I Almost Always Trust My Wife's Advice

Jeffrey L Brown

 When I finally conceded that my wife is the better day-to-day decision-maker, we rarely had any disagreements. She wanted us to adopt a dog. I thought it would complicate our lives, but I became a convert. Now she complains, “You don’t look at me the same way you look at the dog.” Next, I traded my sports car for an SUV because my wife said, “It's silly to own a car with a stick-shift.” She never drives my car, but she was right. The automatic transmission is easier to drive and there is more room for the dog. Then, I stopped wearing my favorite golf shirt because, “The green color reflects off your skin and makes you look sickly.” Right again! No more green shirts, and my doctor says I look healthier than ever.

So, it was no surprise that she came to my rescue when Vinnie, my barber, shuttered his doors and retired to a warmer climate. “No problem,” I thought. I only want a generic medium-length no-frills haircut and minimal conversation. Unfortunately, all the local barbershops had morphed into unisex salons. I ignored them because they reminded me of “beauty parlors” where women of my mother’s generation had their hair cut, colored, and curled before giant drying-hoods swallowed their heads like aliens in a sci-fi movie. The name-change did not fool me. Beauty parlor was marketing hyperbole. Looking-better-parlor would have been more truthful and less stressful for the operators – but maybe not so good for business. Salon implied sophistication. Unisex meant that men could wander in too.

When my wife learned I was searching for a barber who would give me a boring haircut, she referred me to a nearby salon. She told me with a straight face they have a barber named Amanda who cuts lots of guys’ hair just the way they like it. I had a premonition this would not end well. My barbers had always been named Tony, Richie, Nick, or Vinnie – a.k.a. Anthony, Ricardo, Nicholas and Vincenzo when they worked in salons. None were ever named Amanda! And, there was no striped barber's pole at the shop’s entrance.

The salon’s waiting area was populated by two wet-haired women and one sheepish-looking man with a towel on his head. Instead of the traditional narrow storefront with dim lighting and hard barber-chairs, it was spacious, well-lit, and featured pastel colors and contoured lounges. High-quality speakers played comfort music – a definite upgrade from Vinnie’s counter-top radio that played Yankees baseball, operatic arias, and Golden Oldies. And, Amanda’s cute pants outfit was a clear winner over Vinnie’s side-buttoned dentist shirt that barely covered his expanding midriff.  The strong scent of perfume brought tears to my eyes and itching to my nose. But my biggest complaint was the slippery pink-nylon smock – management’s version of prison-orange that discouraged me from making a quick dash to the street.

Mandy (her preferred name) offered me a cup of coffee. A nice touch except for the little hair clippings that swam on the surface like tiny protozoa.  I broke the conversational ice with, “Please clean up my hair a little and don’t cut it too short.”

I liked my barber Vinnie because he seemed like a really nice guy, but I knew nothing about him. I would say, “How’re things goin’?” and he would say, “Good.” End of conversation. Mandy immediately chronicled complex details of her active love-life, summarized local gossip she said was confidential, and described medical symptoms that could make a doctor blush.

My head was spinning from all this information when she tilted my chair backward and gently massaged my temples with warm soapy water. I closed my eyes. This seemed unexpectedly intimate. “Why are you doing this?” I whispered.  “I can give you a better cut when your hair is wet,” she said softly. “Okay,” I whispered. At least I knew that her hands were clean. When I was catapulted to an upright position, I stayed very still and very alert because Mandy waved her arms while talking and her sharp scissor tips were pointed at my right eye. My hair was sprayed with enough lacquer to withstand a tropical storm and she asked what I thought. It was hard to see through the mist, but I thought she cut it too short. I dutifully replied, “It looks very nice.” Then I paid a bill that was twice what Vinnie charged, over-tipped her, and went on my way.

Not admitting defeat, my wife had already scheduled the next haircut at a different salon – this one with an Asian motif. She had warned the manager about my haircutting proclivities in advance. The Caucasian operator never spoke. A brightly colored pseudo-kimono offset her stone-faced expression. She bowed while motioning me toward the well-padded chair. I nodded. Once I was seated, she bowed again, and I nodded again. “I just want my hair cleaned up a bit,” I said. “And please don’t make it too short.” This time, she bowed and I nodded in unison – a good sign. I tried to relax. The earth-tone décor was pleasant, and I already knew the salon-routine from my first experience. But then a young Asian lady presented me with a wooden bowl of steaming-hot lemon-scented towels that had no obvious purpose. Not wishing to offend her, I removed each steaming towel by its edges and tossed it from one hand to the other hoping to avoid a trip to the hospital's burn unit. Their green tea was garnished with the traditional hair clippings and the music sounded like ocean waves crashing on a beach. An excellent choice because my shirt was soaked from a minor mishap during the hair-washing ritual. After 20 minutes of snipping-combing-snipping-combing, the kimono-lady massaged my shoulders with her knuckles. When she held up a mirror, I was too distracted by the welts on my neck to notice that my hair was the same length as when I entered. “It looks very nice,” I said. Then I paid the expensive bill, over-tipped the stone-faced lady, and returned to my car.

It was time to take the initiative and confront any negative comments from my wife later. I spoke into my mobile phone using a military command voice. “Okay Google,” I said. “Directions to nearest barbershop.” I was in luck. Google said Tony’s Barbershop is only 4.6 miles away with light traffic. I recognized it immediately by its familiar barber’s pole and an old-fashioned sign that read, “Tony’s Barber Shoppe.” I peeked through the window to confirm that the shop was narrow, dimly lit, and had traditional-looking barber-chairs. There was even a table-top radio and I could hear it playing Yankees baseball. I sighed and took a deep nostalgic breath before entering. When I opened the rickety door, a little bell tinkled to summon the barber from a back room. “Hi,” the 20s-year-old said. “My name is Britney. How can I help you?”

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The Need for Revision: Traditional History and Physical “Write-up” Provides Inadequate Context for Sharing Patient Information

Brown JL. Communication pitfalls associated with traditional history and physical write-up documentation. Adv Med Ed Pract 2016; 2017(8): 37-41 DOI http://www.ncbi.nlm.nih.gov/pubmed/28096709

The decades-old traditional “write-up” outline used for documenting patient encounters and giving oral presentations provides inadequate context for sharing clinical information: The examiner’s observations made at the start of a patient encounter are described out of sequence ­― after the patient’s history and chief concerns have already been presented.

An experienced clinician correctly understands that diagnosis and treatment begin when patients enter the examination room. The examiner’s early perceptions about the patient's demeanor, severity of illness, level of distress, and obvious abnormalities can affect patient-clinician interaction, triage, content and accuracy of the history, and clinical reasoning: Patients reporting the same chief concern of “chest pain” are likely to be asked different questions with different focus and interpretation of responses when the examiner perceives the patient to be well, in severe pain, dyspneic, toxic, or clinically depressed. Together with background information that includes age, gender, cultural identification, and occupation, these observations are used to place concerns and history in the context of the patient as a person rather than as an intellectual challenge. (“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” – Hippocrates.)

It has been traditional but not entirely reasonable to categorize the patient's "general appearance" in physical findings because they are as pertinent to the history-taking process as they are to conducting a proper examination. To enable others to interpret the history using the same mindset and context as the examiner, it is necessary for early perceptions to be shared before rather than after the chief concerns and history have already been presented.

Perpetuating use of the unofficial but widely-used write-up outline deemphasizes the importance of creating context when formulating diagnoses and sharing clinical information. Suggestions to improve documentation and oral presentations include placing greater emphasis on teaching contextual methodology and modifying the outline sequence to conform to clinical practice. This modification can be incorporated into most electronic health records by adding early observations to the background information or the chief concerns. Objective and subjective components can still be identified by qualifying them with appropriate language: "This acutely-ill appearing Hispanic male states that he has been having headaches for the past two weeks,"

These needed changes have the potential to decrease miscommunication and clinical error. They also teach the importance of context as a basic principle of clinical reasoning

  

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.

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.

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.

The Zen Master and the Hotdog Vendor

The Zen Master and the Hotdog Vendor

 

    Jeffrey L Brown

jeffbrownmd@outlook.com

 

 

The hotdog vendor led a simple life, but he was not a simple person. He woke before sunrise, toileted, showered, shaved, and dressed in semi-darkness. Then, he stood in the quiet of a windowless kitchen and drank a single cup of stale rewarmed coffee – fuel for the twelve-block walk to his pushcart that waited patiently for his return. This routine had not varied from the day he inherited the bright red cart from his mother’s cousin, a gentle elemental soul whose lingering illness puzzled doctors until life escaped from his body – at home, alone, no fuss, no bother. The vendor referred to his dead benefactor as a distant relative; first-cousin once-removed, sounded odd and he wasn’t quite sure what the term meant anyway.

Both men were named Richard which made the transition from one owner to the next an easy task for regular customers. As a new entrepreneur hoping to make his mark, this Richard thought he could avoid confusion by calling himself Richard the Second. Good sense prevailed, however, and he abandoned this terrible idea because it always precipitated fits of laughter in his customers that left them choking and gasping for air.

In another setting, this second Richard might have seemed regal wearing a freshly pressed apron and greeting customers in a courtly but business-like way. He was self-conscious and awkward during the first few months, but with practice, he learned how to grasp a grilled hotdog with metal tongs, release it into a warm sliced bun, wrap it in a white paper napkin, and add varied combinations of brown deli mustard, Heinz catsup, sweet pickle relish, diced onions, and hot sauerkraut in a seamless motion.  He used seedless top-loading New England style buns because some customers thought seeds harmed their digestion. Also, the side-loading American variety was prone to technical error. Richard believed the napkin should remain pristine white as a sign of cleanliness – impossible to achieve when the bun is filled from the side. Years of dedication and long work hours left him with no competing interests and doing his job well became synonymous with his sense of being. It cleared his mind of the mundane and the rote simplicity created a path toward purity.

 At first, Richard was terribly afraid of disappointing his mother’s family. But once he mastered the necessary skills, he struggled with the potentially numbing effects of boredom.  He avoided this conundrum by following advice he once viewed as contradictory: have constant awareness of your surroundings but remain totally immersed in the task at hand. Unfortunately, the stress from balancing these objectives left no room for reflection and there was no place where he could take contemplative refuge. At dark moments, Richard sometimes wondered if his dead cousin’s undiagnosed symptoms could have been caused by this same malady. But, unlike a Sartre protagonist, he did not allow the pain of constant awareness to crush his spirit. In the end, he chose to embrace his work rather than accept the consequence of effortless competence. And when he suddenly realized that he had acquired an uncanny ability to intuit and then satisfy the needs of others, he used this special gift as his greatest asset.

So, it was not surprising that he was unnerved by frequent visits from a person who looked familiar but whose intent he could not decipher. The man approached the cart with trepidation -- joining the line for a few moments, but then retreating at the very last moment.  A customer told Richard that this man who dressed in monk garb was a Zen master who taught religion at a nearby university. The master’s pencil-thin neck and large shaved head protruded from the robe like a pumpkin on a stick. His narrow feet were housed in open leather sandals, and like the ill-fitting robe, they were at least one size too large. The man’s ruddy complexion radiated sunshine despite the overcast sky and unfocused gray eyes suggested that maybe he could not see.

Different from many of his calling, this Zen master grew up in a comfortable setting. His father earned a decent wage and his family accepted his eccentricities. He made friends but was disinterested in friendship; earned good grades but did not care what was taught; and acquired skills that were rarely used to advantage. Paradoxically, these anxiety-free accomplishments became a source of stress because their spiritless nature made his life seem meaningless.

It was serendipitous when he came across a book of Zen that touted the virtues of uncluttering one’s mind as an enlightened antidote to the suffering caused by complexities and extremes. His first spontaneous smile in a long while appeared when the author quoted the adage that everyone is unique – just like everyone else. So, with a new sense of purpose and help from an empathetic teacher, the monk subjugated his few desires and ultimately earned the title of Master. Unfortunately, one essential element was missing. He could not become so lost in thought that he would become one with his surroundings. The many years of austerity had also taken their toll and he was beset by the desire to experience something material that was top-of-the-line – the very best it could be. He hid these shameful thoughts from his teachers and colleagues but could not hide them from himself. And he knew that if he could not overcome these failings, he would always be a fraud living within the community of his peers.

The Zen master did not know why he was drawn to the hotdog vendor. At first, he thought it was the enticing aroma of food. But then he noticed the red pushcart perched precariously at the curb. It listed so far to one side that remaining upright seemed gravitationally impossible. He did not know that the vendor had purposefully created this illusion as a reminder that perfect balance is necessary to maintain harmonious existence.

If there was any doubt of the cart’s purpose, a weathered sign with the hand-painted likeness of a hotdog was fastened to the umbrella’s pole just above the eye-level of passersby. The master studied this vendor who worked so quickly that the line of customers streamed past the cart with barely a pause, each customer empty-handed on arrival, and hotdog-handed at departure. Cooking hotdogs were centered on the brown-stained grill and those already cooked were arranged three-abreast, away from direct heat. Condiments were neatly arranged in square metal tins within easy reach and an oversized salt shaker sat next to four plastic squeeze bottles. Cold drinks, sweating from humidity, were stacked in a prominent display as a reminder to purchase a drink together with the food.

The vendor knew he was very much of this world but was uncertain where the Zen master belonged. He certainly did not belong on this line waiting for a hotdog. A modest serving of brown rice with some thinly sliced cucumbers would have been a more appropriate choice.  Despite best intentions, he was so disturbed by this familiar-looking monk that a dollop of mustard escaped from a roll and soiled the customer’s napkin. The middle-aged woman appreciated Richard’s apology and fresh napkin, but in truth, she had not noticed the mishap and would not have cared. Now, the vendor’s anxiety was obvious. First, an impossible-to-read customer and then a soiled napkin. It was too much to bear.

The master was next in line. An inner strength kept him from fleeing. “Why am I here?” he wondered. Richard’s apprehension vanished. “I know this man and I know why he is here,” he thought. Richard rarely spoke of the seven years he lived in a Buddhist monastery before becoming a secular entrepreneur.  The master stood before him, magically withdrew a twenty-dollar bill from his robe that had no openings and whispered in a barely audible voice. “Can you help me?”  he asked.  “Of course, I can help you,” said the vendor while placing the money in a small metal box. With one swift motion, he plucked a perfectly cooked hotdog from the grill and released it into a pre-wrapped bun. With surgical precision, equal-sized ribbons of brown deli mustard and Heinz catsup were squeezed from their bottles, and thin layers of sweet pickle relish, diced onions, and hot sauerkraut were applied to the hotdog – all within the confines of the warm, moist, lightly toasted bun. For this special customer, he sprinkled a dash of celery salt on top of the steaming sauerkraut.

 The vendor handed the perfectly complete hotdog to the monk.  “I have just made you one with everything,” he said with pride.

“That is very kind, but where is my change?” asked the master.

“You must accept what is and abandon what used to be. Your change must come from within,” answered the vendor.

When the master did not respond, the vendor shrugged. “You may question the wisdom of what I have said, but it is what it is.”

 

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Neurologic Damage in Gulf War Syndrome

Finally. Now there is clear evidence that the symptoms associated with Gulf War Syndrome (sometimes called CMI or chronic multisystem illness) have a biological basis. Recent studies have revealed that veterans of the Persian Gulf War who have been complaining of chronic fatigue, muscle and joint pain, gastrointestinal symptoms, problems of cognition and depression) have areas of their brains that have atrophied (become smaller) and that their physical response to pain and exercise is different from that of control patients. The cause of this condition is not known, but it is strongly suspected that exposure to nerve gas that was released when we destroyed Saddam Hussein's chemical weapon stockpile is the culprit. Other suspected causes include infectious agents, vaccines, and exposure to other toxins - especially when waste is burned to dispose of it. That is why CMI is sometimes called "burn pit" disease.
     Many CMI symptoms are similar to other medical conditions that do not have an obvious cause; these include fibromyalgia and chronic fatigue syndrome. It is interesting that when physicians are faced with treating debilitating symptoms that have no obvious cause, there is a tendency to blame the patient's psyche. The medical euphemism used by doctors is to describe the patient as suffering from a "functional disorder." Without saying so, the doctor is suggesting that the illness is a "function" of the patient's inability to deal with his or her symptoms. It would be more accurate to say the patient has a condition of "undetermined etiology or cause" because the lack of clear diagnosis is often a consequence of the physician's inability to figure out what is causing the symptoms.
     Another commonly used term is "idiopathic" which literally means that the illness is caused by itself. Calling a condition idiopathic sounds more academic than admitting that we are clueless about what causes it. The difference between idiopathic and functional is that idiopathic illnesses are accepted as having a real or organic basis. Not so with functional illnesses where the physician believes it is more likely than not that the cause resides somewhere "in the patient's head." There can be a real dilemma sorting out which symptoms are psychological and which are organic because patients who have chronic symptoms - especially pain -  tend to become anxious or depressed because of the illness.  This is called somatopsychic illness; when anxiety and depression cause physical symptoms or make them worse, the condition is referred to as psychosomatic.
     Even though many physicians still believe that Gulf War Syndrome is a functional illness brought on by exposure to the stress of combat, to its credit, the Veterans Administration has granted benefits to most Gulf War veterans who have filed for disability because of these symptoms.  The military has been tracking patients with MSI using a voluntary registry, but it is probable that many veterans who would be eligible for benefits are not receiving them.

     As discussed in a previous post, 80 percent of veterans receive their healthcare from sources outside of the VHA, but most civilian physicians do not routinely take a Military Health History to determine whether their patients ever served in the military. Similarly, without a prompt, most veterans do not tell their doctors if they served, when and where they were stationed, and if they were exposed to known toxic substances. Without this information, a civilian physician would be unlikely to make the correct diagnosis of Gulf War Syndrome in a symptomatic patient. It is imperative that all patients be asked these questions and that their responses be entered into their electronic medical records. Veterans also need to be proactive and tell their physicians where and when they served  even when physicians did not ask for this information.

Covert Marketing to Physicians Using Direct to Consumer Pharmaceutical Advertising

UK consumers recently rejected the type of direct-to-consumer-pharmaceutical-advertising (DTCPA) that we see in the United States.  BMJ 2002;324:1416.4   Advocates who support a pharmaceutical company's right to advertise prescription drugs directly to patients correctly argue that some patients (and even some physicians) may become aware of treatments they were not previously knowledgeable about. And because the FDA requires these advertisements to carry the same kinds of warnings that a drug's package insert might contain, they believe that these ads are balanced. The presumption is that when a consumer-patient sees the ad, he or she will ask the doctor to prescribe it, and published research seems to support this presumption.
     But the negatives associated with this kind of advertising may not be as apparent. The content of the ad may seem balanced, but the drug's long list of side effects often contains medical jargon that a consumer will not understand, and while the 50 word a minute voice-over cheerfully warns that this medicine may cause heart attacks, stroke, dementia, or psychosis, the visual picture shows a happy patient playing with her grandchildren. I doubt we will ever see the picture of the stroke patient being carted off to the hospital in an ambulance. These ads also don't tell either the doctor or the consumer when a less expensive medicine with a better track record might be a better choice - and because this medicine is "newer" and "Seen on TV" many assume this newer medicine is somehow "better."
     Like any consumer, a physician is susceptible to name recognition, so if she sees this medicine advertised the night before a patient's visit, she might be more likely to prescribe it the following day. More worrisome is that physicians frequently watch these advertisements with the mindset of a consumer rather than a professional. When I read an advertisement for a pharmaceutical in a medical publication, I am much more likely to pay attention to the negatives than I am when I watch the same content during my favorite TV show. Even though I am aware of this problem, it takes great effort for me to maintain focus because I am watching this show as an escape from my work mentality.
     The most covert and dangerous effect of patient advertising on physician behavior is that doctors may be more likely to prescribe medicines for conditions they would not have treated previously. The prototypic example is prescribing Viagra for "Erectile Dysfunction". Before a massive advertising effort, if a patient approached his physician with a complaint of sexual dysfunction, the doctor would have checked the patient for depression, anxiety, cardiovascular disease, diabetes, and other potentially serious conditions. After ruling these out, the patient would usually have been referred to a urologist to rule out anatomic problems and to discuss a variety of treatments. But, because the advertisements for "ED" appeared with the same frequency as those for laundry detergents, it created the impression that this is an everyday non-medical problem that can be adequately treated by any doctor willing to phone in a prescription for blue pills. No examination or history-taking is necessary. Luckily, most patients with ED do not have serious underlying illness, but physicians should remember the Viagra story as a cautionary tale. Advertising to patients may have more impact on physician behavior than has been previously recognized.

Unintended Consequences of Zero Tolerance for Guns in the Home

 

The recent tragic story of a 4 year old boy who accidentally shot and killed his father with a gun "found in the living room" teaches many valuable lessons. As a pediatrician, I am willing to support responsible gun ownership if it includes legislative proposals that require background checks for all gun-buyers, safety and proficiency testing for gun owners, safety devices on weapons kept at home, a ban on the sale of assault weapons to the public, and an increase in penalties for carrying or selling illegal guns. Many pediatricians endorse policies that would help to keep children out of harm's way, but our zero-tolerance for accidental and purposeful behaviors that might harm children can sometimes make us less critical of pertinent data. Emotional responses to stories like this one are understandable but they also make it harder to set priorities when deciding where we should direct  limited time and money in order to accomplish our goal.

Our most common error is not matching numerators with denominators. If one-third of households with young children have guns in the home and a tragic story like this one is reported in the national rather than the local news, a thoughtful reader should wonder whether the incidence of serious accidental gun-related home injuries by young children or to them might actually be VERY low. We are quick to criticize pro-gun enthusiasts when they publicize the rare case of a gun owner who successfully protects his family without also shooting himself or an innocent bystander. And we criticize the media when they ignore numerators and denominators as a way to sensationalize the evening news ("Health officials warn that during this past week there were 20 cases of disease X reported in the greater New York area" - without also mentioning that they occurred in a population of 22 million people.)

Zero tolerance for anything - but especially child injury - is a laudable but emotional goal that is not usually pragmatic and is rarely achievable. (Using the same resources, preventing 80 percent of serious injuries from three sources might save more lives than trying unsuccessfully to prevent 100 percent of the injuries from one high-profile cause.)  Personal and professional emotional responses should not be confused one with the other. We must take care to exercise the same numerator/denominator awareness that we accuse opposing special interest groups of ignoring if we are to maintain credibility and find practical solutions for these difficult problems.