Tuesday, March 31, 2015

Unnecessary Driving Restrictions After Surgery

A recent WSJ article reviewed new protocols to speed #post-operative-recovery. Patients bounce back faster from surgery with hospitals’ new recovery protocols. (http://on.wsj.com/1CE3M6x via @WSJ) The instruction to not drive for two weeks following surgery is a left-over from the days when lack of power steering,power brakes and automatic transmissions required physical work to drive a car. Unless patients are sedated with anti-anxiety or pain meds, in most cases, there should be no contraindication to driving a car. In many cases, the driver was more debilitated from the illness before surgery than afterward. It is time to reevaluate this unnecessary instruction. The morbidity from lack of independence can actually hinder post-operative recovery and lead to depression. Time to rethink #driving-restrictions.

Thursday, March 12, 2015

Curing Hatred Without Granting Forgiveness

Does Hatred Have a Simple Cure?

“Hatred, which could destroy so much, never failed to destroy the man who hated, and this was an immutable law.”   ― James Baldwin,  The Fire Next Time

     I have counselled many families through times of marital discord.  When a breakup occurred because of infidelity or betrayal of common goals, the person who felt wronged described feelings of disbelief, sadness, anger, and hurt.  These patients often appeared ill. They slept poorly; they looked anxious and depressed; and they had multiple somatic complaints. When anger morphed into toxic hatred of a partner, their clinical condition deteriorated further. The advice I offered them was traditional and pragmatic: “Hating someone harms you more than it hurts them. It serves no useful purpose and anchors you to the past. It interferes with your ability to make sound decisions and it keeps you from enjoying pleasures that might replace those that were lost. It is in your best interest to put these hostile feelings aside so you can focus on improving the future.”  I was very aware that the preferred solution would be to suggest forgiving the perceived wrong, but I rarely made this recommendation.  I had already observed that individuals who are consumed by hate for any reason are irrational and think this advice reflects naiveté; some even become hostile at its mention.  Even worse, if forgiveness is believed to be an unattainable goal ("I will never forgive him for this despicable behavior"), it might convince them that their only choice is to keep on hating. My intent was to facilitate functionality. Philosophical discussions about forgiveness would have to wait.
     To address this issue properly, we must first distinguish between hatred that is a transient emotion and hatred that is consuming and pervasive.  Perhaps we should refer to the latter as a “hatred disorder” when it becomes so severe that it interferes with a person’s ability to function normally.  The hater experiences visceral pain that can be so intense it becomes immobilizing and it can be accompanied by a dangerous mistaken belief that only retribution will bring relief.  In our personal lives, this animosity might be directed toward a person who is blamed for our suffering. In a more abstract setting, it can target any group whose values present an existential threat to our own. In both cases, just being alive seems reason enough to hate these individuals.
     The process of hating generates instant reward by using spiritual magic to punish the villain - the equivalent of piercing a voodoo doll.  On the other hand, the delayed gratification that might occur from granting forgiveness requires mental agility because the culprit remains conceptually unpunished.  In addition, when we are told that we must learn how to forgive [1]it implies that this is an acquired rather than innate skill.  So, except for those few individuals whose generosity of spirit allows them to forgive because it is the ™right™ thing to do, forgiving is not forgiveness at all. It is a pragmatic choice to suppress hatred to achieve a longer-term goal.
     I was frustrated by my inability to help these patients and it seemed clear that a different strategy was needed: “Forgive, Forget (Ignore), and Move On” did not seem to be the best answer. A viable solution became apparent once I realized that similar to the act of loving, the act of hating is also a very strong emotional attractant. Both extremes on the spectrum of human interactions constantly draw us toward the other person as reassurance that the intensity of emotion has not changed. In this case, we are attracted to the object of loathing in order to be certain that we still hate it.  And when hatred is used as a psychic weapon, the attraction becomes even stronger: The more we obsess over the person, the more we hate him. And the more we hate him, the more punishment we are inflicting. 
     Trial and error confirmed that if we substitute for hatred equally intense but different emotions that repel rather than attract, we can create an alternate plan that does not require forgiveness. Disgust and repulsion are excellent choices. Voila!  When we think of the hated person as disgusting and repulsive, it pushes their image away and out of our consciousness. As a bonus, the more the individual was hated, the more repulsive and distant he becomes. What difference does it make what this disgusting person did - or is doing - or will do in the future? Why would anyone care why he did it? Repulsive individuals do despicable things; no other explanation is necessary. The desire for retribution suddenly evaporates because exposing this person’s vile nature is satisfaction enough. Aversion has created distance from toxic thoughts and made room for recovery that hopefully will return us to our pre-injured state. And yes – we now have the ability to move on.
     This entire process seemed counter-intuitive. I had to put aside my personal and professional hesitation to prescribe the use of negative thoughts directed toward others. But my reservations were balanced against the effectiveness of this strategy and the knowledge that the patient’s decision is not irrevocable. Circumstances and perceptions can change with healing and time. And if they do, forgiveness remains an open option that can be considered in the future.

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[1] "If we really want to love we must learn how to forgive."
     –Mother Teresa

Less Is More When Discussing Death with Children

When a child asks, "What happens when someone dies?" there is no need for parents to stumble over answers. Many feel insecure because (1) Few of us really know what happens; we accept our concept based on faith not fact. (2) They don't want to frighten their child. (3) They aren't certain if they should be truthful - or if they should use a "feel good" explanation, whether they believe it or not..  A common error is to over-explain the concept of death and dying - which makes it less likely your child will understand  or be reassured by it.

This should not be complicated. All of these concerns are met by saying,  “No one knows for sure what happens when someone dies, but the people in our family or religion or cultural group believe that …” and then say what you really believe. This answer is honest and protects against confusion if another trusted person says something different,  Your child can make her own decisions when she gets older.

Dying is as natural as being born and both can occur at unexpected or inconvenient times.. Discussions should be concise, age appropriate, and accommodate your child's personality. When discussing the loss of a loved one, expressing sadness but not fear is appropriate. It may also be important to stress that you and your child are safe.When a death was unexpected or occurred under tragic circumstances, discuss the concept of death and this occurrence separately.

Honesty is important.  Most of us accept a variant of three basic themes: Biological: “Wherever I was before I was born is where I will be after I die.” Reward and punishment afterlife: “Good people go to heaven; bad people go to hell” And a forgiving afterlife: “God takes us all to a pleasant place where we will be at peace forever.”  Any of these will be understood my all but the youngest children.

Explaining the process of dying is a bit trickier. Guard against equating death with age or illness. You don't want your child to conclude that everyone who is old or sick is about to die. “Life” is an abstract concept that is difficult to put into words. Yes, your brain and heart stop working and you might look like you are in a deep sleep. But life represents a form of energy (physical or spiritual),which provides an opportunity to use an example your child can easily understand: “Many of your toys have batteries that make them run. When the battery wears out, the toy stops working. The same thing happens to people except that the battery can’t be replaced. Luckily most of us have batteries that last for a very very long time.”

Should your child attend a funeral? The answer depends on age, maturity, and custom. A good rule of thumb is that if you would allow your child to attend a happy event that requires similar demeanor (like a wedding), the child can attend a funeral unless there is strong family objection. In many cases. young children can provide a welcome distraction for those who are grieving. Children are more likely to be curious than frightened and it sets a valuable precedent that your family shares both happy and sad occasions together. Not everything in life is fun. And a healthy exposure to happy and sad creates realistic expectations for the future. I was very resentful when I was away at summer camp and my parents did not tell me that my grandfather died because they didn't want to" spoil my summer.” I held a grudge for many years because I thought it was disrespectful to me and to my grandfather. Don’t make a similar mistake.

Friday, February 27, 2015

Parents' Intuition: It Can Harm As Well As Help

    After my children were born I was very surprised by the degree to which emotional rather than rational thinking influenced our parenting decisions. Even simple choices seemed complicated: Should we wake the baby to feed or allow her to sleep? Was the injury risk from contact sports greater than the benefits of team play? Should the kids stay home when they have a cold but miss their math test? Were we setting boundaries that were too strict or not strict enough? The list was endless and intuition quickly earned a prominent place in our parenting tool kit. We came to realize that there was simply no other practical way to make these choices.
     The concept of intuition is quite mysterious. We understand that it is not rational and use vague descriptive terms like “gut feeling” and “sixth sense” but we don’t quite understand how intuitive feelings get into our heads in the first place.  Even more disquieting is the notion that we have to use intuition to know when to trust our intuition. Intuitive thoughts allow us to make predictions that might seem to be based on absolutely nothing, but the most valuable intuitions occur when we unconsciously compare past experience to what is happening in the present. They can warn us away from serious danger, “I don’t want my daughter travelling in that boy’s car,” and they can address the more trivial concerns of a mother who asks through the bathroom door, “Are you okay in there?” Despite its limitations, most of us agree that a parent’s intuition has real value and it is easy to recall situations where potentially terrible mistakes were prevented by responding to a seemingly unexplained anxiety. It is quite possible, however, that we exaggerate its accuracy and minimize its failures because we are more likely to remember those times when we discovered a toddler about to drink furniture polish than when we rushed to the kitchen and found our child happy and safe. 

     There is usually a complimentary relationship between intuitive and rational thought.  But when there isn’t, bad things can happen.:When rational thinking tells us one thing and intuition another, parents can become so immobilized that they can't make any decisions at all. And there are times when parents were absolutely certain that something is true but intuition tells them to ignore it anyway. It is counterintuitive, but very confident parents who believe that “no one knows my child better than I do,” are at extra risk for making mistakes because they are so certain they know what will happen next.
     Group intuition can also lead us astray.  Most recently, it is playing a role in vaccine refusal. Vaccinating against infectious disease is one of the few times a parent can knowingly lessen their child’s chance of developing permanent brain damage and even death. But the strong power of negative intuition might cause a parent to delay or miss this opportunity - especially when it is reinforced by like-minded friends, relatives and pundits. The statistical evidence is very clear that the risk of developing brain inflammation from measles illness is one thousand times greater than from the vaccine: One per thousand vs one per million. Even when we exclude parents whose religious beliefs don’t allow vaccination and those who think that vaccination is a conspiratorial plot, we might reasonably wonder why an informed parent would hesitate to vaccinate against this disease. The answer is that a fairly large group (including some parents who did vaccinate their children) have a strong intuitive feeling that it is the wrong thing to do. They are aware of the benefits and the risks to their child and others, but it just doesn't feel right. Some have understandable but irrational concerns about giving too many shots, tinkering with the immune system, injecting a "foreign" substance, or the discredited association between vaccines and autism. Often, they will not or cannot articulate why they are so wary. But once this feeling of dread has been planted in their heads, a rational discussion with the doctor is unlikely to make it go away. Unfortunately, we pediatricians can be part of the problem. We often tell parents to trust their intuition but then we don’t address their non-rational fears in a respectful or meaningful way. 
We can and should  agree with parents that their iintuition is a very powerful tool ,but then we can offer them some additional advice: First, be certain that the information you are relying on is current and comes from a reliable source. Be especially wary of “junk science,” anecdotes, and unsubstantiated claims that are found on the internet. Next, try to keep rational thinking and intuitive thinking separate. Don't try to rationalize one in terms of the other; we will make better decisions once we can say, “I know that the evidence says this, but my intuition tells me that…,”  Third, get another opinion – preferably from the child’s other parent. In the vaccine example, I was surprised to learn how often parents in stable relationships have never discussed this issue with each other.  (That is why I frequently made both parents sign our refusal to vaccinate form; it is not legally necessary but it forces both parents to have a conversation.). And last, suggest that they give more weight to the best available information and rational thinking when making those decisions that are most important; vaccination is one of them. Life events are unpredictable, but over time, we are more likely to guess right by playing known odds than by betting on a hunch.

A Search for the Perfect Haircut

The plight of a regular guy who just wants a regular haircut has been neglected by mainstream media because of two erroneous presumptions:  An average-looking fellow should have no difficulty obtaining a medium length hair that is parted on the side and any discussion about it will be boring. Neither is true. Appearance can and does affect the weay we feel about ourselves and how we are perceived by others. And since hair style is integral to the way we present ourselves, it is not surprising that there is a regular flow of opinion pieces that describe ways in which hairstyles can give insight into the wearer's personality, make fashion statements, create practical dilemmas, and impact budget. Even the traditionally male-dominated military has been so concerned about ways that hair can impact female members' morale that new regulations were written to allow ponytails that fall fewer than three inches below the collar, corn-rows of specified length and geometric design, and buns that are less wide than the wearer's head. 

To create proper context, it is necessary to revert to my childhood. My mother’s hairstyle was chosen by a caucus of my mother's mother, sister, and first-cousin.  I was inadvertently drawn into this process when I was left to fend for myself in the "beauty parlor" (now hair salon) waiting room. It took the better part of a wasted afternoon for this trio to have their hair washed, cut, colored, and "permed." Most intriguing was the row of shiny hair-drying hoods that looked like props from a low-budget science fiction movie. To combat boredom, I studied the lady clients as they came and went.  Even as a child, it was obvious that the term beauty in beauty parlor was being used rather loosely: “Looking better” parlor might have been more accurate. 

As a counter-point to these dreaded outings, every third or fourth Saturday morning my dad and I visited the local barbershop. It was dingy, narrow and sparsely furnished. There were a few chipped-paint mirrored-cabinets mounted above old-fashioned sinks that were never used. Three barber chairs sat in front of speckled grey linoleum that had been worn bare where the barber stood.  And five barely padded waiting chairs sat in front of a plate glass window with a blind opened just enough to let sunlight enter the room. These chairs always had at least two bored-looking occupants who would be seen before us regardless of our time of arrival. Despite the gradual morphing of beauty parlors into luxurious hair salons and a growth-industry,  this pragmatic simplicity has not changed much over the years. According to industry statistics, salons now outnumber barbershops by more than twenty to one. 

My father was a no nonsense kind of guy, and I came to appreciate the predictability of each barbershop visit. No appointment is needed and I expect a total weight time of about 20 minutes. I am not good with names, but regardless of which shop I visit, I only have to remember Richie, Tony, Frank (a.k.a. Frankie), and Vinnie. When these same barbers “style” hair in an upscale salon, their clients will know them as Richard, Anthony, Francis, and Vincenzo.

My haircut ritual does not vary much from one visit to the next.
“Hey Richie, how are things going?”
“Don’t cut my hair too short. I want it a little on the long side”

The haircut takes less than ten minutes and my barber always cuts it too short. Then, he uses three brushes in the same sequence: A soft brush that applies lavender-scented sneeze-inducing talcum powder to my neck; a stiff bristled brush that rids me of itchy hair remnants, and a push broom that moves hair from the floor to some secret location.  When he is finished sweeping, I say, “Thanks. It looks nice.” I give him a tip and I am on my way. There are no surprises. this is not true for hair salons. They have lots surprises. During the middle ages, barbers cut hair but they also did blood-letting, tooth pulling, and minor surgery. (The red stripe on the barber’s pole is said to have originated from bloody rags draped over the pole.) Modern salons generate twenty billion dollars a year by offering a list of ancillary services that include poking cuticles with sharp objects, applying hot wax to yank out unwanted hair at the root, and rubbing mud on facial skin with the promise that it will glow and look more youthful.

With the admonition that I needed to spruce up my appearance, my wife sent me to a well-known hair salon. Danielle took me right on schedule ‒ which was disappointing because I like reading outdated magazines and reflecting on absolutely nothing. She covered me with a pink nylon smock instead of the familiar white and blue cotton variety.  I said, “Don’t make it too short.” She said. “Okay,” and began washing my hair. This was humiliating. I had washed my hair when I showered that morning and I was probably six years old the last time someone washed my hair for me. There was no chance of escape. The pink gown was like wearing prison orange and prevented me from rushing out into the street. As a peace offering for my “Is this really necessary?” she handed me a cup of coffee garnished with little hair clippings that moved aimlessly about its surface like tiny amoebae. Her animated monologue made me extremely nervous, not because of content, but because her pointed scissors were being waved dangerously close to my right eye. I learned the names of her three most recent boyfriends, which of them were cute, and why she did or did not like them.  My wife had prepped her that I was a physician, so she thought it reasonable to share that she was suffering from cramps and diarrhea. I hadn't said much, but now I was speechless: Tony or Vinnie would have required I.V. fluids and an ambulance before they would admit to having diarrhea.  When she finished, my new best friend (and patient) held up a mirror to show me parts of my head I had never seen before. And when I nodded acceptance, she sprayed it with enough shellac to keep it neat if I decided to walk through a wind tunnel.  Maybe the hair washing was needed to remove any foreign matter that might have been permanently plastered to my skull.  I smiled and said, “The haircut looks very nice.” Then I gave her a generous tip to go with the pricier bill, and I left.

Not admitting defeat, my wife vetted the next establishment more carefully. This time I was sent to a unisex “spa” where an unsmiling Asian woman bowed and offered me steaming lemon-scented towels for which I could find no useful purpose. I unfolded them, squeezed them into a ball, and put them back on the metal tray. As expected, there was no waiting, my hair was washed before it was cut, and this time I drank from a cup filled with bitter-tasting green tea. So far, everything was okay – except for the music. A real barber has a radio sitting on a shelf  plays upbeat 1960’s oldies; the barber' favorite opera favorite opera. or the third inning of a Yankee's game. Instead, I was listening to tinkling noises filtered through the sound of waves crashing on a stormy beach. Maybe this music was chosen because my shirt was soaked from a mishap that occurred during the hair-washing part of my haircut.  There was endless combing and snipping, snipping and combing, until the operator announced that we were almost finished. I skillfully eluded the hair spray but I was unprepared for what came next.  I closed my eyes when she began to gently massage my neck. I opened them wide when she began using her knuckles to “loosen tight muscles” that were probably caused by the stress from the haircut. When she held up a mirror so I could examine the back of my head , I was almost too distracted by the red welts to notice that now my hair was too long. It looked exactly as it did before it was cut. I told her that “It looked nice,” gave her a generous tip, and walked down the block to wait in line at Richie’s barbershop.             # # #