifted away from the pages of the book never to be heard from again. The lack of resolution left me with an uneasy feeling – probably the same feeling that Emergency Medicine physicians experience at the end of each shift.
Nonetheless, I would highly recommend this book to all sexually active young people. It is eye-opening and disturbing in the right sort of way. It’s the kind of book that will help people think twice before they become intimate with others, and take stock of the true health risks involved. I can only hope, along with Jill, that this book will reach the right eyeballs at the right time – and reduce the devastating spread of sexually transmitted diseases in America and beyond.
