tag:blogger.com,1999:blog-53321683722577380922024-03-13T04:05:12.853-07:00Pediatrics in crisisBy the author of Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric CareAnonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.comBlogger26125tag:blogger.com,1999:blog-5332168372257738092.post-4713949457249646232015-07-30T07:59:00.001-07:002015-07-30T08:34:20.548-07:00An Open Letter to Walter Palmer - The Most Hated Man in America<!--[if gte mso 9]><xml>
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Walter,</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You’re probably wondering how you became the most hated man
in America.<span style="mso-spacerun: yes;"> </span>From the tone of your hollow
apologies, it is quite clear that you are befuddled by your rise to infamy and
still have no insight into why you’ve become the target of such contempt.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As a student of human behavior, I think I can help shed some
light on the phenomenon.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The inciting incident was the murder of a beloved lion. His
name was Cecil. He lived for thirteen years in the security that he had no
natural predators and he posed no threat to your livelihood as an obscure
dentist in Minneapolis. He died a torturous death, suffering his wounds for 40
hours, so that you could indulge in your sadistic pleasure.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
That was bad enough. But there’s more.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It is your background, your past, all documented by
photographs you treasured, which triggered psychological reactions of dismay
and disgust around the globe.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
To start with, you’re a dentist; a professional of the
healing arts. One expects certain personality traits in healers, the most
important one being compassion. The idea that a physician would enjoy the
killing of animals purely for sport creates <b style="mso-bidi-font-weight: normal;">psychological dissonance</b> that cannot be reconciled without drawing
ire.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Most people are fair-minded: they can understand the need to hunt for
food; they can even accept the need to cull a particular species whose
overpopulation places other species and habitat at risk. They cannot understand
the motivation of a man, who clearly enjoys a comfortable existence, to travel
across the world to murder a member of an endangered species. You don’t seem to
get this.</div>
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<br /></div>
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Speaking of your comfortable existence, in a period where so
many are still suffering from economic insecurity, it is incomprehensible for
them to contemplate that you spent the equivalent of their annual income to
indulge in sadistic pleasures. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Then there are the pictures. You crouching next to Cecil, you
stooped against a dead rhinoceros, you, shirtless, holding the lifeless body of
a beautiful leopard. These pictures trigger the psychological mechanism of <b style="mso-bidi-font-weight: normal;">contrast</b>: Cecil’s majestic mane versus
your receding hairline; Cecil’s pristine fangs versus your toilet-bowl-white
veneers; the strength and dignity of these noble beings versus the imperfections
and impotence of your waning manhood.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In every case, when one views the pictures, one can’t help
but feel that the wrong party succumbed. Nobody roots for bullies.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
About those pictures, not since Putin released photos of
himself bare-chested has the image of a shirtless man caused such utter
repugnance. And not since Sir Lawrence Olivier played the part of Dr. Szell in <i style="mso-bidi-font-style: normal;">Marathon Man</i> has the public been so
creeped out by dentists.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But again, it comes down to your limp apology. You drummed
up the feeble justification that you believed you were acting within the
allowed limits of the law. This was not an issue of legality, Walt. This was
about right and wrong. It’s so sad that you can’t see that. There is no
sincerity in your words, no remorse, no flash of insight.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
You are doomed by your own incapacity to understand.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Cecil suffered for 40 hours in silent dignity. As you pass
your hours in seclusion, unable to practice your profession, unable to step
freely in your own community, you should think of Cecil: think of his
suffering, think of his loneliness. Perhaps, then you’ll understand.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
If you don’t, your soul will rot under the scorching light
of truth like the carcasses of your innocent victims.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Peter Palmieri</div>
<div class="MsoNormal">
Author of <a href="http://www.amazon.com/Art-Forgetting-medical-suspense-ebook/dp/B00DIHZZRK/ref=sr_1_1?ie=UTF8&qid=1438268248&sr=8-1&keywords=the+art+of+forgetting+kindle" target="_blank"><i style="mso-bidi-font-style: normal;">The Art of Forgetting</i></a></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com4tag:blogger.com,1999:blog-5332168372257738092.post-18770290249996163642014-07-25T11:10:00.001-07:002014-07-25T11:27:49.736-07:00Fearlessness in the Mundane: Yet Another Reason Not to Prescribe Antibiotics Indiscriminately<!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">My stunningly attractive and sophisticated wife happens to be a brilliant
GI and liver pathologist (yes, I married up). From time to time, she’ll try to
educate me by sharing an article from her field with me. Such was the case
about a week ago when she handed me an article titled, <a href="http://www.ncbi.nlm.nih.gov/pubmed/24037963" target="_blank">Hepatic Histological
Findings in Suspected Drug-Induced Liver Injury: Systematic Evaluation and
Clinical Associations.</a><span style="mso-spacerun: yes;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/24037963" target="_blank"> </a> </span>Now, this stuff
is typically way over my little pediatrician head, so I told her I’d read it…
later. But she wouldn’t relent. “Look at Table 1,” she said. “You need to know
this.” Boy, did Table 1 get my attention.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">
</span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">The article was written by members of the
Drug-Induced Liver Injury Network (or DILIN) which is an effort involving some
of the most prestigious medical centers in the country to better categorize and
understand liver injury caused by exposure to drugs. If you had asked me, last
week, what drugs are most commonly associated with liver injury, I would have
guessed some big-gun, heavy-duty medications such as steroids, immune
suppressants such as those used after organ transplantation, chemotherapy
drugs, and perhaps some of the anti-fungals. I was only partly right.</span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Table 1 of the article listed the characteristics of
the 249 consecutive patients who were included in the study. The age range of
the patients was 7 to 87 years of age. What got my attention were the 8 most
common drugs implicated in liver injury.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Turns out I was right only about the steroids. The
heading, “Anabolic Agents” was number 6 on the list. They also happened to be
the only drug class listed that was not an antibiotic.<span style="mso-spacerun: yes;"> </span>Here’s the complete list of the top 8
culprits:</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Amoxicillin/clavulanate</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Nitrofurantoin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Sulfamethoxazole/trimethoprim</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Minocycline</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Ciprofloxacin</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Anabolic
agents</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Azithromycin</span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Levofloxacin</span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">This list should give every physician pause because
they are all medications that are prescribed quite frequently. In fact, I
suspect that it is the very frequency with which we prescribe them that
explains their presence on this list. The likelihood that any one of these
medications result in liver injury in an individual patient is extremely low,
but when you consider how many courses of antibiotics are prescribed, it’s not
surprising that this very small percentage ends up accounting for the majority
of incidents. To make an analogy, many more people die in automobile accidents
than aviation accidents. Yet more people have a fear of flying than a fear of
driving.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;">Of course, this does not mean we should stop using
antibiotics altogether: they are a necessary and useful tool when indications
call for their use. But this is yet another warning that the injudicious,
indiscriminate use of antibiotics is fraught with danger. No patient should
suffer complications from a medication or surgical procedure that was not
needed in the first place.</span><br />
<br />
<div style="text-align: center;">
<a href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-Pediatric-ebook/dp/B004R1QBCY/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1406312220&sr=1-4&keywords=suffer+the+children" target="_blank"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;"><b>Parents! Click here and pick up a copy of my book Suffer the Children</b></span></a></div>
<div style="text-align: center;">
<a href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-Pediatric-ebook/dp/B004R1QBCY/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1406312220&sr=1-4&keywords=suffer+the+children" target="_blank"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;"><b>and be a wiser consumer of health care for your little ones.</b></span></a></div>
<div style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 107%;"><a href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-Pediatric-ebook/dp/B004R1QBCY/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1406312220&sr=1-4&keywords=suffer+the+children" target="_blank"><b>You'll be glad you did! </b></a> </span></div>
</div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-3061517660501926362014-06-27T15:06:00.000-07:002014-06-27T20:48:40.013-07:00Rational Foolishness: mis-communication, mis-perceptions and the over-prescription of antibiotics<br />
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">According to the Centers for Disease Control and Prevention, more than 2 million people in the United States suffer infections due to bacteria that are resistant to antibiotics each year, and 23,000 die as a result of these infections. These statistics are worrisome and sobering. Particularly since this problem is, to a large part, a direct consequence of the unnecessary over-prescribing of antibiotics by physicians. This begs the question: </span><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: italic; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">why do doctors prescribe antibiotics when they are not needed? </span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">I’ll offer my answer to this question at the end of this article but first consider this: a recent<a href="http://www.medscape.com/features/slideshow/public/antibiotic-misuse" target="_blank"> </a><span style="color: red;"><a href="http://www.medscape.com/features/slideshow/public/antibiotic-misuse" target="_blank">survey of clinicians and patients</a> </span>shed some light on this phenomenon. Just 5% of physicians surveyed said they never prescribe antibiotics when they are not absolutely sure that they are not necessary, and 11% said that “antibiotics won’t hurt if not needed and could help the patient sooner if I’m correct.” </span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Twenty-eight percent of clinicians surveyed stated that the patient’s request for an antibiotic was the reason for prescribing it when they are not certain that one is necessary, and 10% will prescribe an antibiotic to satisfy a patient’s request when they know it is not indicated.</span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Satisfying perceived expectations of patients is one of the most often cited reasons pediatricians give for dispensing unneeded antibiotics. Yet, the perception of parental expectations on the part of pediatricians can be completely unfounded as shown by a landmark study published in Pediatrics in April of 1999 (Mangione-Smith et al – <i>The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior</i>). Some of the findings of this study were as follows:</span></div>
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</div>
<ul>
<li><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">About half of the parents reported that they expected to be prescribed an antibiotic when they brought their child in with symptoms of the common cold. </span></span></li>
</ul>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The physician’s perception that the parent expected an antibiotic was the only reliable predictor of prescribing an antibiotic for a viral condition (in which an antibiotic is not expected to be of any use). Doctors prescribed antibiotics 9% of the time for viral infections when they did not think the parent wanted an antibiotic, but did so 52% of the time when they believed the parents expected one. </span></span></li>
</ul>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Surprisingly – or maybe not so surprisingly, if you read my book, </span><a href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-Pediatric-ebook/dp/B004R1QBCY/ref=sr_1_4?s=digital-text&ie=UTF8&qid=1403905521&sr=1-4&keywords=suffer+the+children" target="_blank"><span style="color: red;"><span style="background-color: transparent; font-size: 16px; font-style: italic; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Suffer the Children</span></span></a><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> -- when pediatricians perceived that parents wanted an antibiotic they were more likely to diagnose a bacterial infection. Let me repeat that. The physician’s perception of parental expectations drove the diagnosis rather than the patient’s presentation and physical exam findings. An ear infection was diagnosed 49% of the time if they thought the parent wanted an antibiotic and only 13% of the time when they felt the parent didn’t want one. Overall, pediatricians made a bacterial diagnosis in 70% of children with upper respiratory symptoms if they thought the parent wanted an antibiotic compared to 31% when they felt the parent did not desire one.</span></span></li>
</ul>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">But doctors were often wrong in their assessment of parental expectations. Twenty-seven % of the time they believed a parent wanted an antibiotic when the parent did not desire one, and they correctly surmised that a parent wanted an antibiotic only 41% of the time when the parent did expect a prescription.</span></span></li>
</ul>
<ul>
<li><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Though the desire to satisfy patients is often quoted by physicians as a reason for prescribing unnecessary antibiotics, in this study, failure to provide antibiotics when the parent expected a prescription did not affect satisfaction. The only predictor of dissatisfaction was poor communication.</span></span></li>
</ul>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Good communication between physician and patient is a cornerstone of high-quality medical care. Which is why some proponents argue that the best way to reverse the trend of over-prescribing antibiotics is to improve physician communication skills. One approach is to ask the patient direct questions in regards to their expectations. Yet physicians balk at this, claiming that doing so may exacerbate direct confrontation if the patient were to cling to an unreasonable demand.</span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">“You’re not in a negotiating stand,” a general practitioner interviewed for one study said with regards to when a patient has a high expectation for an antibiotic when one is not warranted. (Mustafa et al, <i>Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study</i>) “You are very much in a direct conflict stand, which doesn’t help anyone.” As a result, practitioners surveyed for this study disclosed that they resorted to indirect ways of eliciting a patient’s expectations, contrary to the advice of many communication’s efforts.</span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>What can parents do to avoid receiving an unnecessary prescription for an antibiotic? </b>Try to do your best to communicate your expectations with your physician. Rather than offering “candidate diagnoses” (“I’m worried Johnny has a sinus infection”) try to stick to describing the actual symptoms. The mention of candidate diagnoses by parents increased the likelihood of antibiotic prescription in one study. If the doctor determines your child has a viral infection that will not improve with an antibiotic, it’s perfectly appropriate to ask her how she came to this conclusion, what to expect in the coming days, what you can do to help alleviate the symptoms, and what to look for as far as worrisome symptoms that might require follow-up. Disputing the diagnosis, on the other hand, will often lead physicians to cave in and prescribe a medication your child will not need.</span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">I told you earlier that I would offer my own explanation as to why physicians are so prone to prescribing antibiotics when they know they are unlikely to help. Isn’t it irrational for highly trained professionals to prescribe treatments that are counter to accepted guidelines of care? </span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Actually, the unnecessary prescription of antibiotics is perfectly rational from their point of view of the physician – what one might term, rational foolishness -- and can best be understood in terms of potential risks and rewards. Risks and rewards for the physician, that is, not for the patient. </span></div>
<div dir="ltr" style="line-height: 1.1500000000000001; margin-bottom: 10pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Though on a population basis the over-prescribing of antibiotics constitutes a public-health risk, with regard to the individual patient, it is hard for the physician to envision any imminent harm (unless the patient suffers an unanticipated allergic reaction to the medication). Thus, the way the doctor sees it, the risk of not prescribing a medication (missed diagnosis, lawsuit, unsatisfied patient, loss of time and unpleasantness resulting from a discussion of why an antibiotic is not needed) outweighs the risk of prescribing (rare allergic reaction, unlikely that MY patient will get a resistant bacterial infection from just one teeny antibiotic script). Besides, we doctors don’t have to pay for the medication.</span></div>
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<span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-55155230513011747162014-04-07T11:31:00.001-07:002014-04-07T11:36:44.389-07:00Does the United States have the best health-care in the world?<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Does the
United States have the best health-care in the world?</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">That was the
question posed by a noted professor of medicine at a recent conference I
attended.<span style="mso-spacerun: yes;"> </span>Of the physicians and other
health professionals that made up the audience, not one raised their hand.<span style="mso-spacerun: yes;"> </span>Not one!<span style="mso-spacerun: yes;">
</span>How could that be?</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Was no one
in the audience aware that the United States has among the highest survival
rates for cancer treatment in the world?<span style="mso-spacerun: yes;">
</span>That our outcomes for complicated surgery are the envy of the
globe?<span style="mso-spacerun: yes;"> </span>That trauma care is not equaled in
any other country?<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Was the
audience composed of a bunch of anti-American radicals intent on destroying the
best system of medical care the world has ever seen?<span style="mso-spacerun: yes;"> </span>After all, look at all the wealthy foreigners
that flock to our hospitals to receive the latest innovations in treatment from
the best and brightest doctors in the world!</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">One can say,
with a fair degree of confidence that the United States is the best country in
the world to be in if you are very sick (definitely where you want to be if you
get shot, stabbed or if you’re involved in a high-impact motor-vehicle accident
– yes, we’re the kings of trauma care!)<span style="mso-spacerun: yes;">
</span>But the objective of a health-care system goes beyond caring for the
ill:<span style="mso-spacerun: yes;"> </span>it has the responsibility to help
preserve health among the non-infirm.<span style="mso-spacerun: yes;">
</span>And that’s where we don’t do so well.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">This is not
a function of the quality of the doctors in our country but of the organization
of the preventive services we have available.<span style="mso-spacerun: yes;">
</span>The key concept at play is that improving the medical care physicians
provide will have a minimal impact on broader outcomes of health in our
country.</span></div>
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<span style="font-size: 12.0pt; line-height: 107%;">This can be
easily understood when we break down the determinants of one’s health listed
here from highest to lowest importance:</span></div>
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<br /></div>
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<span style="font-size: 12.0pt; line-height: 107%;">Behavioral
patterns (smoking, diet/exercise, use of seatbelts, etc.):<span style="mso-spacerun: yes;"> </span>40%</span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Genetic
predisposition:<span style="mso-spacerun: yes;"> </span>30%</span></div>
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<span style="font-size: 12.0pt; line-height: 107%;">Social
circumstances (income, socio-economic status):<span style="mso-spacerun: yes;">
</span>15%</span></div>
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<span style="font-size: 12.0pt; line-height: 107%;">Medical care
received:<span style="mso-spacerun: yes;"> </span>10%</span></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Environmental
exposure:<span style="mso-spacerun: yes;"> </span>5%</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">As you can
see, medical care received is near the bottom of the list.<span style="mso-spacerun: yes;"> </span>So access to great physicians, laboratory
tests and newest medications is relatively unimportant in terms of an
individual’s overall health compared to habits, genetic make-up and
socio-economic status.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">Yet, we
continue to invest disproportionately in medical care; in fact we spend way
more per capita on medical services than any other country in the world.<span style="mso-spacerun: yes;"> </span>To make things worse, the traditional model
of physician re-imbursement has always favored performing as many procedures (often
of dubious value) on the individual patient as possible while not rewarding
efforts towards improving health on a community level.</span></div>
<div class="MsoNormal">
<span style="background-color: yellow;"><br /></span></div>
<div class="MsoNormal" style="text-align: center;">
<span style="background-color: blue;"><b><span style="font-size: 12.0pt; line-height: 107%;"><span style="background-color: yellow;"><a href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-Pediatric-ebook/dp/B004R1QBCY/ref=sr_1_1?ie=UTF8&qid=1396895445&sr=8-1&keywords=suffer+the+children+kindle" target="_blank">Get your copy of Suffer the Children, the acclaimed critique of Pediatric care now!</a> </span></span><span style="font-size: 12.0pt; line-height: 107%;"><span style="background-color: white;"><span></span></span><span style="background-color: white;"><span></span></span></span></b></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">The
professor giving the talk offered the following solution, very much
tongue-in-cheek:<span style="mso-spacerun: yes;"> </span>“If you’re really sick,
come to the United States.<span style="mso-spacerun: yes;"> </span>If you’re
healthy and want to stay that way, go to Norway!”</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: 12.0pt; line-height: 107%;">A better
solution would be to re-examine our health-care priorities in this
country:<span style="mso-spacerun: yes;"> </span>to change physician
compensation so that it rewards preventive care instead of offering perverse
incentives; to address social determinants of illness and eliminate disparities
in delivery of care; and to engage patients as partners in health to promote
healthy behaviors.<span style="mso-spacerun: yes;"> </span>Until we do so, a
large proportion of our health-care dollars will go up in smoke.</span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-29936878118745146622014-03-19T08:42:00.001-07:002014-04-07T12:21:20.877-07:00Winner, North Texas Book FestivalOK, so I'm tooting my horn but every once in a while we're allowed to do this.<br />
<br />
My novel of medical suspense, The Art of Forgetting was awarded 1st place in the adult fiction (as compared to children's books -- this is not erotica) at the 2014 North Texas Book Festival Book Awards.<br />
<br />
If you enjoy authors such as Tess Gerritsen, Michael Palmer, Lisa Genova and Carol Cassella, you'll love The Art of Forgetting. <br />
<br />
Reviewers have called it "unforgettable", "a masterpiece of medical and psychological suspense", and "a beautifully crafted novel of medicine, mystery and triumph."<br />
<br />
So check it out, buy it, write a review on amazon and goodreads and tell all your friends about it.<br />
<br />
Here's the web page for my novel where you can get more info, see a picture of the debonair author and access a free sample:<br />
<br />
<div style="text-align: center;">
<a href="http://theartofforgettingbook.wordpress.com/" target="_blank">Official web page of The Art of Forgetting</a></div>
<br />
<br />
And here's the link to my Amazon page:<br />
<br />
<div style="text-align: center;">
<a href="http://www.amazon.com/Art-Forgetting-Peter-Palmieri-ebook/dp/B00DIHZZRK/ref=sr_1_1?s=digital-text&ie=UTF8&qid=1395242559&sr=1-1&keywords=the+art+of+forgetting" target="_blank">The Art of Forgetting on amazon</a></div>
<br />
<br />
<br />
I wish you good reading and exceptional health!<br />
<br />
PeterAnonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-2343387493646201092013-10-07T16:34:00.002-07:002013-10-07T16:36:58.328-07:00The Reluctant Hypnotist<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal">
The most frequent criticism skeptics receive is that we are
not open-minded. I’m sure this is true to some extent but contrary to popular
belief, it is not a quality that defines us.<span style="mso-spacerun: yes;">
</span>Sure, there are closed-minded skeptics just as there are many
non-skeptics who are closed-minded to the value and validity of the scientific
method. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Most of the skeptics I’ve come across are actually what I
like to think of as reservedly open-minded, which simply means that they defer
acceptance of a belief until after they’ve been presented supporting
evidence.<span style="mso-spacerun: yes;"> </span>The only exception might be in
matters of absolute implausibility based on a preponderance of scientific
knowledge, past experience and logic (things like telepathic weight-loss, proven
systems for winning the Mega-Lotto and the efficiency of government programs
come to mind). </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Many other issues – those that seem to straddle the realms
of possibility and unlikelihood – are downright intriguing to skeptics.<span style="mso-spacerun: yes;"> </span>For me, one such issue is hypnosis.<span style="mso-spacerun: yes;"> </span>I find the topic of hypnosis so intriguing,
in fact, that I’ve actually dabbled in it.<span style="mso-spacerun: yes;">
</span>I want to share my experiences and offer a rational explanation for what
I witnessed.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A few summers ago, I was working as a pediatric hospitalist
in South Texas in the midst of an epidemic of viral meningitis.<span style="mso-spacerun: yes;"> </span>Nearly every day I was charged with admitting
one or more children who presented to the hospital with high fever, chills,
vomiting, a stiff neck and the worst headache of their lives.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The treatment for viral meningitis is “supportive”:<span style="mso-spacerun: yes;"> </span>pain relief, rest and IV hydration in most
cases. The majority of children feel much better after a few rather miserable
days. Physicians also give intravenous antibiotics until they’re quite certain
that the patient doesn’t actually have bacterial meningitis which is a
life-threatening condition.<span style="mso-spacerun: yes;"> </span>The only
sure-fire way to distinguish viral from bacterial meningitis is to analyze the
cerebro-spinal fluid (CSF) which bathes our brain and spinal cord. And the only
way to do that is to do a lumbar puncture or spinal tap.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I’ve done hundreds of spinal taps in my life (most of them
on infants) but I’ve never had one done on me.<span style="mso-spacerun: yes;">
</span>I’m sure it hurts at least a little and, depending on how it’s done,
sometimes it hurts a lot. With the exception of newborns, we try to eliminate
the pain by using local anesthetics. But the injection of lidocaine to numb up
the area stings in and of itself, and the sensation is augmented in a child or
teenager who is ill to start with besides being terribly anxious. So we often must
resort to providing some form of sedation (you really don’t want a child writhing
and jerking when you’re about to insert a needle in their lower spine).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Sedation requires a much higher level of care.<span style="mso-spacerun: yes;"> </span>You need adequate monitoring capabilities and
more staff in order to quickly recognize and deal with any potential adverse
effect from the sedative. You also must have the capability to provide life
supportive measures should the child have a complication from the sedation. <span style="mso-spacerun: yes;"> </span>In our hospital in South Texas the policy
required placing these children in the intensive care unit.<span style="mso-spacerun: yes;"> </span>Yet the ICU was often full and we were
sometimes short-staffed. So what was one to do?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I was pretty convinced that if I could gain the complete
trust of my young patients and succeeded at reducing their anxiety I’d be able
to mitigate some or most of their pain.<span style="mso-spacerun: yes;">
</span>So I decided to give hypnosis a chance.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My first experience with hypnosis was in high school when a
stage hypnotist held a show at our school.<span style="mso-spacerun: yes;">
</span>I was pretty darn impressed (but then again, I was a very gullible lad).<span style="mso-spacerun: yes;"> </span>Still, I didn’t quite know what to make of the
whole thing.<span style="mso-spacerun: yes;"> </span>Were the participants on
stage actually entering a different state of consciousness or were they just
being driven to “play along” with the hypnotist’s suggestions due to some
psychological prerogative of being the center of the show, not wanting to
disappoint the audience, the hypnotist, or maybe both?<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In college, my studies (including a class titled, Altered
States of Consciousness) did little to shed light on the issue.<span style="mso-spacerun: yes;"> </span>Interestingly, I started gaining a clearer
understanding about the phenomenon from the entertainment world, most recently
from Derren Brown (if you don’t know who Derren Brown is, you just have to
watch some of his videos which are everywhere on the internet).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So that summer, I decided to resort to hypnotism as an
adjunct to local anesthetic in performing spinal taps on any child who was old
enough to be able to listen to me and understand what I was saying.<span style="mso-spacerun: yes;"> </span>I developed an “induction script” (the series
of phrases designed to help subjects enter “trance”) that I felt comfortable
with and refined and calibrated it for my purposes.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The first patient I tried it on was a bright teen-aged
girl.<span style="mso-spacerun: yes;"> </span>She listened to my script, closed
her eyes and lay perfectly still as I spoke to her in my best hypnotist
voice.<span style="mso-spacerun: yes;"> </span>When I decided to “test” the
depth of her trance by suggesting that one of her arms was getting lighter and
lighter, as though a bunch of helium balloons were tied to her wrist, her arm
began to drift up in the air, at which point her mother (who was sitting
quietly in the procedure room) leaned forward wide-eyed and <span style="mso-spacerun: yes;"> </span>let her jaw drop.</div>
<div class="MsoNormal">
The procedure went so smoothly that it was an absolute joy.
When I was finished I asked the child if she had experienced much pain.<span style="mso-spacerun: yes;"> </span>She said, “I didn’t feel a thing.”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
My second patient was an extremely anxious boy who was the
son of a high-ranking county official. The nurses had struggled to draw blood
work and insert an IV because he was so terribly scared by the entire
experience of being in the hospital. I honestly didn’t think my hypnosis would
work at all with him.<span style="mso-spacerun: yes;"> </span>But to my
surprise, and to his mother’s utter delight, he too remained comfortable for
the entire procedure and later told me, “That was great!”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Over the next few weeks I performed nearly two dozen lumbar
punctures under hypnosis.<span style="mso-spacerun: yes;"> </span>Most of the
patients had extremely pleasant experiences. I was not able to provide comfort
in one case.<span style="mso-spacerun: yes;"> </span>Overall, I was very happy
with the ability to comfort my young patients.<span style="mso-spacerun: yes;">
</span>Some of the parents were skeptical at first but thrilled by the end
result.<span style="mso-spacerun: yes;"> </span>Nurses volunteered to assist me
with the procedure, intrigued by the whole process.<span style="mso-spacerun: yes;"> </span>None of my patients required ICU stays for
sedation.</div>
<div class="MsoNormal">
Let’s be clear. This is complete anecdotal experience, but
will I perform hypnosis on the next child or teenager that needs a lumbar
puncture?<span style="mso-spacerun: yes;"> </span>Absolutely.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This is how I see it.<span style="mso-spacerun: yes;">
</span>As a hospitalist, I was providing care to patients who in most cases I
had never met.<span style="mso-spacerun: yes;"> </span>Along with the anxiety
sparked by the child’s illness and by the intimidating surroundings, there was
the added apprehension that neither the family nor the child knew me.<span style="mso-spacerun: yes;"> </span>So, how could they know if they should trust
me?</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Hypnosis, in my opinion, goes a long way in such a setting
to establish trust.<span style="mso-spacerun: yes;"> </span>I clearly
communicated to the parents and the children that patient comfort and relief
from pain were my utmost priorities.<span style="mso-spacerun: yes;">
</span>This in itself was very reassuring.<span style="mso-spacerun: yes;">
</span>I listened, answered questions and deliberately did not rush (the
process of hypnosis does have a cost in terms of physician time, but is well
worth it and may actually save a lot of time in the long run).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
So do I believe that hypnosis is a true altered state of
consciousness?<span style="mso-spacerun: yes;"> </span>I’m still not sure.<span style="mso-spacerun: yes;"> </span>I think that for most individuals it is simply
a state of great relaxation, of extreme serenity and trust, and of heightened
suggestibility.<span style="mso-spacerun: yes;"> </span>To me, hypnosis is just
an extension of good bed-side manners.<span style="mso-spacerun: yes;">
</span>It is an explicit expression and demonstration of concern that requires
an investment of time and patience.<span style="mso-spacerun: yes;"> </span><br />
</div>
<div class="MsoNormal">
Besides benefitting the patient, hypnosis is a boon to the
physician as well.<span style="mso-spacerun: yes;"> </span>It helps to establish
a cooperative and trusting relationship.<span style="mso-spacerun: yes;">
</span>It creates a sense of goodwill and calm that is highly therapeutic for
all involved.<span style="mso-spacerun: yes;"> </span>And it helps you care more
deeply for the patient, which is always a good thing.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
And what about those stage hypnotists?<span style="mso-spacerun: yes;"> </span>Is that stuff for real? I believe very
different psychological mechanisms may be at work there.<span style="mso-spacerun: yes;"> </span>I can’t say that I’m very concerned or
impressed by them anymore (except for Derren Brown – he is beyond impressive;
he’s outright fascinating, but of course he’s not technically a stage hypnotist).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As I was saying, skepticism is not a position of
closed-mindedness.<span style="mso-spacerun: yes;"> </span>In fact, it is
frequently a position of absolute fascination and appreciation for the wonders
of the universe.<span style="mso-spacerun: yes;"> </span>It is a devotion to
pursuing the truth wherever it may lead us.<span style="mso-spacerun: yes;">
</span>But the pursuit of the truth is not likely to be fruitful when we leave
the path of plausibility. And the truth does not require the investment of
faith; it does not require us to believe first so that we may experience the
truth first-hand; it does not demand that we forfeit thoughtfulness and a
questioning, critical stance; it does not require the sacrificing of objective
evidence in favor of subjective validation.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Call me the reluctant hypnotist;<span style="mso-spacerun: yes;"> </span>just another soul trying to make sense of the
utter complexity of the world we are part of, meagerly equipped with a fallible
mind that is prone to error, easily seduced by the siren-song of false prophets
but fortunately tied to the mast of a steady ship with the ropes of reason,
empiricism and questioning. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Am I
closed-minded?<span style="mso-spacerun: yes;"> </span>I’ll let you decide.</div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-5719797434359564502013-08-13T18:00:00.002-07:002013-08-13T18:00:34.022-07:00The Delusion of Dilution: When Pharmacists Recommend Homeopathy<!--[if gte mso 9]><xml>
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</xml><![endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">You’re awakened just after midnight by a
scream.<span style="mso-spacerun: yes;"> </span>You pull on a robe, step through
the darkened hallway and tiptoe into the bedroom of your three-year old.<span style="mso-spacerun: yes;"> </span>He’s sitting up in bed, clutching his ear,
sobbing.<span style="mso-spacerun: yes;"> </span>As you try to comfort him he
settles into a plaintive wail.</span>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">“It hurts,
Mommy.”</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">That’s when you
realize you’re all out of pain medication.<span style="mso-spacerun: yes;">
</span>You pull on a pair of jeans and a sweatshirt to make a run to the
24-hour pharmacy.<span style="mso-spacerun: yes;"> </span>When you get there,
you notice a kindly-looking man in a starch-white smock behind the
counter.<span style="mso-spacerun: yes;"> </span>He doesn’t appear particularly
busy, so you decide to ask him for advice. After relaying your son’s symptoms,
he nods, walks around the counter and leads you down an aisle stocked with
brightly colored boxes of medicine. </span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">“Try these,” he
says, as he hands you a small box of ear drops.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Not what you
expected, you think.<span style="mso-spacerun: yes;"> </span>But you’re
glad.<span style="mso-spacerun: yes;"> </span>In fact, you’re only too happy to
shell out twelve bucks to relieve your child’s pain.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">What you don’t
know is that the drops the pharmacist gave you will not work.<span style="mso-spacerun: yes;"> </span>In fact, they couldn’t possibly work because
they contain no medicine at all.<span style="mso-spacerun: yes;"> </span>What
you don’t realize – what he didn’t tell you – is that the “medicine” he gave
you is a homeopathic preparation.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Anyone who’s
read my book, <i style="mso-bidi-font-style: normal;">Suffer the Children</i>
knows that I hold no punches in holding my profession of pediatrics accountable
when its practitioners stray from accepted standards of care. I’ve strongly
criticized physicians for exposing children to potential harm by missing basic
diagnoses, by excessively prescribing unnecessary medications and needless
laboratory tests, and in some instance, by putting profit above patient care.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">In this article,
I will turn my attention to a non-scientific philosophy of healing created by
the German physician, Samuel Hahnemann in the late 18<sup>th</sup> century.
Normally I don’t fret too much about this subject, but lately I’ve noted a
worrisome trend.<span style="mso-spacerun: yes;"> </span>I see more and more
families who are “prescribed” homeopathic remedies by pharmacists, often for
the treatment of diarrhea or teething, and more frequently to relieve ear pain
due to infection.<span style="mso-spacerun: yes;"> </span>Almost always, the
family is unaware that the medicine they purchased is homeopathic.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">When I ask my
patients’ parents what their understanding of homeopathy is, many answer that
it’s “natural” and involves herbs and such.<span style="mso-spacerun: yes;">
</span>Actually, that’s not true at all.<span style="mso-spacerun: yes;">
</span>If you read the list of ingredients on homeopathic preparations, you’ll
often find the names of highly toxic materials such as lead, mercury and sulfur.<span style="mso-spacerun: yes;"> </span>But don’t worry if you’ve taken these in the
past:<span style="mso-spacerun: yes;"> </span>they don’t really contain these
ingredients at all (I’ll explain in just a bit).</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Actually,
homeopathy is based on a couple of fundamental precepts.<span style="mso-spacerun: yes;"> </span>The first, known as the “law of similars”
holds that a substance that is able to create a particular symptom holds the
key in treating a disease in which the symptom is present.<span style="mso-spacerun: yes;"> </span>This is sometimes knows as “like treats
like”.<span style="mso-spacerun: yes;"> </span>So something that makes you
sneeze, according to homeopathy, would be a good choice for the treatment of
hay-fever. As long as it is prepared in accordance to the second law:<span style="mso-spacerun: yes;"> </span>“the law of infinitesimals”.<span style="mso-spacerun: yes;"> </span>This law holds that the more dilute a
substance is, the more effective it will be.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">How dilute?<span style="mso-spacerun: yes;"> </span>Let’s take the example of the earache drops
that are commonly recommended by pharmacists and advertised on the web page of
the largest national franchise pharmacies.<span style="mso-spacerun: yes;">
</span>Here’s what the box says:</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Active
Ingredients </span></b></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br />
Pulsatilla 30C, Chamomilla 30C, Sulphur 30C, Calcium Carbonate 30C, Belladonna
30C, Lycopodium Clavatum (Club Moss) 30C </span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Inactive
Ingredients</span></b></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><br />
Citric Acid, Water (Purified), Sodium Benzoate, Vegetable Glycerin </span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">The “30C” following each of the active ingredients reveals
their supposed dilution.<span style="mso-spacerun: yes;"> </span>In homeopathy,
an “X” represents a dilution of one part active ingredient in 10 parts of
water.<span style="mso-spacerun: yes;"> </span>A “C” is one part active
ingredient in 100 parts of water.<span style="mso-spacerun: yes;"> </span>To
achieve a 30C dilution, we start with one part of the active ingredient, drop
it in 100 parts water and shake real well.<span style="mso-spacerun: yes;">
</span>Then you get an aliquot of that suspension, put in another 100 parts of
water and stir well.<span style="mso-spacerun: yes;"> </span>Repeat the
operation 28 more times.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Basic chemistry tells us just how much we can dilute a
substance and still retain the original ingredient.<span style="mso-spacerun: yes;"> </span>The prominent physicist, author and debunker
of pseudo-science, Robert Park Ph.D. calculated that to retain a single molecule
of the original substance, a 30C dilution would need to be dissolved in at
least 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000
molecules of water (see the excellent article on <a href="http://quackwatch.com/">quackwatch.com</a>) which
corresponds to a volume 30,000,000,000 times the size of our planet.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">Modern practitioners of homeopathy don’t dispute these
calculations. They agree that none of the active ingredient is likely to be
present at such dilutions but they claim their medications are effective
nonetheless because the water retains a memory or essence of the original
substance.<span style="mso-spacerun: yes;"> </span>This is sheer nonsense.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-align: center; text-indent: 0.5in;">
<span style="font-size: small;"><span style="font-family: "Times New Roman","serif"; line-height: 115%;"><span style="font-family: Georgia, "Times New Roman", serif;">Join me in celebrating the launch of my medical suspense, <a href="http://theartofforgettingbook.wordpress.com/" target="_blank"><i>The Art of Forgetting</i></a></span></span></span></div>
<div class="MsoNormalCxSpMiddle" style="text-align: center; text-indent: 0.5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="font-family: Georgia, "Times New Roman", serif; font-size: small;">August and September, 2013<i> </i></span> </span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";"><span style="background-color: blue;"><span></span></span>It may be hard to believe that pharmacists, who are educated
in basic chemistry, biology, pharmacokinetics and pharmacodynamics would buy
into the claims proposed by homeopathy (and most don’t), but I’ve learned that
a good education and even intelligence does not necessarily render an
individual immune from irrational beliefs. </span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">A couple of years ago, I wrote a letter to the executive
directors of two major pharmacy chains to ask if they endorsed the use of
homeopathy and whether it was company policy for pharmacists to recommend
homeopathic products.<span style="mso-spacerun: yes;"> </span>I never received a
reply, which I guess should be no surprise.<span style="mso-spacerun: yes;">
</span>As is so often the case, the best way to protect consumers from this
type of fraudulent practice is through education, and I hope I’ve done my small
part with this article.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">In truth, if I had been alive in 1795, I’d have gladly
chosen Hahnemann’s nostrums over the leeching, purging and blood-letting that
was rampant in the day – homeopathy doesn’t work, but at least it doesn’t
outright kill you. But the year is 2013.<span style="mso-spacerun: yes;">
</span>The world has changed dramatically.<span style="mso-spacerun: yes;">
</span>Homeopathy has not.<span style="mso-spacerun: yes;"> </span>So I’ll take the
cold, objectiveness of science over the warm fuzziness of pseudoscience every
time.<span style="mso-spacerun: yes;"> </span>In the end, nothing is as soothing
as rationality.</span></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="text-indent: .5in;">
<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">There are few pediatric topics that fuel as much
passionate debate (among physicians and laypeople alike) as to whether healthy
newborn boys should be routinely circumcised. One camp argues that the
procedure is essential to avert potentially catastrophic illnesses whereas the
opposition go as far as calling the procedure a wanton violation of human
rights.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Claims from the most ardent advocates on either side
can be strident and silly, which is not helpful to parents caught in the
middle. Much of the controversy, I believe, stems from the fact that
circumcision is the only elective surgical procedure that is performed on
neonates. Unfortunately, a policy statement from the American Academy of
Pediatrics and its recent revision have neither doused the flames of
controversy nor imparted clarity on the debate.</span></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 18.0pt; line-height: 115%;">Circumcision
is the only elective surgical procedure performed on neonates.</span></i></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">For many well-meaning parents, the entire issue is
befuddling and adds unnecessary stress to what should be a joyful time. To the
anxious parent, I’d like to offer a simple message: relax! The choice you make
is not likely to have a major impact on your child’s health one way or the
other. And your child, I assure you, will not be asked his circumcision status
on his application to Harvard. To stress the point, I am told that there have
been great men who have made significant contributions to human society and
lived healthy lives well into their nineties both with and without their
foreskins.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">What I do advise parents to do is to become aware of
the issues involved so that they can be comfortable with whichever decision
they settle on. Know <i style="mso-bidi-font-style: normal;">why</i> you chose
what you chose.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Part of the reason this issue is mired in
controversy is that it is colored by religious and cultural considerations. If
you wish to circumcise your child for religious reasons, this article is not
for you. You already know the reason behind your choice, and presumably, you
are comfortable with it.<span style="mso-spacerun: yes;"> </span>Go in peace.
But please do not misinterpret this as my supporting the procedure for
religious reasons. It’s just that the reason for your choice is outside the purview
of this particular article. On the other hand, if you are interested solely on
the potential health benefits of circumcision, please read on.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">The best place to start in making sense of the
debate is to glance at the policy statement from the American Academy of
Pediatrics (available in its entirety here: </span><a href="http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1989</span></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">).
The Academy proposes that the “</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-fareast-font-family: "Times New Roman";">preventive
health benefits of elective circumcision of male newborns outweigh the risks of
the procedure… Although health benefits are not great enough to recommend
routine circumcision for all male newborns, the benefits of circumcision are sufficient
to justify access to this procedure.”<span style="mso-spacerun: yes;">
</span>This is a more enthusiastic endorsement of the procedure compared to the
1999 position that stated that there were some potential health benefits to
circumcision “</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">yet the procedure is not essential to the child's
current well-being, parents should determine what is in the best interest of
the child</span>.”</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">So, what are these health benefits?<span style="mso-spacerun: yes;"> </span>The AAP cites a reduction in the rate of
urinary tract infections, penile cancer and some sexually transmitted diseases
(STDs) including HIV infection. That sounds pretty impressive, but what the AAP
statement does not specifically address is whether the risk of these diseases
needs to be addressed in the newborn period or whether the procedure is the
most effective way at preventing these conditions. Let’s break them down one by
one.</span></div>
<div class="MsoNormal">
<br /></div>
<h1>
<span style="color: #002060;">Urinary tract infections</span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">About 1% of uncircumcised boys will develop a
urinary tract infection in the first year of life (UTIs in older boys are much
rarer). Boys that are circumcised have only a 1 in 1,000 risk of developing a
UTI in the same time period. Some people look at this data and are impressed by
the fact that circumcision imparts a 10 fold reduction in UTI. Others look at
the same numbers and conclude that a 1% risk is not so bad for a condition that
can be readily treated with a course of oral antibiotics.<span style="mso-spacerun: yes;"> </span>To be clear, a UTI in the first 3 months of
life does carry additional risks and typically requires hospitalization.</span></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 18.0pt; line-height: 115%;">The
prevention of urinary tract infections in the first 3 months of life is,
without a doubt, the single most compelling argument in favor of routine circumcision
in the newborn period.</span></i></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">The prevention of urinary tract infections in the
first 3 months of life is, without a doubt, the single most compelling argument
in favor of routine circumcision in the newborn period. But to analyze whether
a surgical procedure is warranted we must consider a statistical tool known as
the Number Needed to Treat (NNT) which asks, ‘how many patients must undergo a
treatment in order to prevent a single case of the disease we’re trying to
prevent?’<span style="mso-spacerun: yes;"> </span>According to a study published
in the Archives of Diseases in Children in 2005, the NNT for preventing UTI is
111.<span style="mso-spacerun: yes;"> </span>That is, 111 boys must be
circumcised in order to prevent 1 case of UTI. Another way of phrasing it is to
say that 110 out of every 111 boys circumcised will not derive a benefit from
the procedure in terms of UTI prevention. But that one baby who <i style="mso-bidi-font-style: normal;">will</i> be spared a UTI may avoid possible
hospitalization and multiple interventions.</span><br />
<br />
</div>
<h1>
<span style="color: black; mso-themecolor: text1;">Penile cancer</span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">I wish I could tell you I was an expert on cancer of
the penis but I most certainly am not. I’ve never seen a case of cancer of the
penis and I’ve never met anyone who’s had the condition or even one who knows
of someone who’s had the condition. That’s because this is an extremely rare
form of cancer. (Thus my lack of personal expertise.)</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">But here are the facts.<span style="mso-spacerun: yes;"> </span>According to the American Cancer Society, in
the United States penile cancer is extremely rare, affecting only 1 in 100,000
men and accounting for about 1% of all cancers. The cancer arises from the
foreskin (the tissue cut off by circumcision) 21% of the time, and from the
head of the penis 48% of the time. The remaining 31% of these tumors arise from
the shaft of the penis and are likely not influenced by whether the individual
is circumcised or not.</span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Penile cancer is a disease of older men, with the
prevalence rising abruptly after 60 years of age, with a peak in incidence at
age 80. In 2005, 310 men died of this disease in the United States representing
a mortality rate of 24.8% among sufferers of this condition. This number reflects
a frequent delay in diagnosis due to a reluctance to seek care for the disease.
With early treatment, cancer of the penis is highly treatable.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">The NNT to prevent cancer of the penis has been
calculated to be 909.<span style="mso-spacerun: yes;"> </span>That is, 909 boys
must be circumcised to prevent a single case of invasive cancer of the penis
many decades later.<span style="mso-spacerun: yes;"> </span>Look, there are
plenty of things to worry about when your baby is born – <i style="mso-bidi-font-style: normal;">cancer of the penis ain’t one of ‘em!</i></span></div>
<div class="MsoNormal">
<br /></div>
<h1>
<span style="color: black; mso-themecolor: text1;">Sexually transmitted
diseases/HIV</span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Studies in countries where heterosexual HIV is
epidemic (the United States is not one of those countries) have demonstrated a
lower rate of HIV in men who are circumcised. However, the link between HIV and
circumcision in developed countries is not nearly as clear cut. Some studies
have found no difference in rates of HIV among men based on their circumcision
status whereas others found a mild association.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">One thing is clear: the likelihood that a man will
develop STDs including HIV in the United States is related to his sexual
practices including the number of partners he has and whether he engages in
high-risk sexual activity. Public health interventions that reduce high-risk
sexual behaviors are going to be far more effective at reducing HIV in the
United States than circumcision will ever be.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">But to follow through with number needed to treat
analysis, all we can say is that the NNT varies dramatically by region. In
Uganda, the NNT for HIV prevention via circumcision is 55. In Canada, on the
other hand, more than 5,000 circumcisions must be performed to prevent a case
of HIV infection (</span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231534/"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231534/</span></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">).</span><br />
<br />
<div style="text-align: center;">
<br /></div>
<div style="text-align: center;">
<span style="color: #3d85c6;"><span style="font-size: x-large;"><a href="http://tinyurl.com/nw7d5ez" target="_blank"><span style="font-family: "Times New Roman","serif"; line-height: 115%;"><i><b>Pick up a copy of my new medical novel:</b></i></span></a></span></span></div>
<div style="text-align: center;">
<div class="separator" style="clear: both; text-align: center;">
<a href="http://tinyurl.com/nw7d5ez" target="_blank"><span style="color: #3d85c6;"><span style="font-size: x-large;"><span style="font-family: "Times New Roman","serif"; line-height: 115%;"><i><b><img border="0" height="320" src="http://2.bp.blogspot.com/-fgoFxnroAG4/UbCnP3941UI/AAAAAAAAACE/tXPfyPG2F1E/s320/3D_Medium.png" width="248" /></b></i></span></span></span></a></div>
</div>
<div style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;"><br /></span></div>
</div>
<div class="MsoNormal">
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<h1>
<span style="color: black; mso-themecolor: text1;">Anatomical variations </span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Many parents are just not comfortable with the
appearance and the perceived need for special care of the uncircumcised penis,
particularly if the father of the baby is circumcised.<span style="mso-spacerun: yes;"> </span>They are alarmed when the foreskin cannot be
retracted past the head of the penis (a completely normal situation in the
first few years of life, known as physiologic phimosis) and they sometimes
complicate matters by unnecessary manipulation of the foreskin leading to a
painful and urgent condition known as paraphimosis, where the skin gets stuck
behind the head of the penis.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">These conditions can be easily handled and prevented
with simple care, though many doctors contribute to this problem by dispensing
misguided advice (read Forcing the tissue in Why Doctors Believe Weird Things: </span><a href="http://pediatricsincrisis.blogspot.com/2013/06/800x600-normal-0-false-false-false-en.html"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">http://pediatricsincrisis.blogspot.com/2013/06/800x600-normal-0-false-false-false-en.html</span></a><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">).</span></div>
<div class="MsoNormal">
<br /></div>
<h1>
<span style="color: black; mso-themecolor: text1;">Risks of circumcision</span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">In the hands of an experienced surgeon, the risks of
circumcision are quite low. The rate of immediate complications ranges from
0.2% to 10%.<span style="mso-spacerun: yes;"> </span>The most commonly reported
problem is bleeding. Rare catastrophic complications include amputation of the
penis, kidney failure and overwhelming infection.<span style="mso-spacerun: yes;"> </span>Late complications include meatal stenosis (a
narrowing of the opening of the urethra) and, among some men, the report of an
alteration in the sensitivity of the penis, particularly in the act of sexual
intercourse.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Certainly, another downside to the procedure is the
pain associated with it. In years past, this was brushed away with the breezy
argument that babies do not perceive pain the way older children do, and
wouldn’t it be best to have a painful procedure done when the child will not
remember it (and can’t fight you off quite as effectively)?<span style="mso-spacerun: yes;"> </span>It goes without saying that infants do
perceive pain, and the sensation of pain in the newborn period interferes with
sleep and feeding and may even modulate the perception of pain later in life.</span></div>
<div class="MsoNormal">
<br /></div>
<h1>
<span style="color: black; mso-themecolor: text1;">Putting it all together</span></h1>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">Circumcision is a common and generally safe
procedure in the newborn period.<span style="mso-spacerun: yes;"> </span>It is
the only elective procedure that is performed in neonates. The most compelling
medical reason to have the procedure performed is to reduce the likelihood your
baby will experience a urinary tract infection in the first year of life.<span style="mso-spacerun: yes;"> </span>Other health benefits are minimal or less
well established and can be addressed with more effective strategies and
interventions. At a minimum, some of the purported health benefits involve issues
that probably don’t need to be dealt with in the first 48 hours of life when
other challenges, such as the successful establishment of breast feeding, are
far more important.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">If you've decided you’d like to have your baby circumcised, I
advise the following: </span></div>
<div class="MsoNormal">
<br /></div>
<br />
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">1. Understand your reasoning in reaching this
decision and be sure you’re comfortable with your choice. Almost always, this
is best achieved by having a frank discussion with your baby’s doctor.</span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">2. Decide
on the most appropriate timing to establish your goals.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">3. As with any
procedure, select a practitioner that is experienced in performing the
procedure and who is able and available to deal with the odd complication. </span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">4. Discuss
the method of pain control selected by the surgeon. General anesthesia is only
used in older children due to the higher risk of complications with its use in
newborns. But all babies deserve some form of pain control during and after and
surgery. </span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">5. Be sure you understand and are comfortable with all post-operative
care.</span></div>
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<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%;">And whatever choice you make, don’t sweat it. It’s
unlikely that it will have a major, lasting impact on your child’s health
either way.</span></div>
<br />
<br />Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com9tag:blogger.com,1999:blog-5332168372257738092.post-73663043906392945332013-06-24T08:35:00.000-07:002013-06-24T08:46:40.089-07:00Why Doctors Believe Weird Things: How pediatricians embrace superstition and magical beliefs<!--[if gte mso 9]><xml>
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<br />
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<b><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: 12.0pt;">(This is an excerpt from my book, Suffer the Children)</span></span></b><br />
<b><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: 12.0pt;"> </span></span></b><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span></i></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">All men are
liable to error; and most men are, in many points, by passion or interest,
under temptation to it.</span></i></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">John Locke</span></i><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"></span></i></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A wise man proportions his belief to the
evidence.</span></i></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">David Hume</span></i></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The history of the progress of the human
mind is a history of a struggle with its delusions.</span></i></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Sir William
Osler</span></i><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"></span></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
few summers ago I had the pleasure of visiting the beautiful northeastern
Italian region of Val D’Aosta, nestled at the feet of Mont Blanc on the border
with France.<span style="mso-spacerun: yes;"> </span>One evening, after a
particularly scrumptious dinner, we were invited to the 19<sup>th</sup> century
villa of a dentist, whose sons worked with one of my brothers at the time.<span style="mso-spacerun: yes;"> </span>As we sat on the stone veranda, enjoying the
cool mountain air, the conversation turned to differences between Italian and
American dental practices.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Our
host first surprised me by saying that orthodontic appliances are over-utilized
in the United States and, in some individuals, can result in harm.<span style="mso-spacerun: yes;"> </span>I remain ignorant on this subject and, though
it was a novel idea to me, I had no reason to dispute the claim.<span style="mso-spacerun: yes;"> </span>Next, he brought up the issue of silver
dental fillings (or amalgams) which he considered a significant health hazard
due to mercury poisoning.<span style="mso-spacerun: yes;"> </span>This I
immediately recognized as a pseudo-scientific idea that is well outside the
mainstream opinion in dentistry.<span style="mso-spacerun: yes;"> </span>I was
put on edge, anticipating the possibility that our host might cling to other
unusual beliefs.<span style="mso-spacerun: yes;"> </span>He did.<span style="mso-spacerun: yes;"> </span>He wished to display how his youngest of two
sons was allergic to milk.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">He
brought out a carton of milk from the kitchen, and after a moment’s hesitation,
apparently to add a touch of suspense to the demonstration, he handed it to his
22 year old son who was sitting on a patio chair.<span style="mso-spacerun: yes;"> </span>Almost immediately the young man’s fit and
muscular frame crumpled, and, as his father pointed out, the arm not holding
the carton of milk was limp and weak.<span style="mso-spacerun: yes;"> </span>I
immediately recognized this as a demonstration of Applied Kinesiology: an
unproven belief system often employed by naturopaths and chiropractors, that
uses muscle testing to diagnose presumed allergies and nutrient deficiencies.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">At
this point, I asked if I could perform a test of my own.<span style="mso-spacerun: yes;"> </span>The dentist eagerly complied.<span style="mso-spacerun: yes;"> </span>I went to the kitchen with the carton of milk
where I was able to find, with the aid of his wife, two small, dark ochre glass
vials.<span style="mso-spacerun: yes;"> </span>I filled these vials and returned
to the patio.<span style="mso-spacerun: yes;"> </span>After receiving assurance
from my host that the “allergy” symptoms would be evident even through glass, I
asked his son to tell me, based on his symptoms, which of the two vials
contained the milk and which one was filled with water.<span style="mso-spacerun: yes;"> </span>After a minute of alternately holding one
vial, then the other, he confidently asserted that the one on the left rendered
him weak, while the one on the right did not.<span style="mso-spacerun: yes;">
</span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Actually,
both vials contained milk.<span style="mso-spacerun: yes;"> </span>When the
young man was blinded as to whether a vial contained milk or not, his cataplexy
seemingly resolved.<span style="mso-spacerun: yes;"> </span>Alternatively, I
could have filled both vials with water to see if weakness might have been
elicited by the mere thought that a vial contained milk.<span style="mso-spacerun: yes;"> </span>I might be criticized for having employed
deception in my test, but had I indeed filled one vial with milk, the other
with water, my subject would have had a 50% likelihood of guessing which one
contained the milk by pure chance.<span style="mso-spacerun: yes;"> </span>I
would therefore have had to do repeated tests and compare the results to those
expected by mere chance: a bit tedious for an after-dinner rendezvous.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span>The dentist found this interesting, but
concluded that his son’s allergies must be improving with the treatment that he
is being provided, even though just minutes earlier he gave us a dramatic
demonstration of the severity of his symptoms.<span style="mso-spacerun: yes;">
</span>And if one opaque vial filled with milk caused weakness, logic mandates
that the other one must have as well.<span style="mso-spacerun: yes;">
</span>But that was not the case.</span></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">*****</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Doctors,
like all humans, are vulnerable to forming irrational beliefs; lending more
credence to gut feelings than available evidence, making non-existent
associations of cause and effect, falling prey to preconceived biases, and
sometimes, engaging in outright superstition: a belief that there are
occurrences that cannot be explained by the laws of nature, that are influenced
by magical or supernatural forces. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
medical school, in an attempt to boost our performance on exams, many of us
utilized amulets or good luck charms.<span style="mso-spacerun: yes;"> </span>A
published survey of medical students from Basel, Switzerland revealed that 10%
of medical students admitted taking good luck charms to their first exam in the
medical curriculum.<span style="mso-spacerun: yes;"> </span>Other students
adhere to inane rituals involving peculiar diets, preferred items of clothing
and favorite study locations that have no connection to the actual mastering of
the material being studied.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
residency, superstitious beliefs are even more prevalent.<span style="mso-spacerun: yes;"> </span>Newly minted physicians are quickly
categorized into two groups:<span style="mso-spacerun: yes;"> </span>white
clouds and black clouds, with the latter group comprised of individuals who
seem to be jinxed, having the busiest nights on call, invariably forced to tend
to patients who seem to have the worst complications while on their watch.<span style="mso-spacerun: yes;"> </span>Understand that this is not viewed as a set
of work habits and traits possessed by the individual that makes him more prone
to encounter difficulties (as is clearly the case sometimes) but rather the
result of an unalterable fate; a type of cosmic karma. Once branded a white
cloud or a black cloud, the designation sticks throughout one’s training, and
often, many years into practice.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
one survey, 22% of residents admitted to being superstitious in general (which
the authors defined as firmly holding beliefs in the absence of objective
evidence), 32% had developed belief systems about their nights on call, and 65%
subscribed to the belief that some residents are “black clouds”.<span style="mso-spacerun: yes;"> </span>A variety of ideas were commonly shared:<span style="mso-spacerun: yes;"> </span>that weather patterns can affect how busy
one’s night on call is, as does a full moon; that the word “quiet” must never
be uttered, as certain words or actions may spark<span style="mso-spacerun: yes;"> </span>the ire of “vaguely defined call gods”.<span style="mso-spacerun: yes;"> </span>Interestingly, or dismayingly, some of these
beliefs intensified through the years of training.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12pt; text-align: center; text-indent: 0.5in;">
<span style="color: #38761d;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="font-size: x-large;"><i><b>Check out my new medical suspense:</b></i></span></span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12pt; text-align: center; text-indent: 0.5in;">
<span style="color: #38761d;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="font-size: x-large;"><i><b> The Art of Forgetting</b></i></span></span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12pt; text-align: center; text-indent: 0.5in;">
<span style="font-size: x-large;"><span style="font-family: "Times New Roman","serif";"><span style="color: #38761d;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><i><b> now on sale!</b></i></span></span></span></span><br />
<span style="font-size: x-large;"><span style="font-family: "Times New Roman","serif";"><span style="color: #38761d; font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><a href="http://theartofforgettingbook.wordpress.com/" target="_blank">The Art of Forgetting: the new novel by Peter Palmieri</a> </span></span> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Superstition
is a way to deal with uncertainty, especially when one senses a lack of control
over one’s environment.<span style="mso-spacerun: yes;"> </span>It is witnessed
in competitive athletes as well as in soldiers deployed to the battlefront;
settings that share features in common with the experiences of medical students
and residents: a high level of competition, stress, fatigue, and sleep
deprivation.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Although
the beliefs discussed so far can be viewed as innocent if fatuous notions, of
no consequence to the actual practice of medicine, they betray a surprising
lack of skepticism for such highly learned individuals.<span style="mso-spacerun: yes;"> </span>This ease with which physicians believe
dubious ideas exposes a pliability in their thought processes that inclines
them to accepting unproven axioms that <i style="mso-bidi-font-style: normal;">do</i>
have a direct effect on patient care.<span style="mso-spacerun: yes;">
</span>Often, what we physicians presume to be scientifically validated
precepts are actually a hodge-podge of folklore and myth, passed from one
generation of physicians to the next, peppered with untruths, promulgated by
questionable sources such as the cleverly edited script of a pharmaceutical
representative.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Doctors
are not gullible, nor are they eager to be the first to try a new treatment
with little deliberation; in fact many among our ranks are outright
conservatives, reluctant to revisit, not to mention change, any aspect of our
practice.<span style="mso-spacerun: yes;"> </span>Yet many doctors base
treatment decisions not on available evidence, but on fickle criteria:
following the advice of drug company representatives that call on them with
free samples, mimicking what other physicians in their group or community are
doing, or by simply proclaiming, “That’s how we did it in Chicago when I was a
resident”.<span style="mso-spacerun: yes;"> </span>Physicians should be able to
research the medical literature and evaluate the quality of information
available to choose the best way to manage a particular condition.<span style="mso-spacerun: yes;"> </span>But many physicians either neglect to do so,
or they lack the skill to synthesize data into a workable approach.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12pt; text-align: left; text-indent: 0.5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Learning Science Versus Thinking like a
Scientist</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">When
I was applying to medical school as an undergraduate student, I asked one of my
favorite professors for a letter of recommendation.<span style="mso-spacerun: yes;"> </span>I was surprised to find he was disappointed
with my career choice.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">“Why
would you want to be a doctor and work as a glorified technician when you could
be a scientist?” he asked me.<span style="mso-spacerun: yes;"> </span>I was
taken aback.<span style="mso-spacerun: yes;"> </span>Doctors as mere
technicians?<span style="mso-spacerun: yes;"> </span>Medicine <i style="mso-bidi-font-style: normal;">was</i> science, I insisted.<span style="mso-spacerun: yes;"> </span>After all I had to master Physics, Chemistry,
Organic Chemistry, Biochemistry and Physiology just to become a candidate for
medical school.<span style="mso-spacerun: yes;"> </span>It was only years later,
when I was already in practice (and I had read Sinclair Lewis’ novel, <i style="mso-bidi-font-style: normal;">Arrowsmith</i>) that I understood and
grudgingly acknowledged the basic truth of my professor’s assertion.<span style="mso-spacerun: yes;"> </span>The point is rendered limpid by the words of
Carl Sagan taken from an interview with Charlie Rose: “Science is more than a
body of knowledge; it’s a way of thinking, a way of skeptically interrogating
the universe with a fine understanding of human fallibility.”<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">This
way of thinking is lacking in the average general practitioner who in addition,
is too often oblivious to his human fallibility.<span style="mso-spacerun: yes;"> </span>There is the distinct risk among us
physicians to abandon thinking altogether in favor of a cookbook approach to
delivering care, incorporating bizarre ideas along the way, adopting a
self-congratulatory smugness as we claim expertise when none is present,
becoming unjustifiably arrogant in the process.<span style="mso-spacerun: yes;">
</span>To understand how this is possible we must start with a glimpse at the
long and arduous training process that aspiring doctors must undertake to earn
their degrees and allow them to become fully licensed.</span></div>
<div align="center" class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-align: center; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">*****</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Traditionally,
medical school is divided into two parts.<span style="mso-spacerun: yes;">
</span>The first two years are heavily weighted towards classroom learning of
basic science subjects such as Anatomy, Biochemistry, Physiology, Pharmacology,
and Pathology, while the last two years are spent in hospital clerkships, at
the bedside, refining the skills of taking medical histories from patients,
performing physical exams, presenting information in an organized fashion to
other team members, and mastering a variety of medical procedures, such as
venipuncture, intravenous catheter insertion, placement of naso-gastric tubes,
even scrubbing in for surgery.<span style="mso-spacerun: yes;"> </span>Though of
late most medical schools have introduced clinical coursework earlier in the
curriculum, for the most part the basic structure remains unaltered.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
amount of material, the sheer number of bits of information that has to be
assimilated in those first two years in order to pass standardized exams, is
overwhelming. One of my classmates put it best when he said that medical school
was like trying to take a drink of water from a wide open fire hydrant.<span style="mso-spacerun: yes;"> </span>Frequently, a professor, wanting to stress
the unique importance of a concept she is about to teach, will say, “You will
only retain 5% of what you learn in medical school, and this is part of the 5%
you can’t afford to forget.”</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">So
how do medical students manage to soak up the ocean of information they are
expected to retain, at least long enough to pass their exams, with their puny
sponges of gray matter?<span style="mso-spacerun: yes;"> </span>Often they
resort to shortcuts, tricks and mnemonics, many made more memorable by their
sexually explicit nature.<span style="mso-spacerun: yes;"> </span>I still
remember the twelve cranial nerves by reciting: “On Old Olympus Towering Tops A
Finn And German Viewed Some Hops”. When I first used the mnemonic, however, I
had particular difficulty remembering the tenth cranial nerve, the Vagus,
because I would mistakenly replace “Viewed” with “Brewed”; a seemingly more
logical activity for a German to embark in with hops.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Likewise,
to remember whether a particular cranial nerve has only sensory function (S),
motor function (M), or both (B), I still employ the mnemonic: “Some Say Marry
Money But My Brother Says Big Boobs Matter Most”.<span style="mso-spacerun: yes;"> </span>A good trick, a particularly memorable
mnemonic device, is a hot commodity in medical school because it creates
reliable scaffolding onto which one can pile information quickly and for the
long term.<span style="mso-spacerun: yes;"> </span>And speed is of the essence
in medical school:<span style="mso-spacerun: yes;"> </span>we must memorize so
much information that we don’t have the time or inclination to question the
validity of what we learn.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">This
attitude carries on with even greater urgency in residency.<span style="mso-spacerun: yes;"> </span>Now we must know things not for exam
purposes, but in order to provide appropriate care to patients, particularly
when we find ourselves relatively isolated on our nights on call.<span style="mso-spacerun: yes;"> </span>To some degree the internet now provides
residents with a wealth of information at their fingertips, without having to
stuff the pockets of their white coats with medical reference books, but there
is still a hunger for learning simple algorithms to buoy us in our ocean of
uncertainty.<span style="mso-spacerun: yes;"> </span>And the proximate source of
these algorithms is inevitably a more senior resident, who in turn learned a
particular pearl from his senior residents, with tenets being passed from
generation to generation, with hardly a trace of the original source.<span style="mso-spacerun: yes;"> </span>This is thankfully balanced by exposure to
dedicated academic physicians, true role models, who engage residents and
stimulate critical thinking using a Socratic method of discourse and bedside
demonstrations of proper interviewing and examination techniques.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Gradually,
despite the deficiencies in their training, many Pediatric residents, through
experience and study, mature into competent practitioners, able to embark on
their life-long commitment to learning and perfecting their craft.<span style="mso-spacerun: yes;"> </span>But if they pursue a typical private
practice position they may find that their training leaned far too heavily
towards tertiary care leaving large lacunae in their knowledge of primary care
issues.<span style="mso-spacerun: yes;"> </span>Paradoxically, a pediatrician
who has just finished residency may feel more comfortable providing care to a
child hospitalized with a perforated appendix than answering a mother’s
questions about the timing of introduction of solid foods.<span style="mso-spacerun: yes;"> </span>The entire process is akin to training bus
drivers by having them fly Boeing-747 jumbo jets.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">As
doctors are separated from their training by geographic distance and the
passage of years, no longer constrained in their actions by the supervising eye
of attending physicians, some start toying with creative, if questionable,
approaches (creativity is a dubious virtue for a physician). Never having fully
embraced the necessarily skeptic and disciplined stance typical of science,
they become vulnerable to unproven claims, myths and, in extreme cases,
pseudo-science. Some doctors start believing all manner of bunk:<span style="mso-spacerun: yes;"> </span>that child obesity is due to vitamin
deficiencies; that almost all human illness is caused by insufficient levels of
HDL (high density lipo-protein) cholesterol; and that immunizing children is
more harmful than beneficial.<span style="mso-spacerun: yes;"> </span>They start
making sweeping generalizations based on the flimsiest experience, turning a
blind eye to tangible evidence.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">They
are encouraged in proffering advice on matters of which they are ignorant
believing to be guided by a well-grounded common sense.<span style="mso-spacerun: yes;"> </span>But as Albert Einstein pointed out, “Common
sense is the collection of prejudices acquired by age eighteen”.<span style="mso-spacerun: yes;"> </span>Some things in medicine are
counter-intuitive.<span style="mso-spacerun: yes;"> </span>Before advising we
should confirm that our intuitions are correct with research and study.</span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">White Coat Phobia:</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">It
is time to analyze some of the most common misconceptions among pediatricians,
starting with a rather trivial question, “What should I wear?”<span style="mso-spacerun: yes;"> </span>Many Pediatricians have shed their white
coats for more comfortable and relaxed attire.<span style="mso-spacerun: yes;">
</span>After all, kids are scared of white coats, right?<span style="mso-spacerun: yes;"> </span>Well, not so fast.<span style="mso-spacerun: yes;"> </span>There are a few studies evaluating the
perception that patients have of physicians based on their attire.<span style="mso-spacerun: yes;"> </span>Overall, most patients have a more positive
impression of the physician in the traditional white smock.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
couple of studies specifically looked at children’s impression of physicians
wearing different clothing.<span style="mso-spacerun: yes;"> </span>One study
showed that physicians wearing white coats were more likely to be rated as
competent by children.<span style="mso-spacerun: yes;"> </span>Those dressed
casually were more likely to be regarded as friendly, but not competent.<span style="mso-spacerun: yes;"> </span>Another study had children and parents rate
pairs of photographs of physicians in different poses (standing versus stooping,
smiling versus stern expression) and wearing different forms of attire.<span style="mso-spacerun: yes;"> </span>The smiling doctors were preferred over the
stern ones by both parents and children; however, 54% of children preferred the
ones wearing white coats over the ones in casual dress, compared to only 35% of
parents (parents have bought into this myth, likely affecting their
preference).<span style="mso-spacerun: yes;"> </span>So the lesson to be learned
is that if we want to be perceived as competent, yet caring, we should wear white
coats and smile, and if you prefer not to don the white coat, realize that you
are not doing it for the child’s benefit.<span style="mso-spacerun: yes;">
</span>The worst faux-pas, from a patient’s perspective and a stylistic one as
well, was to wear sneakers.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">I
admit that the issue of apparel is petty but I use it to exemplify the fact
that almost no one questions the misconception that children are scared of
white coats:<span style="mso-spacerun: yes;"> </span>it is a belief that is
accepted prima facie.<span style="mso-spacerun: yes;"> </span>Kids may be scared
in doctors’ offices and hospitals to be sure:<span style="mso-spacerun: yes;">
</span>they are often threatening, unwelcoming places where uncomfortable, if
not outright painful procedures take place.<span style="mso-spacerun: yes;">
</span>They may very well be even more frightened when the doctor enters the
room, but the fear has little to do with the doctor’s white coat.</span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Formula Follies:</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">To
the neophyte, newborn babies appear to have a limited repertoire of behavior:
they sleep, they cry, they eat, they pass what they just ate.<span style="mso-spacerun: yes;"> </span>Whenever there is a perturbation in what
parents perceive to be the customary behavior for the baby, the usual suspect
is the milk being fed to it.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Despite
efforts by many health organizations to encourage breast-feeding, many families
continue to choose infant formulas as the primary source of nutrition for their
newborns.<span style="mso-spacerun: yes;"> </span>Formulas are frequently blamed
by parents for a wide variety of symptoms such as fussiness, gas,
regurgitation, and changes in the frequency, consistency, color and smell of
stool.<span style="mso-spacerun: yes;"> </span>Though true cow’s milk protein
allergy (the most common bona fide type of milk intolerance in infancy)<span style="mso-spacerun: yes;"> </span>has been shown to exist in less than 6% of the
population, in some practices as many as 30% of formula-fed infants are
switched to expensive hypoallergenic formulas.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
the past, the most common myth surrounding formulas was the belief that iron
was responsible for constipation and other problems with defecation.<span style="mso-spacerun: yes;"> </span>Many infants were inappropriately fed low
iron formulas, placing them at risk for iron deficiency and its many
complications (Iron is an important nutrient for the developing brain).<span style="mso-spacerun: yes;"> </span>Most pediatricians have fortunately abandoned
this practice though new acts have taken its place.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
little over a decade ago, it became vastly popular to utilize cow’s milk based
formulas that were enzymatically treated to remove (or at least reduce) the
sugar, lactose.<span style="mso-spacerun: yes;"> </span>I remember having a
conversation with a representative of a large formula manufacturer who tried to
persuade me that lactose intolerance was the most common feeding problem in
infancy.<span style="mso-spacerun: yes;"> </span>When I argued that he was
grossly mistaken and provided him with actual statistics he quickly changed the
subject, yet his efforts, and those of his colleagues were hugely successful in
promoting these unnecessary formulas.<span style="mso-spacerun: yes;">
</span>Within a year or two, an inordinate number of infants (some 30% of
market share in my community in South Texas) were being fed the milk he was
promoting. Even now, I hear many parents report the fallacy that their infant
was diagnosed with “lactose intolerance”.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
newborn nurseries, infants are switched from standard formulas to lactose-free
formula, often on the first day of life, if the baby happens to spit up on a
single occasion – an event that should hardly surprise anyone.<span style="mso-spacerun: yes;"> </span>In other instances the formula is being used
to mitigate constipation, and, with many families I care for, the parents
haven’t a clue as to why the baby is on a lactose-free formula. The most
baffling practice, one that I’ve witnessed repeatedly, is that of feeding
infants breast milk (which contains lactose) while, at the same time,
supplementing with a lactose-free formula.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Lactose
is a disaccharide: it is composed of two simple sugars, glucose and galactose,
which are linked together by a single molecular bond.<span style="mso-spacerun: yes;"> </span>In order for these simple sugars to be
absorbed by the lining of the intestine, to then be utilized by the body, this
molecular bond must be cleaved in two by the enzyme, “lactase” which is located
on the surface of the intestine in a specialized area called the brush
border.<span style="mso-spacerun: yes;"> </span>An enzyme is a protein that
helps to promote a specific chemical reaction in the body.<span style="mso-spacerun: yes;"> </span>The names of enzymes can be easily recognized
by the suffix, “-ase”.<span style="mso-spacerun: yes;"> </span>It is interesting
to note that the only place in nature where the sugar lactose is found is
mammalian milk, and baby mammals, including baby humans, are exquisitely
equipped to digest lactose with only remarkably rare exceptions.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">These
exceptions include Congenital Lactase Deficiency and Secondary Disaccharidase
Deficiency.<span style="mso-spacerun: yes;"> </span>Congenital Lactase
Deficiency occurs when a baby inherits two abnormal copies, one from each
parent, of the gene for lactase, which is located on Chromosome number 2 in
humans.<span style="mso-spacerun: yes;"> </span>This results in a markedly
decreased ability to synthesize the enzyme, causing newborns to develop severe
diarrhea which leads to dehydration, metabolic abnormalities and almost certain
death, unless the lactose is removed from the diet.<span style="mso-spacerun: yes;"> </span>Fortunately, this condition is extremely
rare.<span style="mso-spacerun: yes;"> </span>In one series of more than 1,600
small intestine biopsies obtained in infants suspected of having this
condition, the diagnosis was confirmed in only one case.<span style="mso-spacerun: yes;"> </span>The average pediatrician, with 2,000 to 3,000
children in her practice at any one time, is unlikely to care for a single
child with this disease in her career.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Secondary
Disaccharidase Deficiency is far more common but is usually a temporary
condition.<span style="mso-spacerun: yes;"> </span>It results in insufficient
levels of the enzyme lactase due to injury to the brush border of the intestine
as a result of illness (most typically prolonged diarrhea) or surgery.<span style="mso-spacerun: yes;"> </span>Some infants with Secondary Disaccharidase
Deficiency may need a temporary reprieve from lactose-containing milk until
they are able to build up adequate levels of lactase in their brush
border.<span style="mso-spacerun: yes;"> </span>Soy formulas, which are
naturally free of lactose, are successfully used in this setting.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">For
the sake of completeness I will briefly mention yet another condition that
results in severe diarrhea and bloating due to the inability to absorb milk
sugar, but in this case, removing lactose does not lead to resolution of the
symptoms.<span style="mso-spacerun: yes;"> </span>Glucose-Galactose
Malabsorption is a life-threatening disease in which the cells lining the
intestine are unable to take in the simple sugars, glucose and galactose.<span style="mso-spacerun: yes;"> </span>This condition is so rare that only a few
hundred cases have been identified worldwide.<span style="mso-spacerun: yes;">
</span>As you may have surmised, a formula where the lactose is artificially
cleaved into its two components cannot be fed to these infants.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Much
of the misunderstanding surrounding lactose intolerance in infants comes from
the fact that the majority of adults, nearly 4 billion people worldwide by some
estimates, are unable to digest lactose, though not all are symptomatic.<span style="mso-spacerun: yes;"> </span>Most mammals nurse their young until the baby
is around three times its birth weight.<span style="mso-spacerun: yes;">
</span>In humans this corresponds to about one year of age.<span style="mso-spacerun: yes;"> </span>In most individuals, the production of the
enzyme lactase starts to decline at about two years of age, yet symptoms of
acquired lactose intolerance rarely develop before age six or seven.<span style="mso-spacerun: yes;"> </span>If adult members of the family have problems
with lactose intolerance, the natural perception is that the progeny must have
acquired the same trait; and they probably have, though the symptoms should not
be apparent during infancy.<span style="mso-spacerun: yes;"> </span>The
widespread popularity of lactose-free formulas cannot be explained by our
knowledge of physiology, genetics and nutrition, and one can only conclude that
it is a result of faulty reasoning.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Formula
manufacturers prey on these misconceptions, trying to gain market share and
maximizing profits by promoting “special formulas” in settings where there is
no recognized medical indication for their use.<span style="mso-spacerun: yes;">
</span>One strategy is to attach meaningless labels such as “gentle” or
“sensitive” to the names of formulas that are not truly hypoallergenic.<span style="mso-spacerun: yes;"> </span>Yet another is to try to persuade parents to
purchase expensive hypoallergenic formulas to soothe colic symptoms, even
though our current understanding is that colic is not due to digestive
issues.<span style="mso-spacerun: yes;"> </span>Many physicians become the
unwitting accomplices in this charade, recommending formula changes at the drop
of a hat instead of attempting to understand parental concerns, deciding
whether reported symptoms are normal variants of infantile behavior, and
thinking logically about nutritional choices in infancy. </span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Diagnostic Fetishes:</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Occasionally,
some doctors develop pet theories that may contain a tiny kernel of truth, but
are over-generalized and misapplied.<span style="mso-spacerun: yes;"> </span>I
already alluded to a physician I know of who thinks that all illnesses, from
septic shock to behavioral disorders, are due to low levels of HDL, also known
as the “good cholesterol”.<span style="mso-spacerun: yes;"> </span>For almost
every medical condition, he advocates treatment with high doses of Niacin. Though
HDL has been shown to be relatively protective when it comes to the development
of heart disease, and may be a factor in the development of sepsis in
critically ill patients, many of the claims of this colleague are a bit of a
stretch.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">When
doctors adopt a pet disease, they apply the most inclusive criteria to make the
diagnosis, so that soon any collection of symptoms can be seen as evidence of
the condition.<span style="mso-spacerun: yes;"> </span>If you make a slot large
enough, you can fit pegs of any shape through it.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">One
of my previous partners was obsessed with gastro-esophageal reflux in
infants.<span style="mso-spacerun: yes;"> </span>GE reflux, as it is often
referred to, is an extremely common phenomenon in babies, as it simply implies
that food that is ingested and reaches the stomach is occasionally regurgitated
back up the esophagus, and sometimes, as any parent has had the opportunity to
witness, back out of the mouth.<span style="mso-spacerun: yes;"> </span>But
effortless regurgitation is not necessarily pathologic.<span style="mso-spacerun: yes;"> </span>It can be demonstrated in virtually all
newborns at some time or another if one employs specialized tests.<span style="mso-spacerun: yes;"> </span>More than a disease, it represents incomplete
development of the complex neural circuitry involved in keeping food going one
way, down-stream in the intestinal tract.<span style="mso-spacerun: yes;">
</span>By the age of six months, many infants stop spitting up, and almost all
do by the age of one year.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">There
are some babies whose regurgitation is frequent and severe enough to affect
their growth, cause respiratory problems, or manifest other symptoms such as
fussiness and unusual posturing.<span style="mso-spacerun: yes;"> </span>Some of
these children have recognizable underlying neurologic conditions such as
cerebral palsy.<span style="mso-spacerun: yes;"> </span>In this case the
condition is referred to as Gastro Esophageal Reflux Disease (GERD).<span style="mso-spacerun: yes;"> </span>It is important to make the distinction
between the nearly universal GER and the rare GERD: the latter is a disease,
the former is not.<span style="mso-spacerun: yes;"> </span>The treatment for
infants with GER may include simple reassurance, providing smaller more
frequent feedings, and occasionally thickening of the feedings.<span style="mso-spacerun: yes;"> </span>On the other hand, babies with GERD typically
need medications to reduce the acidity of the stomach or to promote the forward
movement of food down the alimentary canal. In some cases they may even require
surgery.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
1999, my partner had most of the infants in her practice on one or more
anti-reflux medications.<span style="mso-spacerun: yes;"> </span>Though some of
these medications are generally safe – particularly those used to reduce the
acidity of the stomach – others have troublesome side-effects.<span style="mso-spacerun: yes;"> </span>Some of her patients were taking cocktails of
drugs that included Bethanecol; a drug often used to treat urinary incontinence
in adults but seldom used in infants.<span style="mso-spacerun: yes;">
</span>One of the medications she most frequently employed, even in babies with
minimal symptoms, was Cisapride: perhaps the most effective drug available for
the treatment of reflux, but with a potentially lethal side-effect.<span style="mso-spacerun: yes;"> </span>Earlier in the year all prescribing
physicians, including my partner, received a letter from the manufacturer of
the drug warning that some infants taking Cisapride had died due to irregular
heart rhythms. Nonetheless she continued prescribing the medication without a moment’s
hesitation to a large proportion of her patients under the age of 12 months.
Then my partner unexpectedly left the practice, and I inherited many of her
patients.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Over
the following months I re-evaluated dozens of infants that were taking
medications for GE reflux, none of whom, in my opinion, required treatment with
pharmaceuticals.<span style="mso-spacerun: yes;"> </span>I stopped the
medications, sometimes to the consternation of the parents, who by now were
convinced that their children had a serious illness. Some parents left the
practice to find a doctor who would continue refilling the Cisapride
prescriptions when I refused to.<span style="mso-spacerun: yes;"> </span>Then,
on July 14, 2000, Cisapride was voluntarily recalled from the United States
market as a result of persistent concerns over its safety.<span style="mso-spacerun: yes;"> </span>For weeks I received a deluge of phone calls
from worried parents, including some who were originally resistant to the idea
of discontinuing the use of the medication, now baffled by the decision to use
it in the first place.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Years
later, I worked with another partner who prescribed the drug Cholestyramine to
all his patients that presented with diarrhea.<span style="mso-spacerun: yes;">
</span>Cholestyramine is a drug that binds to bile acids in the intestine,
preventing their reabsorption, thus aiding in their excretion.<span style="mso-spacerun: yes;"> </span>It is most frequently used for the treatment
of high cholesterol.<span style="mso-spacerun: yes;"> </span>There is some basis
to employ it in the treatment of diarrhea under limited circumstances:<span style="mso-spacerun: yes;"> </span>when the diarrhea is compounded by the
presence of unbound bile acids in the intestine, such as when the portion of
the gut that normally absorbs bile acids is surgically resected.<span style="mso-spacerun: yes;"> </span>But the diarrhea we most often encounter in
children is not due to malabsorption of bile acids, but to secretion of fluid
by the intestinal lining as a result of a viral infection.<span style="mso-spacerun: yes;"> </span>The use of Cholestyramine to treat childhood
diarrhea is not only ineffective; it is highly illogical.<span style="mso-spacerun: yes;"> </span>But there was no convincing my partner who
had found his pet treatment.<span style="mso-spacerun: yes;"> </span>Here was a
prescription he could write, something he could do, and his patients were
getting better after all.<span style="mso-spacerun: yes;"> </span>They would
have even without the medicine.</span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Of Warblers and Doctors:</span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Most
doctors develop habits in their approach to patients and preferences in the
medications they prescribe that is customarily referred to as their “practice
style”.<span style="mso-spacerun: yes;"> </span>When I worked as a pediatric
hospitalist, being referred patients for hospitalization from throughout the
community, my colleagues and I were often able to recognize the doctors who had
previously seen a particular patient by the treatment that had been provided; a
skill I likened to the ability a birdwatcher has in distinguishing the mating
call of the Northern Mockingbird from that of the Gray Catbird.<span style="mso-spacerun: yes;"> </span></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
child was prescribed oral Albuterol to soothe a cough along with a syrup
containing dextromethorphan?<span style="mso-spacerun: yes;"> </span>Why, that’s
the unmistakable song of the doctor who works at the clinic down the
street.<span style="mso-spacerun: yes;"> </span>A playful toddler presents with
the diagnosis of “occult bacteremia” due to an elevated white blood cell
count?<span style="mso-spacerun: yes;"> </span>Well, well; this could be any of
a number of birds, but wait, the child was given an intramuscular injection of
Cefotaxime in the office prior to being sent to the hospital.<span style="mso-spacerun: yes;"> </span>That little inflection in the song is quite
specific for the warbler that runs the Medicaid mill just outside of town.<span style="mso-spacerun: yes;"> </span>The bird call game lost all its charm when,
instead of a curious sounding chirp, the noise reaching our ears was a
distinctive, honking quack.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">That
there are differences in practice style among physicians which can be supported
by evidence is understandable, as quite often there is no single clearly
preferable approach to a problem.<span style="mso-spacerun: yes;"> </span>One
can argue that these variations are even desirable.<span style="mso-spacerun: yes;"> </span>What is unjustifiable is the embracing of a
favorite treatment that encourages the over-diagnosing of a particular
condition, placing the cart in front of the horse, so to speak.<span style="mso-spacerun: yes;"> </span>As the saying goes, when all you have is a
hammer, everything starts looking like a nail.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">*****</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">America
has a long tradition of dubious pediatric advice.<span style="mso-spacerun: yes;"> </span>In the 1920’s, American child-rearing
philosophy was strongly influenced by Dr. John B. Watson, considered by many
the father of behavioral psychology, whose book, <i style="mso-bidi-font-style: normal;">Psychological Care of Infant and Child</i> recommended mothers use the
following approach towards their children:<span style="mso-spacerun: yes;">
</span>“Never hug and kiss them.<span style="mso-spacerun: yes;"> </span>Never
let them sit on your lap.<span style="mso-spacerun: yes;"> </span>If you must,
kiss them once on the forehead when they say good night.<span style="mso-spacerun: yes;"> </span>Shake hands with them in the morning.<span style="mso-spacerun: yes;"> </span>Give them a pat on the head if they have made
an extraordinary job of a difficult task.”</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">To
further discourage demonstrations of affection he admonished, “Won’t you then
remember when you are tempted to pet your child that mother love is a dangerous
instrument?<span style="mso-spacerun: yes;"> </span>An instrument which may
inflict a never healing wound, a wound which may make infancy unhappy,
adolescence a nightmare, an instrument which may wreck your adult son or
daughter’s vocational future and their chances for marital happiness?”<span style="mso-spacerun: yes;"> </span>More than half a century later, Watson’s
granddaughter, the actress Mariette Hartley, would blame the practical
application of her grandfather’s theories for the family dysfunction that
contributed to her life-long struggles with psychological challenges.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">It
is easy to scoff at Dr. Watson’s stern warnings, dismissing them as symptomatic
of a less illuminated era, until we analyze the quality of pediatric advice
that continues to be dispensed.<span style="mso-spacerun: yes;">
</span>Recently, Dr. Andrew Adesman, chief of developmental and behavioral
pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New
York sent a survey, called the Pediatric Health Beliefs Questionnaire, to a
sample of board-certified pediatricians.He found that thousands of
pediatricians still subscribe to popular parenting myths and false
beliefs.<span style="mso-spacerun: yes;"> </span>More worrisome, 76% endorsed
one or more practices that could pose a significant health hazard to
children.<span style="mso-spacerun: yes;"> </span>More than 1/3 of
pediatricians mistakenly believed 8 out of 40 pediatric myths presented to
them.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">One
symptom that is of particular concern to parents, and is thus not surprisingly
associated with a myriad of myths, is fever.<span style="mso-spacerun: yes;">
</span>In fact, the fear of fever, which is often accentuated by dramatic
portrayals in the popular media, is so intense in some cases that it has been
dubbed “fever-phobia”.<span style="mso-spacerun: yes;"> </span>A practice that
has become almost universal in the pediatric community is that of alternating
the fever reducing medications, Acetaminophen and Ibuprofen (using a variety of
dosing schedules) in an attempt to suppress fever more completely.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
a published survey of 161 pediatricians, half of the respondents stated that
they routinely advised alternating Acetaminophen with Ibuprofen for fever
control.<span style="mso-spacerun: yes;"> </span>When asked the basis for this
advice, 29% said they were following recommendations from the American Academy
of Pediatrics.<span style="mso-spacerun: yes;"> </span>A puzzling statistic,
seeing as the American Academy of Pediatrics does not have a policy that
recommends this practice. </span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">There
are several problems with using both medications in conjunction as a routine
for fever control.<span style="mso-spacerun: yes;"> </span>The inconsistency of
the schedules employed can easily lead to dosage errors with possible
overdosing.<span style="mso-spacerun: yes;"> </span>Published reports have
illustrated the potential for some children to develop reversible kidney
failure when both medications are used.<span style="mso-spacerun: yes;">
</span>Furthermore, there is the unintended side-effect of increasing parental
anxiety with such an aggressive approach.<span style="mso-spacerun: yes;">
</span>If the doctor is so keen on eliminating fever, after all, it must be
quite dangerous.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Instead,
fever is a potentially beneficial mechanism, an important part of our immune
system’s response to infection, the product of millions of years of
evolution.<span style="mso-spacerun: yes;"> </span>Even cold-blooded animals
(scientifically referred to as poikilotherms, from the Greek roots “poikilo”,
meaning varied, and “therm”, heat), such as reptiles, amphibians, fish, and even
worms, will produce, in response to infection, what is known as behavioral
fever. They raise their body temperature, not through a complex interplay
involving the production of hormones and other chemicals as is typical in
mammals, but by moving into a warmer environment: a lizard may lay on a stone
heated by the sun, while a fish will swim to warmer water.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Regular
use of fever suppressing medications, also known as antipyretics, may prolong
illness in individuals infected with influenza A and other infections.<span style="mso-spacerun: yes;"> </span>In animal models, use of these medications is
associated with more severe organ damage and higher mortality with a range of
infections. So why treat fever at all?<span style="mso-spacerun: yes;">
</span>Simply put, fever is uncomfortable.<span style="mso-spacerun: yes;">
</span>It is often accompanied by headache, body aches, fatigue, lethargy and
lack of appetite.<span style="mso-spacerun: yes;"> </span>The goal of using
these medications in children should not be the quashing of even the slightest
elevation in temperature, but to provide comfort.<span style="mso-spacerun: yes;"> </span>This can be easily accomplished with the use
of just one medication. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Yet,
the advice to alternate medications has become nearly universal despite the
fact that there is precious little evidence to support it.<span style="mso-spacerun: yes;"> </span>Several published analyses of available data
have discouraged this practice.<span style="mso-spacerun: yes;"> </span>But it
is wrong to think that doctors and nurses choose to ignore these warnings:<span style="mso-spacerun: yes;"> </span>the truth is they are completely unaware of
them.<span style="mso-spacerun: yes;"> </span>They are utterly convinced that
what they are recommending is the standard of care, without ever questioning
the origin of this practice or its validity.<span style="mso-spacerun: yes;">
</span>As is so often the case, there is a huge gulch separating available
knowledge and current practices.</span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Forcing the Tissue:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Another
frequent source of parental confusion and apprehension, the direct result of
poor advice from professionals, is the handling of the intact foreskin in
uncircumcised boys.<span style="mso-spacerun: yes;"> </span>This confusion and
insecurity leads many parents to opt for circumcision outside of the newborn
period to mitigate perceived problems.<span style="mso-spacerun: yes;">
</span>Many doctors persist in wrongly urging parents to forcibly pull back the
foreskin in infants, even chastising them for not doing so more aggressively
and cruelly blaming them for any problems that occur as a direct result of
their own bad counsel.<span style="mso-spacerun: yes;"> </span>But as anyone who
has examined an uncircumcised newborn can plainly see, it is impossible to
retract the foreskin of a baby without causing pain and injury. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Most
medical school curricula include precious little when it comes to the normal
anatomy of the prepuce, so it should be no surprise that there is a fair amount
of ignorance among physicians when it comes to this subject.<span style="mso-spacerun: yes;"> </span>Our understanding of the anatomy and
physiology of the foreskin was advanced by a sentinel article by Douglas
Gardner, titled “The Fate of the Foreskin”, published in the British Journal of
Urology in 1949.<span style="mso-spacerun: yes;"> </span>In his study, he found
that the foreskin was retractable in only 4% of normal newborns, 20% of six
month old boys, and 50% of twelve month old boys.<span style="mso-spacerun: yes;"> </span>In uncircumcised boys between the ages of 5
and 13, 6% had a foreskin that could only partially be retracted.<span style="mso-spacerun: yes;"> </span>By the teenage years, only 1% of boys have
foreskins that do not fully retract.<span style="mso-spacerun: yes;">
</span>This illustrates the fact that there is a normal, gradual process of
separation between the tip of the penis and the foreskin that occurs at
different rates among children.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
condition in which the foreskin cannot be retracted due to the presence of
adhesions is known as “physiologic phimosis”.<span style="mso-spacerun: yes;">
</span>The word “physiologic” highlights the fact that this is a normal
condition.<span style="mso-spacerun: yes;"> </span>On the other hand, pathologic
phimosis is a condition in which the foreskin cannot be retracted due to the
presence of an abnormal fibrous ring around the tip of the foreskin; the
product of scarring and loss of elasticity of the tissue. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
forcing apart of normal adhesions in children with physiologic phimosis can
result in micro-tears of the prepuce, bleeding and, if repeated with
persistence, scarring, with the final result being pathologic phimosis.<span style="mso-spacerun: yes;"> </span>Furthermore, forcibly retracting a foreskin
with a small opening can result in the foreskin remaining trapped behind the
head of the penis, compromising the blood supply to its tip; a medical
emergency known as paraphimosis.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
repeated forcing back of a tight foreskin is an exercise in futility that is
furthermore, completely unnecessary.<span style="mso-spacerun: yes;">
</span>Adhesions will promptly form again even when temporarily torn apart,
whereas, if left alone, over time the inside lining of the foreskin undergoes a
process known as squamous metaplasia. Cells slough from the inner lining of the
foreskin, the tissue becoming less sticky, and a preputial space is created,
separating the two tissues laying in direct apposition.<span style="mso-spacerun: yes;"> </span>At the same time, the opening of the prepuce
stretches and enlarges, with the help of tension provided by erections and
gentle manipulation, allowing full retraction to occur safely and painlessly. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
advice by doctors to forcibly retract the foreskin of babes in the hope of
avoiding pathologic phimosis leads to a self-fulfilling prophecy.<span style="mso-spacerun: yes;"> </span>Though there are plenty of scholarly articles
and position papers on this topic warning of the potential harm of using force
to push back the foreskin, physicians continue to recommend this fallacious and
cruel act, with many children being referred for circumcision for a normal
condition.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">An Alternate Universe of Pediatrics:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">There
are countless other circumstances in which the actual practice of medicine
bears little resemblance to what is regarded as the standard of care.<span style="mso-spacerun: yes;"> </span>It is as if an alternate universe exists; one
where principles obtained through scientific rigor are ignored in favor of a
new reality whose only proof is its popularity.<span style="mso-spacerun: yes;">
</span>Interventions develop a veneer of propriety simply through their
repetition. Gradually foolishness attains respectability. Unfounded ideas
propagate, spreading from the mind of one host to another, seemingly achieving
a life of their own.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
concept that ideas can replicate much in the way that genes do, and be
transmitted throughout a culture, competing for their survival in a manner
analogous to Darwinian evolution, was popularized by the British evolutionary
biologist Richard Dawkins in his book, <i style="mso-bidi-font-style: normal;">The
Selfish Gene.<span style="mso-spacerun: yes;"> </span></i>A unit of cultural
idea, according to this theory, is referred to as a “meme”, and a new field of
study, known as “memetics”, has been created.<span style="mso-spacerun: yes;">
</span>The nascent theory certainly has its shortfalls and its critics, yet it provides
a useful framework for understanding how beliefs take hold in a culture.<span style="mso-spacerun: yes;"> </span>In the culture of Pediatrics, one can easily
envision how certain hosts, possessing specific personality and psychological
traits, and located in strategic practice locations, can spread an idea to
others (shall I dare say, infect?) in a particularly effective way.<span style="mso-spacerun: yes;"> </span>Absurdity becomes epidemic.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Hardwired fallibility:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Though
most people would like to think of themselves as objective, rational and
logical, the way we come to embrace and hold onto certain opinions demonstrates
that we are far from that.<span style="mso-spacerun: yes;"> </span>This has
little to do with innate intelligence; in fact highly intelligent individuals
may be more skilled at rationalizing and defending an invalid point of
view.<span style="mso-spacerun: yes;"> </span>Rather, it is a reflection of our
human fallibility; the consequence of recognizable psychological mechanisms, of
fallacies in information processing, that can wreak havoc with the development
of strongly held beliefs.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Our
brains are constantly bombarded with information originating from our five
senses.<span style="mso-spacerun: yes;"> </span>They must process, analyze and
interpret this information, before deciding what type of reaction is
appropriate on our part.<span style="mso-spacerun: yes;"> </span>There is a limit
to the amount of information our brains can handle at one time, dictated by the
number of brain cells (also known as neurons) available to perform a task, the
number of connections between different groups of neurons, and the speed by
which impulses are able to travel the length of a cell and across the gulches
between neurons known as synapses.<span style="mso-spacerun: yes;"> </span>Thus,
the brain has evolved a repertoire of tricks and shortcuts to provide us with
an adequate, though imprecise, representation of our world. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">We
are not consciously aware of the blind spots created by the optic nerve of each
eye leaving the retina because the brain fudges a little and fills in the gap
with a useful, if inaccurate, approximation.<span style="mso-spacerun: yes;">
</span>We don’t require a pixel by pixel analysis of the image of a mountain
lion crouched on a rock in order for our brains to immediately recognize danger
and activate the fight or flight response.<span style="mso-spacerun: yes;">
</span>Our brains need just recognize certain salient features to recognize a
pattern.<span style="mso-spacerun: yes;"> </span>This capacity for pattern
recognition has undoubtedly provided our ancestors with a survival advantage:
the sooner you are aware of that mountain lion on the rock overhead, the more
likely you are to escape with your life. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span>This capacity for rapid identification,
however, can make us recognize patterns that are not really present.<span style="mso-spacerun: yes;"> </span>We identify figures in clouds drifting overhead,
and we perceive human faces (frequently that of Jesus, the Virgin Mary, or
Elvis) in a stain on a wall, in the wood grain of a door or even on a grilled
cheese sandwich.Likewise, in witnessing a series of events we can convince
ourselves that there is a pattern where none exists.<span style="mso-spacerun: yes;"> </span>We can associate events that occur
simultaneously or in rapid succession, convincing ourselves that there is a
cause and effect relationship.<span style="mso-spacerun: yes;"> </span>Quickly
we formulate a rule or law that describes this pattern.<span style="mso-spacerun: yes;"> </span>After all, such a rule may aid in quickly
reaching an important decision in the future.<span style="mso-spacerun: yes;">
</span>It would be apropos at this point to try to categorize some of the
common fallacies that humans fall prey to in formulating erroneous beliefs.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Bias:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
word “bias” is sometimes used synonymously with “prejudice” and almost always
carries a negative connotation.<span style="mso-spacerun: yes;"> </span>For the
purposes of our discussion it will specifically refer to a tendency or
predisposition to believe a particular explanation of observed phenomena.<span style="mso-spacerun: yes;"> </span>Biases are a sort of shorthand of the mind
in an attempt to make sense of events surrounding us.<span style="mso-spacerun: yes;"> </span>In that sense they can be thought of as the
most rudimentary and crude formulation of a hypothesis.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
generation of ideas and hypotheses is a valuable skill; one that humans are
particularly good at.<span style="mso-spacerun: yes;"> </span>Problems arise,
however, when our tentative hypotheses are not questioned, scrutinized and
tested more thoroughly.<span style="mso-spacerun: yes;"> </span>The inherent
problem with bias is how we go about handling additional information.<span style="mso-spacerun: yes;"> </span>The tendency is to give more weight to
information that confirms our preconceived notions, and to dismiss
contradictory information, reasoning that it is either flawed or not relevant
to the case in point.<span style="mso-spacerun: yes;"> </span>In the same vein,
we tend to remember events that confirm our viewpoints better than we can those
that dispute them.<span style="mso-spacerun: yes;"> </span>This phenomenon is
referred to as “confirmation bias”.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
success of science in explaining natural phenomena has been its cognizance of
our tendency towards bias, and its attempt to eliminate it by adhering to a set
of formal procedures that includes testing hypotheses under controlled
conditions, confirming observations by attempting to replicate them, and the
adoption of a rigorously skeptical approach.<span style="mso-spacerun: yes;">
</span>One must be ever vigilant for attempts to couch untested theories in the
language of science.<span style="mso-spacerun: yes;"> </span>This approach, best
defined as “pseudoscience”, borrows scientific principles, often employing them
in an allegorical or metaphorical way, misapplying and misconstruing them, to
support their fallacious assumptions.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Thus
we hear about Candidiasis Hypersensitivity Syndrome, Chelation therapy for
behavioral problems and Quantum healing, as practitioners attempt to blur the
distinction between science and nonsensical speculation.<span style="mso-spacerun: yes;"> </span>As we have seen, individuals with a Medical
degree are apt to fall for this approach as well, if not by embracing a
particular form of pseudo-science, by adopting pet theories that they do not
submit to the necessary process of skeptical scrutiny.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">It
may be impossible to eliminate bias altogether if it is a cognitive process
that is essentially hardwired in our brains.<span style="mso-spacerun: yes;">
</span>We must, therefore, at a minimum be aware of our biases and understand
how they may sway our perceptions and our decisions.<span style="mso-spacerun: yes;"> </span>For example, when it comes to the practice of
Pediatrics I am aware of my personal biases:<span style="mso-spacerun: yes;">
</span>I believe that most children are intrinsically healthy and the challenge
of the Pediatrician is to identify the minority that are not; I believe most of
the common problems that bring children to the attention of their doctors tend
to resolve without treatment and require at most, only comfort measures; I
believe that children should be on the fewest medicines for the shortest period
of time, and whenever possible, should take no medications at all; and I
believe that every medical encounter is as likely to produce harm as it is to
generate a beneficial outcome.<span style="mso-spacerun: yes;"> </span>The
nature of my biases may expose me to the possibility of erring in the direction
of missing an important diagnosis and of not providing necessary treatment to a
child that desperately needs it.<span style="mso-spacerun: yes;"> </span>By
reminding myself of my biases I activate a self-correcting mechanism; a type of
damper that I can only hope will restrain me from stumbling into flawed
assessments.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Over-generalization:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Generalization
is one road to bias and prejudice: forming opinions about many on the
experience with a few; an improper form of induction.<span style="mso-spacerun: yes;"> </span>In medical practice, hasty generalization can
have several effects.<span style="mso-spacerun: yes;"> </span>Doctors learn to
diagnose diseases, in great part, through a process of pattern recognition.<span style="mso-spacerun: yes;"> </span>Though much time may be spent absorbed in
books, memorizing lists of symptoms associated with a particular condition, the
most vivid lessons are those provided by our experience, caring for a patient
with a particular condition.<span style="mso-spacerun: yes;"> </span>That
patient, seen during our residency, becomes the prototype for that particular
disease, helping to remind us of its identifying signs and symptoms.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
problem is that the same disease process can have a variety of presentations
and Mr. Jones, whom we remember from our internal medicine clerkship as a
fourth year medical student, may not have had a typical presentation for
ulcerative colitis.<span style="mso-spacerun: yes;"> </span>In the words of Sir
William Osler: “We, the doctors, are so fallible, ever beset with the common
fatal facility of reaching conclusions from superficial observations, and
constantly misled by the ease with which our minds fall into the ruts of one or
two experiences”.<span style="mso-spacerun: yes;"> </span>Our entire conception
of a particular disease may be skewed by our limited experience, helping us
fail to recognize it when it presents in a different way.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The Rooster syndrome:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
child that lives on a farm notices that every day, just before dawn, the
rooster crows.<span style="mso-spacerun: yes;"> </span>Soon after, the first
rays of morning sun begin filtering through the cracks of his window curtain.<span style="mso-spacerun: yes;"> </span>He concludes that the crowing of the rooster
causes the sun to rise.<span style="mso-spacerun: yes;"> </span>This fallacy in
logic, also known by its Latin name of <i style="mso-bidi-font-style: normal;">post
hoc ergo propter hoc</i> (after this, therefore because of this), describes the
tendency, when two events happen in succession, to infer that the first event
caused the second one to happen.<span style="mso-spacerun: yes;"> </span>As a
matter of fact, cause and effect do tend to occur in close temporal order, yet
often, two unrelated events can occur in succession by coincidence.<span style="mso-spacerun: yes;"> </span>Alternatively, two or more events that happen
in sequence can be the result of a yet unrecognized cause.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A
child is brought to the doctor because he’s had a cough for one week.<span style="mso-spacerun: yes;"> </span>The doctor prescribes an antibiotic and asks
the family to bring the child back one week later.<span style="mso-spacerun: yes;"> </span>At the follow up appointment the child is
doing much better.<span style="mso-spacerun: yes;"> </span>The doctor credits
the antibiotic for the cure. Actually, the child would have gotten better
anyway since the cough was due to a self-resolving viral infection. The doctor
fell prey to the rooster syndrome.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span>The human body’s magnificent self-healing
abilities and the tendency of even chronic diseases to have periods where
symptoms wane, predispose us to attribute healing properties to all manner of
ineffective treatments, both conventional and “alternative”.<span style="mso-spacerun: yes;"> </span>Pharmaceutical company representatives, when
calling on physicians, are fond of asking how their product is working out for
us, in a manner similar, I suppose to that used years ago by salesmen of
leeches and patent medicines.<span style="mso-spacerun: yes;"> </span>The only
way a physician’s personal experience would be reliable and relevant is if it
were uniformly negative:<span style="mso-spacerun: yes;"> </span>none of the
patients improved, or they all suffered a particularly troublesome of
disfiguring complication.<span style="mso-spacerun: yes;"> </span>To be
confident that a treatment has true therapeutic properties, on the other hand,
one must insist on objective data in the form of a well-conducted scientific
study, where a large number of subjects are randomly assigned to different
forms of treatment, and neither the patient nor the doctor know which type of
treatment the patient is receiving.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">When
submitted to this type of scrutiny the results of alternative therapies are
routinely disappointing, but so are many “conventional” therapies that were
previously thought to be beneficial.<span style="mso-spacerun: yes;">
</span>Even some operations once thought to be beneficial, such as the ligation
of the internal mammary artery for the treatment of chest pain, when rigorously
examined are found to be no better than sham treatments, whose benefits are now
recognized to be solely due to the placebo effect: the subjective perception,
on the part of the patient, of an improvement in symptoms based on the belief
that an effective treatment was rendered.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">A Need for simplicity:</span></b></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Human
physiology is extremely complicated, as are the mechanisms with which our
bodies respond to disease states and to therapeutic interventions.<span style="mso-spacerun: yes;"> </span>A particular outcome may be due to the
interplay of many more variables than our minds are able to juggle at the same
time.<span style="mso-spacerun: yes;"> </span>As a result, doctors resort to
wholesale simplification to help them steer their way. This simplification may
lead us to neglect important elements, however.<span style="mso-spacerun: yes;">
</span>Thus we are navigating fully conscious of the direction of the
prevailing wind, aware of the angle of the tiller, but neglecting to consider
the size of the sails, the size of the rudder, the strength of the cross
currents and the effect of wind shear.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">We
come to favor a limited number of diagnoses for the majority of the patients we
encounter, developing a type of tunnel vision that does not allow us to
consider other possibilities.<span style="mso-spacerun: yes;"> </span>Fever is
immediately ascribed to an infection, and a child may be subjected multiple
treatments with antibiotics over a period of months before the correct
diagnosis of Juvenile Rheumatoid Arthritis is even considered.<span style="mso-spacerun: yes;"> </span>A one month old infant may undergo multiple
formula switches before his inexorable deterioration leads to the diagnosis of
pyloric stenosis: an obstruction in the outflow tract of the stomach.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Some
practitioners skip the step of assigning a diagnosis altogether, opting for an <i style="mso-bidi-font-style: normal;">if-then</i> approach of makeshift
algorithms.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">If</i> the baby is fussy, <i style="mso-bidi-font-style: normal;">then</i>
give gas relief drops.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">If</i> the child has a fever, <i style="mso-bidi-font-style: normal;">then</i> get a White Blood Cell count.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">If</i>
the White Blood Cell count is greater than 15,000, <i style="mso-bidi-font-style: normal;">then</i> give an injection of antibiotic.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">If</i>
a child is anemic, <i style="mso-bidi-font-style: normal;">then</i> give
iron.<span style="mso-spacerun: yes;"> </span>Any of these interventions in
specific circumstances may be appropriate (except for the gas drops), but not
before even considering the likely diagnosis.<span style="mso-spacerun: yes;">
</span>This simplistic strategy is often utilized by less experienced individuals
who have yet to develop a more sophisticated understanding of Pediatrics, and
are using this leap-frog method to keep from submerging in their lack of
knowledge. Among its users are residents, midlevel practitioners, and
physicians practicing outside of the scope of their training. All physicians
are vulnerable to this tactic when we find that no diagnosis is forthcoming
based on pattern recognition.<span style="mso-spacerun: yes;"> </span>We are
then forced to think systematically, using our knowledge of physiology, anatomy
and pathology to propose a list of potential diagnoses – referred to by
physicians as the differential diagnosis – before selecting out the most
probable of these and determining an approach that will allow us to zero in on
the correct choice.<span style="mso-spacerun: yes;"> </span>But thinking is such
hard work, especially when you have a waiting room full of patients yet to be
seen.<span style="mso-spacerun: yes;"> </span>It is far easier to just do
something, create the illusion of propriety and hope for the best.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">*****</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal; margin-bottom: 12.0pt; mso-add-space: auto; mso-add-space: auto; mso-para-margin-bottom: 1.0gd; text-indent: .5in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">If
human fallibility makes us vulnerable to being seduced by unfounded beliefs,
the antidote is to adopt a scientific stance: to question our pet theories and
long-held ideas; to insist on evidence and be wary of arguments weighted on
authority; to reject dogma in favor of a skeptical attitude.<span style="mso-spacerun: yes;"> </span>Some may find such an approach inflexible,
cold, narrow minded and lacking intuition.<span style="mso-spacerun: yes;">
</span>They may argue that the scientific approach is only one of many equally
valid world views, and there is much that other traditions have to offer.<span style="mso-spacerun: yes;"> </span>But at the end of the day, science works in a
highly reliable way.<span style="mso-spacerun: yes;"> </span>Cellular phones,
air conditioning, computers, jet airplanes, satellite radio, and garage door
openers all work reliably as a result of an understanding of natural laws, the
result of rigorous discipline in the application of the scientific method.<span style="mso-spacerun: yes;"> </span>Science may not be able to answer many of the
questions that have troubled humans through the millennia, and it may fall
short of providing the warmth and comfort that other philosophical approaches
purport to offer.<span style="mso-spacerun: yes;"> </span>Some may argue that
science will never be capable of fulfilling some of our deepest emotional
needs.<span style="mso-spacerun: yes;"> </span>But whether I’m on an airplane cruising
at 500 miles per hour at 35,000 feet, or I’m about to be anesthetized to have
my gall bladder taken out, I’ll gladly choose science over any other way of
understanding our world.</span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com6tag:blogger.com,1999:blog-5332168372257738092.post-46372418781994892332013-06-10T10:14:00.002-07:002013-07-13T08:54:11.330-07:00The Most Abused Lab Test in Pediatrics<!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Often, when a child with a fever is evaluated in a doctor's office or emergency room, a complete blood count or CBC is ordered as part of the workup. This can be reassuring to parents. After all, a blood test is an objective test, immune to the human errors we might attribute to the "art" of medicine. Think again. In most cases, the CBC is completely unnecessary in the evaluation of fever in children. In many cases it is downright harmful because of the regularity with which it is misinterpreted and leads to the wrong diagnosis and unnecessary treatment.</span><br />
<br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
history of the use of the CBC is inextricably intertwined with that of Occult
Bacteremia, a condition whose mysterious name has nothing to do with the
supernatural.<span style="mso-spacerun: yes;"> </span>“Bacteremia” refers to the
presence of bacteria in the blood stream, whereas “occult” just means “hidden”.
Occult Bacteremia is the presence of bacteria in the bloodstream in a
well-appearing febrile child, usually between the ages of 3 months and 36
months, with no identifiable focus of infection.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">To
demonstrate bacteria in the blood stream one must utilize a blood culture: a
test whose result can be delayed several days as blood must be incubated in a
proper medium before the growth of bacteria can be detected.<span style="mso-spacerun: yes;"> </span>Understandably, doctors have wanted a quicker
test, as bacteremia can be associated, albeit rarely, with the development of
other serious infections such as meningitis.<span style="mso-spacerun: yes;">
</span>In the search for a reliable quick test, the first order of business was
to look at the statistics on the rate of prevalence of Occult Bacteremia.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
the 1970s, the rate of Occult Bacteremia in febrile children outside the
newborn period but less than three years of age ranged from 3% to 10% based on
several studies.<span style="mso-spacerun: yes;"> </span>One clear discriminator
in identifying children at particular risk for this condition was the height of
the temperature:<span style="mso-spacerun: yes;"> </span>children with a
temperature of less than 102.2 degrees Fahrenheit (39 degrees Celsius) were
found to almost never have Occult Bacteremia.<span style="mso-spacerun: yes;">
</span>The results were very similar when the white blood cell count was
utilized with a WBC greater than 10,000 being considered abnormal.<span style="mso-spacerun: yes;"> </span>Using this cutoff however, an abnormal white
count vastly overestimated the likelihood of bacteremia:<span style="mso-spacerun: yes;"> </span>only 5.8% of children would actually be expected
to have positive blood cultures when the WBC was greater than 10,000.<span style="mso-spacerun: yes;"> </span>A WBC less than 10,000, on the other hand,
was highly predictive of the absence of bacteremia with an accuracy of
99.2%.<span style="mso-spacerun: yes;"> </span>This may come as no surprise
after our earlier examples, because this is another case of a disease with a
low prevalence.</span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">What
if we tried to be more discriminating, by using the height of temperature in
conjunction with an elevated WBC?<span style="mso-spacerun: yes;"> </span>In
fact, let’s try using 15,000 instead of 10,000 as our cut-off for an abnormal
WBC.<span style="mso-spacerun: yes;"> </span>In the 1970s, a child under 2 years
of age with a temperature greater than 102.2 and a white blood cell count
greater than 15,000 had a 10% chance of having occult bacteremia.<span style="mso-spacerun: yes;"> </span></span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Based
on this data, several recommended approaches to the highly febrile child with
no apparent source of infection were published.<span style="mso-spacerun: yes;">
</span>The most influential was a consensus paper published in July of 1993 in
the journal, <i style="mso-bidi-font-style: normal;">Pediatrics,</i> the official
journal of the American Academy of Pediatrics.<span style="mso-spacerun: yes;">
</span>This paper established guidelines which included the recommendation that
children 3 to 36 months of age with fever greater than 102.2 degrees Fahrenheit
and a WBC greater than 15,000 should have a blood culture and be treated with
antibiotics at least until the results of the blood cultures are available.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">It
is important to understand that when recommendations such as these are
formulated they are not a direct consequence of the available data but involve
the making of judgment calls that take into account economic, political,
ethical and socio-cultural factors.<span style="mso-spacerun: yes;"> </span>The
data available at the time demonstrated that of 10,000 children with a
temperature greater than 102.2 ̊̊, 300 would be expected to have Occult
Bacteremia (using a rate of 3%).<span style="mso-spacerun: yes;"> </span>Of
these, only about 25 would go on to have an invasive infection.<span style="mso-spacerun: yes;"> </span>The panel thus concluded that it is
preferable to submit thousands of children to further blood testing and
unnecessary antibiotics than allow 25 from developing a serious infection.<span style="mso-spacerun: yes;"> </span>I am not disputing the decision; rather, I
want to point out that there is a trade-off.<span style="mso-spacerun: yes;">
</span>Other countries, particularly those with fewer resources or at a time
where antibiotic resistance is of graver concern, may have easily reached
different conclusions.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">The
net effect was to establish the WBC of 15,000 as an important signpost in the
evaluation of fever in children, but many doctors forgot the details of these
recommendations or completely misunderstood their limited scope.<span style="mso-spacerun: yes;"> </span>The guidelines applied only to children
between the age of 3 months and 36 months – older children are not at risk for
Occult Bacteremia.<span style="mso-spacerun: yes;"> </span>Also, they were
specifically geared for children who do not have an otherwise recognizable
source of infection.<span style="mso-spacerun: yes;"> </span>Many practices
routinely obtain CBCs to “rule out Occult Bacteremia” in situations that are
completely different from those outlined in the consensus paper wrongly
believing that they are adhering to these guidelines.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">I
once attended a tall, stocky 14 year old who was dispatched to the hospital by
his Pediatrician; his mother frantic because she had just been told that the
child had “an infection in his blood”.<span style="mso-spacerun: yes;">
</span>From the young man’s appearance I was immediately doubtful of the
accuracy of this assessment.<span style="mso-spacerun: yes;"> </span>It turns
out that the young man had started having an achy throat the night before, and
had started running a fever during the night.<span style="mso-spacerun: yes;">
</span>Earlier that morning he had a headache and was having pain with
swallowing his breakfast.</span><br />
<br />
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</div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">He
went to his pediatrician who diagnosed a Strep Throat infection based on a
positive rapid strep test.<span style="mso-spacerun: yes;"> </span>But then the
pediatrician also obtained a CBC which showed a White Blood Cell count of
17,000.<span style="mso-spacerun: yes;"> </span>He told the mother that the teen
had “Occult Bacteremia, a serious blood infection”, and referred him to the hospital.<span style="mso-spacerun: yes;"> </span>I carefully explained to the mother that her
son did not actually have a blood infection and, though I would end up angering
the referring pediatrician (who thereafter stopped sending me patients), I
wrote a prescription for Penicillin to treat his throat infection and
immediately sent the family home.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">There
were so many foibles in this case that it is hard to know where to start.<span style="mso-spacerun: yes;"> </span>First off, Occult Bacteremia is a concern for
children under 36 months of life, not teenagers.<span style="mso-spacerun: yes;"> </span>Even if we invoked the 1993 guidelines in
this setting, this young man would not be suspected of having this
condition.<span style="mso-spacerun: yes;"> </span>Furthermore, even in 1993,
most children under 36 months of age did not actually have Occult Bacteremia;
only about 3% did.<span style="mso-spacerun: yes;"> </span>But what of the
elevated WBC of 17,000?<span style="mso-spacerun: yes;"> </span>Since the CBC is
not part of the routine evaluation of Strep Throat infections, this test is
simply indecipherable.<span style="mso-spacerun: yes;"> </span>What is the
expected WBC in a child with Strep Pharyngitis?<span style="mso-spacerun: yes;">
</span>Who knows!<span style="mso-spacerun: yes;"> </span>I tried researching
this question but was unable to find any concrete answer.<span style="mso-spacerun: yes;"> </span>To my knowledge, there never has been a study
on the height of the WBC in children with strep throat infection because it is
an irrelevant test for this condition.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Unfortunately,
I’ve been involved in scores of similar instances where children were diagnosed
with having “an infection in the blood” on the sole basis of the WBC:<span style="mso-spacerun: yes;"> </span>an impossible assessment. I would therefore
like to take this opportunity to launch an appeal to all pediatricians:<span style="mso-spacerun: yes;"> </span><u>please stop telling parents that children
have a blood infection on the basis of an elevated white blood cell count</u>!</span></div>
<div align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd; text-align: center;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">In
the 1970s, two bacteria accounted for the majority of Occult Bacteremia:
Streptococcus Pneumonia (65% to 70% of cases) and Haemophilus Influenza B (10%
to 20% of cases).<span style="mso-spacerun: yes;"> </span>Much has changed since
the 1970s.<span style="mso-spacerun: yes;"> </span>In 1990 a Haemophilus
Influenza B vaccine was introduced, and in 2000 one for Streptococcus
Pneumoniae became part of the vaccination schedule for all infants.<span style="mso-spacerun: yes;"> </span>The result has been a steep drop in the
occurrence of this disease in the last twenty years.<span style="mso-spacerun: yes;"> </span>Whereas in the 1970s studies reported that 3%
to 10% of children with fever had occult bacteremia, more recent studies
indicate rates below 1%.<span style="mso-spacerun: yes;"> </span>The CBC is even
less reliable as a predictor of occult bacteremia than it was when the 1993
guidelines were issued.<span style="mso-spacerun: yes;"> </span>The current
consensus is that well appearing children with high fever do not require a CBC
or a blood culture.<span style="mso-spacerun: yes;"> </span>Many pediatricians,
however, seem to be stuck in the early 1990’s.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">There
<b>is </b>one test that is indispensable in the evaluation of high fever in boys under
one year of age and in girls under 36 months of age: the evaluation of a urine
sample for evidence of a Urinary Tract Infection (UTI).<span style="mso-spacerun: yes;"> </span>Of the “hidden” infections, this is by far
the most common: one that can have serious repercussions if not identified and
treated early.<span style="mso-spacerun: yes;"> </span>But pediatricians prefer
to get a CBC than a urine sample.<span style="mso-spacerun: yes;"> </span>In the
office, obtaining a blood sample for a CBC is a simple procedure that requires
little skill: a needle is used to poke a finger and a few drops of blood are
obtained.<span style="mso-spacerun: yes;"> </span>On the other hand, to get an
adequate, uncontaminated urine sample in a child who is not yet toilet trained
requires introducing a tiny catheter through the urethra and into the
bladder.<span style="mso-spacerun: yes;"> </span>This is a procedure that
requires some degree of skill, patience and time.<span style="mso-spacerun: yes;"> </span>Many doctors avoid it altogether by referring
children to the Emergency Room if they believe that a urine specimen is
needed.<span style="mso-spacerun: yes;"> </span>But they happily poke holes in
children’s fingers.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">This
reminds me of the joke of a gentleman who, late one night after having too much
to drink, is seen on all fours under a lamppost feeling his way around the
pavement.<span style="mso-spacerun: yes;"> </span>A Good Samaritan stops and
asks if he can be of assistance.<span style="mso-spacerun: yes;"> </span>The
inebriated man explains that he’s lost his keys.<span style="mso-spacerun: yes;"> </span>The kind stranger at once crouches down and
joins the search.<span style="mso-spacerun: yes;"> </span>After some ten minutes
of rummaging, the Samaritan asked the other man if he was sure he’d dropped the
keys in that area.<span style="mso-spacerun: yes;"> </span>“Oh no”, says the
carouser, “I dropped them in that dark alley across the street”.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">“Then
why in good heavens are you looking for them here?”</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span>“Well”, the tipsy man said, “the light’s much
better under the lamppost”.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Some
doctors would rather embark in a fruitless search with blood work than looking
in the right place, simply because obtaining the indicated test is
inconvenient.<span style="mso-spacerun: yes;"> </span>They’d rather avoid the
dark alleys.</span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 12.0pt; mso-para-margin-bottom: 1.0gd;">
<br /></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com3tag:blogger.com,1999:blog-5332168372257738092.post-78049138079805563122013-06-04T09:43:00.000-07:002013-07-27T13:43:26.837-07:00When is Fever in Children a True Emergency?<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormalCxSpFirst" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Data from the
CDC confirms what every pediatrician already knows: the most common reason for
ER visits for both boys and girls is fever.<span style="mso-spacerun: yes;">
</span>Fever continues to be a symptom that strikes fear in the hearts of
parents though, thanks in large part to vaccines, most childhood illnesses that
cause temperature elevation are either self-resolving viral syndromes or minor
ailments that respond promptly to treatment. </span></div>
<div class="MsoNormalCxSpLast" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">In
most instances, a fever does not warrant a trip to the emergency room – the child
can be provided comfort with an over-the-counter antipyretic medicine and safely
be seen in their doctor’s office the next day.<span style="mso-spacerun: yes;">
</span>There are some exceptions to this.<span style="mso-spacerun: yes;">
</span>The following is a list of situations in which fever is a true medical
emergency.</span></div>
<div class="MsoListParagraph" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The child is less than 6 weeks old.
</span></b></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Newborn
babies are more susceptible to serious infections and are less able to fight
them off.<span style="mso-spacerun: yes;"> </span>A febrile infant under 6 weeks
of age requires immediate medical attention and in many cases will require
hospital admission.</span></div>
<div class="MsoListParagraph" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The child has an underlying
illness.</span></b></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Some
chronic conditions predispose to serious infections or thwart the body’s
ability to fight mild infections.<span style="mso-spacerun: yes;"> </span>Among
these are genetic diseases such as Sickle Cell Disease and Cystic Fibrosis;
acquired diseases including leukemia and other forms of cancer; and all
diseases that affect the immune system, from inherited immune-deficiencies to
HIV infection/AIDS.</span><br />
<br />
<div style="text-align: center;">
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<div style="text-align: center;">
<a href="http://tinyurl.com/nw7d5ez" target="_blank"><span style="font-family: "Times New Roman","serif"; font-size: large; line-height: 200%;">The Art of Forgetting <i>is one of the summer's hottest new novels.</i></span></a></div>
<div style="text-align: center;">
<a href="http://tinyurl.com/nw7d5ez" target="_blank"><span style="font-family: "Times New Roman","serif"; font-size: large; line-height: 200%;"><i>Click here and see for yourself...</i></span></a></div>
<div style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><i> </i> </span></div>
</div>
<div class="MsoListParagraph" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Children who take immunosuppressive
medications.</span></b></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Some
medications, such as steroids and drugs that alter the immune system, place
children at risk for serious infection.<span style="mso-spacerun: yes;">
</span>These medications are often used to treat chronic conditions including
juvenile arthritis.</span></div>
<div class="MsoListParagraph" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Recent travel to foreign countries.</span></b></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">We
sometimes take for granted the fact that many infectious diseases are extremely
rare or virtually inexistent within the borders of our country.<span style="mso-spacerun: yes;"> </span>Travel to some parts of the world may put
children at risk for malaria, yellow fever, typhus and other “exotic” diseases.</span></div>
<div class="MsoListParagraph" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-spacerun: yes;"> </span><b style="mso-bidi-font-weight: normal;">Children
who are not vaccinated.</b></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
incidence of blood infections, bacterial meningitis and measles has plummeted
in the last twenty years due to safe and effective vaccines. One benefit of
widespread vaccination efforts is herd immunity, which to some extent protects
individuals who are not vaccinated by virtue of the fact that these diseases
are much rarer.<span style="mso-spacerun: yes;"> </span>Nonetheless, outbreaks
of preventable infectious diseases happen with regularity among unvaccinated
children.</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Finally, children who appear ill.</span></b></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">I’m
often asked by parents at what temperature they should start to worry.<span style="mso-spacerun: yes;"> </span>The actual reading on the thermometer is just
one piece of information that should be considered in the context of the
overall picture of how the child acts and feels.<span style="mso-spacerun: yes;"> </span>Any child with the worst headache of his
life, especially in conjunction with a stiff neck or vomiting should be seen
immediately.<span style="mso-spacerun: yes;"> </span>So should ill appearing
children with a rash, particularly if the rash doesn’t blanch when pressure is
applied to the skin. I do ask that children with a temperature of 105 degrees
Fahrenheit or higher receive rapid evaluation, and any child who has had a
febrile seizure needs to be seen the same day.<span style="mso-spacerun: yes;">
</span>Finally, I ask parents to trust their gut feeling.<span style="mso-spacerun: yes;"> </span>Pay attention to that little voice tells you
something is just not right.<span style="mso-spacerun: yes;"> </span>Your
subconscious may be picking up on something you just can’t put into words.<span style="mso-spacerun: yes;"> </span>This is sometimes referred to as “tacit
knowledge”.</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Though
most childhood fevers are not true emergencies, some situations do require
immediate evaluation.<span style="mso-spacerun: yes;"> </span>This article is not
intended to discourage parents from seeking appropriate medical care for their
children but to empower them with knowledge.<span style="mso-spacerun: yes;">
</span>As always, questions and concerns should be addressed to your child’s
pediatrician.</span></div>
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin;"></span><br />
<div class="MsoNormal" style="line-height: 200%; margin-left: .25in;">
<br /></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-62298191793902235872013-05-17T12:28:00.002-07:002013-06-06T08:33:03.566-07:00Praise for Suffer the ChildrenSuffer the Children addresses the following themes:<br /><br />
* the shortcomings of how primary medical care is delivered<br />
* how the expectations of parents affects the decision making of pediatricians<br />
* the over-prescribing of antibiotics<br />
* the lost art of obtaining a medical history and performing a physical diagnosis<br />
* how laboratory studies are routinely misinterpreted and can subject your child to unnecessary treatments<br />
* cognitive errors that lead physicians to mistaken diagnoses<br />
* financial conflicts of interest in medical care<br />
* suggestions for improving the quality of medical care. We can and must do better!<br />
<br />
<br />
Here's what readers have said of my book:<br />
<br />
“a gem of a book...Its lessons are important and are not limited to
pediatrics: every health care provider and every patient could benefit
from reading this book.”<br />
Harriet Hall M.D.<br />
sciencebasedmedicine.org<br />
<br />
“Dr. Palmieri has an admirably clear style and an enviable ability to
explain scientific and medical concepts so that anyone can understand
them… This is an excellent book that every parent and pediatrician
should read and take to heart.”<br />
Mama Mara, <br />
“Science, medicine, and psychology for the discerning mommy”<br />
<br />
"Suffer the Children is a comprehensive and accurate assessment of what
needs to change in the practice of pediatrics. It should be read by the
directors of every pediatric training program".<br />
William Wilkoff, M.D.<br />
Pediatrician and author, "Coping with a Picky Eater: A Guide for the Perplexed Parent"<br />
<br />
"It's rare to see such an insider's view of his own profession,
especially one that so eloquently and caustically exposes widespread
systemic flaws. This isn't a book for the faint-of-heart, or for those
who wish to blithely continue to obey the experts in whom they've
trusted their children's care. It is a tome designed from the first page
to open eyes and change thinking."<br />
Roy Benaroch, M.D.<br />
Pediatrician and author, "A Guide to Getting the Best Care for Your Child"<br />
<br />
"Dr. Palmieri's book should be read by all medical students, residents
and practitioners, regardless of their specialty. In today's age of
evidence-based medicine (or better yet, science-based medicine), we
cannot afford to constantly rely on folklore, logical fallacies and
doctors who ignore science."<br />
John J. Byrne, M.D.<br />
Pediatrician<br />
<br />
"Dr. Palmieri is correct, but what he describes equally applies to all medical professions."<br />
Paul Prescott, M.D., F.A.A.P.<br />
Pediatrician<br />
<br />Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-11450775977245878402013-05-16T10:18:00.002-07:002013-05-16T10:38:38.190-07:00When Should I Pierce My Baby's Ears?<!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Parents of
newborns often ask me what is the best time to pierce a baby’s ears.<span style="mso-spacerun: yes;"> </span>My standard answer leaves many
perplexed.<span style="mso-spacerun: yes;"> </span>Before I reveal what that
reply is, let’s briefly analyze the relevant issues surrounding ear piercing.</span></div>
<div class="MsoNormalCxSpLast" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>Earrings have been used since
biblical times and it seems that the practice of piercing infants’ ears dates
back to that era. The most common reasons for ear piercing reported by parents
are the following:</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">It is traditional in our culture.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">It hurts less to have it done when they’re
babies, or at least, they won’t remember the pain.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">They look cute.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">How else will people know that it’s a
girl?</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
arguments against early piercing revolve around the potential risks of
complications and issues of safety.<span style="mso-spacerun: yes;">
</span>There is the concern that babies have a higher risk for localized skin
infections as well as for life-threatening generalized sepsis. The possibility
of acquiring tetanus is quoted by those physicians who advocate waiting until
six months of age (to complete three doses of tetanus vaccine) though it is
hard to find any solid data on the actual incidence of this disease following
ear piercing. Children are more likely to develop sensitivity to metals if
exposed at an earlier age.<span style="mso-spacerun: yes;"> </span>And when the
child grows into a toddler, the risks of suffocation and injuries to the ear
lobe increase as the child becomes more active.<span style="mso-spacerun: yes;">
</span>Also, the studs of earrings have a propensity to become stuck or
embedded under the skin on the back of the ear lobes of infants.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The
weighing of risks and benefits in medicine incorporates two ethical
prerogatives:<span style="mso-spacerun: yes;"> </span>the principle of
beneficence (the desire to provide aid and relief) and the principle of
non-maleficence (the desire not to harm).<span style="mso-spacerun: yes;">
</span>But, the issue of ear piercing should include yet another aspect of
ethical consideration: the principle of autonomy – that an individual has the
right to choose or refuse a treatment.<span style="mso-spacerun: yes;">
</span>The individual, in this case, is the baby, and though we can’t ask her,
there is no urgency that we can’t wait until she is able to express her
opinion.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Some
may scoff at this notion, pointing out that parents routinely make medical
decisions for their children, but they do so in situations where there is a
clear health benefit to their child, where it’s not feasible to wait a few
years until the child is able to understand the choice and verbalize it.<span style="mso-spacerun: yes;"> </span>No such benefit can be surmised with ear
piercing. Still, most children wouldn’t make a big fuss about having had their
ears pierced when they were infants, you may say.<span style="mso-spacerun: yes;"> </span>But what about baby girls who have multiple ear
piercings? How about boys that have had their ears pierced as infants?<span style="mso-spacerun: yes;"> </span>Both of these are becoming more common
trends.<span style="mso-spacerun: yes;"> </span>Are they not entitled to make
that choice for themselves?</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">So
this is what I tell parents.<span style="mso-spacerun: yes;"> </span>Jewelry is
used in our society to connote social status (why else would someone drop
thousands of dollars on a Rolex when they can use their cell phone to tell the
time) and for cosmetic reasons.<span style="mso-spacerun: yes;"> </span>Babies
don’t care to flash Bling and they are adorable without jewelry (in fact,
jewelry on babies is a tad gaudy – what’s next? Lipstick? High heels?).<span style="mso-spacerun: yes;"> </span>If it is absolutely crucial to you that
people know the gender of your child, use the old pink/blue color scheme, pick
names that are not ambivalent as to sex, or just tell people, “She’s a girl!”
or “He’s a boy!”</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">As
far as the pain issue, it is clear that infants feel pain just as acutely as
older children and adults do.<span style="mso-spacerun: yes;"> </span>In fact,
there is some evidence that early painful experiences might modulate the
perception of pain later in life. If you think your child will not want to have
her ears pierced when she’s older out of fear of pain, think again.<span style="mso-spacerun: yes;"> </span>Teenagers hardly think twice about piercing
their ears, noses, eye-brows, tongues, navels… and more sensitive parts.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">What
about the sense of culture and maintaining tradition? Traditions change.<span style="mso-spacerun: yes;"> </span>When I was an infant no one used infant car
seats and few buckled up their seat-belts, doctors smoked as they made hospital rounds and there was no
talk of “health foods”.<span style="mso-spacerun: yes;"> </span>Bucking
tradition is one of the great joys of life, particularly when you are making a
rational choice for your child.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">So
when is the best time to pierce your baby’s ears?<span style="mso-spacerun: yes;"> </span>Answer: when she (or he) requests to have it
done.<span style="mso-spacerun: yes;"> </span>Now wasn’t that simple?</span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-81469767129892258352013-05-14T10:12:00.003-07:002013-05-14T10:12:30.911-07:00SLIM DOWN: A Healthy Approach to Preventing Childhood Obesity<!--[if gte mso 9]><xml>
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<div class="MsoNormalCxSpFirst" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Here’s an
interesting fact: animals do not become overweight in their natural habitat. In
the wild, cats are not fed Meow Morsels Select from a crystal bowl and must
prowl and hunt for their meals. A fat cat makes a poor hunter. Even large
animals, elephants and water buffalo, are not obese in the wild in the sense
that they do not reach a weight that is physiologically detrimental to their
health.<span style="mso-spacerun: yes;"> </span>Bears fatten up before
hibernating but this too is a normal physiologic mechanism that aids in their
survival.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>Why do I bring this up? Because I’d
like to make the point that humans no longer live in their natural habitat, and
the explosion of obesity is a direct result of this fact.<span style="mso-spacerun: yes;"> </span>Humans have not evolved in the last 100,000
years, yet we moved from our hunter-gatherer roots (our natural habitat) through
the agrarian period, past the industrial revolution and into the information age.<span style="mso-spacerun: yes;"> </span>But our physiology is still that of
hunter-gatherers.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>Of course I’m not suggesting we all
return to the forest to eat berries and trap squirrels. Yet we have to be
mindful that we are living in an environment which is conducive to accumulating
weight to a point that impairs our well-being. And we are raising our children
in this challenging and unhealthy environment.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>So what can a parent do to try to
buck the trend and help keep their children achieve a healthy weight? Over the
years, as a board certified pediatrician, I’ve developed an acronym that I use
as a mnemonic device in counseling my patients.<span style="mso-spacerun: yes;">
</span>It captures a range of behaviors and habits that lead to healthier
living. The goal, I always stress, is not to shoot for an arbitrary
pre-selected weight, but to incorporate healthy habits.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>The acronym is SLIM DOWN, and I’ll
go through each element briefly.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">S = Sit at the
table to eat</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Perhaps as a
result of the hustle and bustle of our lives, perhaps due to the pull of
entertainment that attracts us like moths to a patio light, children nowadays
eat in all sorts of unusual places: in the back seats of cars, in their
bedrooms at their computer, on the sofa as they watch TV… I believe this is an
unhealthy trend. First, kids are missing out on the significant social
interaction of a family meal. Second, they are distracted when they are
eating.<span style="mso-spacerun: yes;"> </span>Distracted eaters have
difficulty gauging satiety clues and tend to overeat.<span style="mso-spacerun: yes;"> </span>Try to eat at least one meal a day as a
family.<span style="mso-spacerun: yes;"> </span>Your children can model their
eating habits from you, you’ll be better able to monitor your child’s food
choices, and there are countless other benefits stemming from the social
interaction.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">L = Limit screen
time</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">From television
to video games and computers, children are more sedentary than ever. Even
reading a book burns more calories than sitting on the couch watching TV.<span style="mso-spacerun: yes;"> </span>The best way to limit screen time is to give
your children other options.<span style="mso-spacerun: yes;"> </span>This may
require going in the backyard to play catch with your child, or going to a park
for a walk. Unfortunately, many children live in neighborhoods that are
inherently unsafe which makes outdoor activity nearly unfeasible.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">I = Include
exercise as a daily routine</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">This doesn’t
necessarily require participation in sports though certainly that is a good
option for some children.<span style="mso-spacerun: yes;"> </span>Riding a bike,
playing in the park, walking the dog, just playing outdoors are all forms of
exercise.<span style="mso-spacerun: yes;"> </span>The key is to select an
activity that is fun so that children look forward to it.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">M = Motivate
with rewards, not punishment</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">We can all use a
pat on the back sometimes. Don’t use threats or demean your children when they
resist incorporating new habits. Learn to use the carrot rather than the
stick.<span style="mso-spacerun: yes;"> </span>Set achievable goals and provide
appropriate rewards to encourage your child.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">D = Dine
restaurant style, not buffet style</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">At a restaurant,
you order an entrée and the waiter brings it to you (by the way, the size of
dishes at many restaurants are way too big!).<span style="mso-spacerun: yes;">
</span>If you finish everything that is on your plate, it is understood that
the waiter will not bring you a second helping.<span style="mso-spacerun: yes;">
</span>You ate what you ordered, that’s it! (Unless you order more food, which
you probably shouldn’t.) At a buffet, on the other hand, if you like the fried
chicken, you can go back in line and get some more, and why not pick up some
more shrimp while you’re at it, to make sure you get your money’s worth? </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>At home, the buffet setting happens
whenever there is food available for second helpings; bowls on the table filled
with delicacies within arm’s reach. Convert your home meals into a restaurant
experience. Start by cooking less – it’ll save you money!<span style="mso-spacerun: yes;"> </span>Plate appropriately sized portions. If your
family members eat everything on the plate, guess what?<span style="mso-spacerun: yes;"> </span>That’s it!<span style="mso-spacerun: yes;">
</span>If you really misjudged the portion sizes, you can always bring a bowl
of fruit to the table.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">O = Offer fewer,
better snacks</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Grazing is the
eating pattern of large mammals. When humans graze, they become large
mammals.<span style="mso-spacerun: yes;"> </span>Kids graze when they are
constantly eating snacks.<span style="mso-spacerun: yes;"> </span>Some children
get the majority of their calories from snack foods (including drinks) rather than
from their scheduled meals. Also realize that there is no Recommended Dietary
Allowance for Flaming Hot Corn Chips. Your child can do without some food
choices altogether.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>The best way to achieve this is to
simply not buy massive amounts of food that require little or no
preparation.<span style="mso-spacerun: yes;"> </span>Your child might be able to
quickly microwave some macaroni and cheese, but will not cook a chicken from
scratch.<span style="mso-spacerun: yes;"> </span>Food choices start at the
grocery store, and if your purchases are strongly influenced by your child’s
preferences (or tantrums), plan to go to the supermarket alone.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">W = When in
doubt, walk.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Many communities
are designed in a way that discourages walking.<span style="mso-spacerun: yes;">
</span>Distances to schools, stores and entertainment venues are prohibitively
far or dangerous for pedestrians. Yet, by simply walking more, we can help burn
a significant number of calories.<span style="mso-spacerun: yes;"> </span>Park
your car at the far end of parking lots.<span style="mso-spacerun: yes;">
</span>This forces you to walk a little farther and your car will get fewer
dents and dings. Take the stairs instead of the elevator if you need to go up
or down less than three floors. Go for a walk at the local mall (leave your
credit cards at home). Whenever the opportunity presents itself, walk.</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">N = Never talk
the talk if you don’t walk the walk</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">The best way to
teach your child is to be a role model.<span style="mso-spacerun: yes;">
</span>They may not listen to everything you say (don’t be so sure) but they
will notice everything you do.<span style="mso-spacerun: yes;"> </span>Don’t
expect your children to pick up any habit you are not willing to incorporate
yourself, <i style="mso-bidi-font-style: normal;">first</i>.<span style="mso-spacerun: yes;"> </span>And the key word is, “first”.<span style="mso-spacerun: yes;"> </span>You want your child to exercise?<span style="mso-spacerun: yes;"> </span>Start by getting into an exercising
routine.<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;">Then</i>, invite your child to join you.<span style="mso-spacerun: yes;"> </span>You want to wedge your child away from the computer?<span style="mso-spacerun: yes;"> </span>Then get off the computer (but not until
after you check out my book, Suffer the Children: Flaws, Foibles, Fallacies and
the Grave Shortcomings of Pediatric Care available for Kindle on amazon.com).</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">What if your
child is doing all the things I’ve listed above and is still not losing
weight?<span style="mso-spacerun: yes;"> </span>That’s fine!<span style="mso-spacerun: yes;"> </span>First off, many children who are at an
unhealthy weight don’t need to lose weight – they just have to stop gaining
weight.<span style="mso-spacerun: yes;"> </span>So a prolonged period with no
weight gain (as long as it is done through healthy habits) is a great
outcome.<span style="mso-spacerun: yes;"> </span>And either way, if your family
adopts the strategies I’ve suggested, you will have picked up some healthy
lifestyle choices.<span style="mso-spacerun: yes;"> </span>Remember, it’s not a
number you’re shooting for. Your goal is healthy habits.<span style="mso-spacerun: yes;"> </span>Best of luck!</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Peter Palmieri, M.D., M.B.A. </span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: 200%;">
<br /></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-52630122665211852092013-05-06T10:03:00.002-07:002013-05-08T09:23:32.475-07:00When A Diaper Rash Just Won't Go Away<!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Most diaper rashes are the
result of sensitive skin irritated by moisture and friction and aggravated by
exposure to urine and feces. In most cases, gentle cleansing and the use of any
number of over the counter creams that create a protective barrier over the
skin are enough to help the rash resolve. There are instances however, where a
rash just doesn’t seem to want to go away. Rarely, a stubborn diaper rash may
be the sign of a serious underlying illness.</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Fungal
rash. When over the counter creams just don’t seem to work, the most frequent
offender is yeast. The most common, Candida, <span style="mso-spacerun: yes;"> </span>just loves the moist environment inside a
diaper. This rash will often be more noticeable in the canyons of the skin
folds rather than the over the mounds of flesh, at least when it’s first
starting. It can cause a faint peeling, and there will often be tiny red spots
surrounding the main area of rash which we call “satellite lesions”.<span style="mso-spacerun: yes;"> </span>Your doctor will prescribe an an anti-fungal
cream which may need to be used regularly for a couple of weeks.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Scabies.
This rash is generalized over the entire body, but it can have a predilection
for the genitalia.<span style="mso-spacerun: yes;"> </span>It is caused by a
tiny mite that parasitizes the skin. The rash is very itchy, particularly at
night when the mite tends to be more active. It is common for multiple family
members to be affected at the same time. The typical treatment is a one-time
application of Permethrin cream.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Steroid
diaper dermatitis. Steroid creams come in a range of potency. When a
topical steroid is covered by a membrane such as plastic wrap or a diaper, the medicine
is absorbed more readily and, as a result, the strength of the cream is
augmented. Even creams of relatively weak potency become much more powerful,
which is why we only use the weakest potency Hydrocortisone in a diaper area
(if one is needed at all) for the shortest period of time. </span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; text-indent: .25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Some doctors
inappropriately prescribe a popular combination of an antifungal cream with a
medium potency steroid to be applied to the diaper area (see my article on the
Seven Medications Pediatricians Should Never Use But Still Do). The result can
be severe irritation with the formation of skin ulcers. The treatment for this
is to stop the steroid medication.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Perianal
Streptococcal Dermatitis. You’ve probably heard of strep throat, but you might
not have known that children can get strep butt. The same bacteria that causes
throat infections can cause an infection of the skin around the anus.<span style="mso-spacerun: yes;"> </span>The affected area will look bright red. The
child may be somewhat ill and run a fever. The diagnosis can be verified by
obtaining a culture with a cotton- tipped applicator. The treatment is much
like that of strep throat: a short course of an oral antibiotic.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Hemangioma.
This is not a rash at all but a benign skin growth composed of dilated blood
vessels. Hemangiomas are very common in infancy and the majority will resolve
by themselves though they often grown in size in the first nine months of life.
The ones in the diaper area can be a bit more of a problem because they have a
higher propensity for ulcerating and bleeding. A referral to dermatology is
sometimes required.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Psoriasis.
This is a much rarer cause of diaper rash so it is often missed. Psoriasis in
infants will often present with diaper rash and no other obvious signs and
symptoms. Dermatologic evaluation is typically needed to verify the diagnosis
and provide treatment.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Zinc
Deficiency. The deficiency of this mineral in the diet can cause a severe
unremitting rash, often accompanied by a rash around the mouth and hair loss.
The child may have an underlying condition that results in defective absorption
of nutrients (such as cystic fibrosis) or may be malnourished. A rare genetic
disease known as Acrodermatitis Enterohepathica is an inherited disorder of
zinc metabolism. These children require expert consultation to address the
underlying nutritional deficiencies.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 200%; margin-left: .75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Langerhans
Cell Histiocytosis. This is a poorly understood group of disorders that affect
the cells that originate from the bone marrow as well as a specific type of
skin cell known as the Langerhans cells. Children with this condition have a
variety of symptoms, including chronically draining ears, a rash behind the
ears, bone lesions and blood disorders in addition to severe diaper rashes that
are generally unresponsive to common treatments.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Even with the most
meticulous skin care, most infants will develop mild irritation in
the diaper area from time to time. Most diaper rashes are transient and respond
quickly to traditional treatments. The ones that don’t improve require
evaluation by a physician. Rarely, a diaper rash can be a sign of a more
serious malady.</span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com319tag:blogger.com,1999:blog-5332168372257738092.post-74541237967795756812013-05-02T18:52:00.002-07:002013-05-02T18:53:29.636-07:00The Most Common Reasons for Unnecessary Pediatric ER Visits (And Why We Should All Care) <!--[if gte mso 9]><xml>
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<div class="MsoNormalCxSpFirst" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">A large
proportion of pediatric ER visits do not involve true emergencies. These
children would better be served by their own physician in the office setting. But
the number of children receiving part or all of their primary care in the
hospital emergency room is growing. This should be a concern to all of us for
several reasons. First, unnecessary visits clog up emergency departments, so if
you or your family members have a true emergency there is the risk of delayed
treatment, even when a good system of triage is maintained. Secondly, a
majority of children receiving substantial care from ERs for trivial problems
receive government sponsored insurance which is paid by all of us. Whereas an
office visit might cost the taxpayer about fifty bucks, the same care in an ER
usually saddles the tax payer with a bill for around $1,000. And perhaps most
importantly, the ER is a poor place to receive primary pediatric care: the
patient is seen by a different physician every time; the physician does not
have access to important aspects of the child’s medical record; no follow-up or
continuity of care can be provided.</span></div>
<div class="MsoNormalCxSpLast" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>So why do so many families rely on
Emergency departments for the medical care of their children? There are many
reasons but these are by far the most common.</span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">A perceived emergency. We often deal
with routine childhood illnesses that are not emergencies but are perceived as
such by parents. This, in my view, is a perfectly appropriate reason to go to
the ED but should be remedied by providing education and what is known as
anticipatory guidance. The most important part of the education is to advise
parents that, with the exception of trauma, poisonings, severe allergic
reactions or respiratory distress they should phone their doctor’s office
before going to the Emergency Room to receive advice and triage.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Travel. For families on a trip away from
home (particularly those who have government funded health insurance) the
hospital ER is the only alternative to obtain care.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Lack of insurance. In many cases this
involves a lapse of Medicaid due to not complying with the renewal
requirements. If you have no insurance and no independent financial means, you
will not be seen in doctor’s offices or free-standing clinics, but the ER
cannot refuse to provide care.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Unavailability of primary care
providers. This sounds ridiculous, but some physicians will close their offices
for extended periods of time and not provide reasonable alternative coverage.
Their coverage is the local ER. More frequently, the office is open but the
doctor refuses to see a “sick” patient. <i style="mso-bidi-font-style: normal;">The
child has a high fever? Go to the ER. She has a tummy pain? Could be
appendicitis. Go to the ER.</i> Yes, it might be appendicitis, but you can’t
possibly form a reasonable judgment unless you examine the child. And if it is,
you might spare a wait in the ER and arrange for the child to be directly
admitted to the hospital.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Referrals from primary care provider.
The emergency department has become a major destination for referrals in many
cities. I have been referred patients for problems related to growth and even
for dermatological problems. This is a waste of everyone’s time and an
inappropriate use of resources. The thinking from the referring physician is
that once the child is in the hospital, the ER doctor will make the proper
referral, or a specialist will materialize in the ER out of thin air.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Convenience. For families with working
parents it is difficult to get to a doctor’s office if it does not have
extended hours. The ER, on the other hand, is always open. It is disheartening
to see how often families bring in three or four children at the same time. One
child is ill, they explain, and they want to take the opportunity to just get
the other kids checked out even though they’re feeling just fine.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Second opinion. Many of the kids we see
in Emergency Rooms have already seen one or more physicians for their child’s
illness – often the very same day. They come to the ER to ask if the treatment
provided by their own doctor is reasonable and appropriate, or because they
haven’t noticed an improvement in their child’s ear infection after the first
dose of antibiotic.</span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Desire for specialty care. The family
has already seen their physician who has reached a diagnosis and may or may not
have instituted a plan of treatment but then the family decides they want a
specialist to see the child. They register in the ED with the expectation that
ENT, orthopedics, dermatology and endocrinology will see their child in the
emergency room for a non-urgent problem. Not only will the specialist not see
the child in the ER, the ER doctor may not be able to provide the desired
referral because many health plans require the primary care doctor to submit
this request for approval.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;">Children deserve to
receive their medical care in a medical home; from a physician who knows the
child and the family and is available to provide continuity of care. We all
deserve Emergency Rooms that are not so bogged down in the management of
trivial problems that when a true emergency happens our loved ones are able to
receive immediate attention by professionals providing the care they were
trained to provide.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; line-height: 200%;"><span style="mso-tab-count: 1;"> </span>There is no simple fix to this problem, but certainly it
must include a change in paradigm in the financing of care. Charging a small
co-pay to Medicaid patients for ER visits is likely to assuage its use out of
sheer convenience without discouraging appropriate visits. Altering payment
patterns for physicians is also essential. Medicaid re-imbursement for sick
visits is so low that it hardly is worth the effort to many pediatricians. It
is imperative that patients, physicians and policy makers work together to find
solutions or we will all suffer the consequences.</span></div>
Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com5tag:blogger.com,1999:blog-5332168372257738092.post-44583488657622475452011-06-18T10:02:00.000-07:002011-06-18T10:03:22.680-07:00Munchausen's by Doctor: A Previously Unrecognized Entity<div id="article-content"> <p>One of the most important jobs of a pediatrician is to imbue parents with self-confidence. Instead, we often confuse them, scare them and fill them with self-doubt. This can have a long-term detrimental effect on the parent-child relationship. Parents whose child experienced an illness early in life can fall prey to the Vulnerable Child Syndrome, where they perceive that their now healthy child is still somehow medically fragile and prone to illness. This not only can result in unnecessary medical interventions; it can lead to behavioral and developmental problems in the child.</p><p>Why do doctors create the belief that children are ill when they are not? For starters, with the exception of checkups, every encounter a child has with his physician results in a diagnosis. This is obligatory, as physician visits are compensated by insurance companies based on diagnostic codes that are catalogued in a constantly updated publication known as the International Classification of Disease Manual or ICDM. There is no code for "healthy child" or "normal", though there is code V65.5: "Person with feared complaint in whom no diagnosis was made" or "worried well". But physicians who use this code run the risk of not getting paid for the visit. Insurance companies view such encounters as superfluous. No, it's safer, from a financial standpoint, to report that the child was sick.</p><p>So most children are assigned an ersatz diagnosis to justify a medical visit. From the doctor's perspective, the diagnosis is tentative and plays more of a bookkeeping function than a medical one. There is danger in this. Diagnostic labels tend to stick. What was a provisional diagnosis, long discarded by the treating physician, becomes a permanent part of the medical record. And the diagnosis remains cemented in the parent's mind. That perfect little baby is no longer perfect. He has "Reflux". He is sick. He is vulnerable.</p><p>The tendency to diagnose illness in healthy children is also driven by the failure of many pediatricians to recognize the wide range of normal when it comes to children's behavior, development, growth, and pattern of expulsion of bodily contents from various orifices. Differences in doctors' confidence in their clinical skills, variations in comfort in dealing with uncertainty, and unique personality traits of the physician all lead to wide discrepancies in how symptoms are interpreted. I have met many a neurotic pediatrician who instinctively sees a tempest when a lonely cloud drifts across a blue sky. These doctors tend to have practices full of high strung parents.</p><p>In some instances doctors jump at the chance of making an "interesting diagnosis" to relieve the drudgery of seeing an endless parade of runny noses. In the television coverage of a recent devastating earthquake, I was surprised to learn that in order to keep search and rescue dogs from becoming discouraged, human volunteers hide in the rubble from time to time so that they can be "found". This is essential to keep the dogs keen and it has a salubrious effect on their psychological well-being. I believe doctors have the same need. If a "good find" is not available, a doctor will sometimes just make one up.</p><p>I once attended a drug company sponsored lecture featuring a distinguished visiting allergist at a restaurant with gaudy Victorian décor. Having arrived early, I was invited to dine with the scheduled speaker and a local family practitioner who had also come early for the talk. The family doctor, a kindly gentleman whose long face was exaggerated by his bald pate, started describing a very interesting case he had seen some weeks earlier.</p><p>A middle aged man presented to his office with a hacking cough. Further discussion brought to light that the patient owned a parrot. The family doctor paused for effect, smiled, leaned forward as if revealing a secret and said, "The gentleman had Psittacosis".</p><p>Psittacosis, also known as "parrot fever", is an infection caused by the bacteria Chlamydiophila Psittacci, which can be inhaled from bird droppings. The diagnosis is suspected based on history and physical and is confirmed by one of several blood tests.</p><p>"How interesting", said the allergist. "How did you make the diagnosis?"</p><p>The smile vanished from the family doctor's face. He straightened his spine and said, "Sir, he had a parrot!"</p><p>The gentleman may have had Psittacosis, but the family doctor fell a little short of proving the diagnosis. And he was offended by the allergist's query which in effect questioned the validity of his diagnosis. The family doctor was proud of having made the diagnosis of psittacosis. To suggest that the diagnosis was wrong was like finding a live person in the rubble of an earthquake, only to be told he is a stooge.</p><p>What I am suggesting is that doctors get an emotional high from doctoring. Medical students experience this when they successfully insert their first I.V. Residents are overjoyed when they succeed in performing a spinal tap on an infant on their first try. And many doctors in practice like to boast that they have a high proportion of ill children on their patient panel.</p><p>There is nothing wrong in deriving pleasure from helping your fellow man, after all it is a common motivator for pursuing a career in medicine. But we must be sure that the procedure we are doing is in the interest of the patient rather than for our own mental well-being. Along these lines, I believe there is a previously unrecognized phenomenon that I have dubbed "Munchausen's syndrome by doctor".</p><p>Munchausen's syndrome, named after Baron Karl Friedrich von Munchausen, an eighteenth century German nobleman with a penchant for telling fantastic tales of his implausible feats and unbelievable exploits, is a condition in which an individual fabricates symptoms in order to receive medical care. It must be distinguished from malingering, which is the feigning of illness in order to gain a surreptitious objective (such as skipping work or defrauding an insurance company) in that the entire goal is to be a patient and assume the role of the infirm. It is also distinct from conversion disorder, an involuntary condition with psychological underpinnings in which an individual perceives symptoms consistent with a morbid condition even when the condition is not present.<br />Munchausen syndrome by proxy is a form of child abuse in which an adult (usually a parent) fabricates symptoms or induces illness in a child so as to get attention and fulfill a pathologic psychological need. Some parent groups argue that there is no such thing as Munchausen's by proxy, that it is a diagnosis invented by a callous medical establishment that is unsympathetic to the plight of parents whose children have true medical needs. Yet there is ample documentation, including the use of covert video surveillance in the hospital setting, that shows parents suffocating, poisoning and producing fractures in their own children.</p><p>I believe that there is a Munchausen Syndrome by doctor, where a perfectly healthy child is diagnosed with, and treated as having a disease for the pure psychological need of the treating physician. The parent becomes an unwitting accomplice, becoming thoroughly convinced that their child is terribly ill, always on the brink of a medical catastrophe, requiring multiple daily medications to allay a crisis. These children tend to be labeled with several diagnoses from a limited pool, most frequently asthma, gastro-esophageal reflux, gluten insensitivity, recurrent infections (bronchitis, sinusitis and ear infections), and allergies to multiple foods and medications. The child frequently presents to the Emergency Room with a shopping bag full of medications, often including Metoclopramide, Lansoprazole, Fluticasone, Montelukast, Levalbuterol, Tacrolimus, antihistamines and the ubiquitous antibiotic. And the child looks completely well despite the parents' and referring doctor's anxiety. And stopping the pharmaceuticals results in no ill effect.</p><p>I believe that Munchausen's syndrome by doctor is far more common than Munchausen by proxy, which has been estimated to affect 2 out of 100,000 children. As in Munchausen by proxy, there are, in my opinion, certain personality traits that are more common in those doctors that perpetrate Munchausen syndrome by doctor. These individuals are basically insecure, and try to compensate by interpreting every symptom in its most malicious form, falling victim to a neurotic paranoia which can be kept at bay only through the incessant ordering of laboratory studies and the prescription of treatment upon treatment. The offices of these doctors are almost always full, seeing as each patient requires frequent visits. And they attract ever more individuals who, in their state of anxiety, are oddly reassured by being told that their child is ill; but at least they are in the hands of a doctor that will see them over and over, and who will provide the most aggressive treatments (whereas the other doctor just kept telling them there was nothing wrong with their child).</p><p>Convincing a parent that her child is ill is a treacherous threshold to cross. The perception that one's child is ill always alters the way the parent views and treats her child. It can undermine the confidence and sabotage the effectiveness of a parent. Again, one of the most important jobs a pediatrician has is to reassure parents so they can be more effective and self-confident, yet we frequently do the opposite, either as a result of our own insecurity, out of sheer ignorance and, on occasion, because of a pathologic impulse to feel needed, appreciated and valuable.</p><div id="article-resource"> <p style="font-style: italic;">Dr. Palmieri is a board-certified pediatrician and the author of "Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care".</p><p><a target="_new" href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_3?ie=UTF8&qid=1308158437&sr=8-3">http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_3?ie=UTF8&qid=1308158437&sr=8-3</a></p> </div><div style="overflow: hidden;"><br /> Article Source: http://EzineArticles.com/6354347<br /></div> </div><div style="overflow: hidden;"><br /> Article Source: http://EzineArticles.com/6354347<br /></div>Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-10475840039738593012011-06-10T06:47:00.000-07:002011-06-10T06:54:02.840-07:007 Medications Pediatricians Should Never Prescribe...But Still DoAlmost every visit to the pediatrician results in the prescription of one or more medications. As a parent, you'd like to trust that the medications your doctor prescribes for your child are selected based on careful reflection, and are not only effective, but safe. Unfortunately that's not always the case. As a board-certified pediatrician of sixteen years I regret to confess that many of the treatments we provide are ineffective, while others can cause grave harm. Too often, we doctors stray from accepted standards of care as a matter of expediency, the result of habit, or to satisfy perceived parental expectations. Nowhere is this so apparent as when a pediatrician prescribes a medication that experts agree should never be used by primary care doctors.<div id="article-content"><p>A medication that is shunned by pediatricians typically possesses one or more of the following features: it is not safe; it is not effective; its use has been supplanted by newer, better choices; pediatricians do not have the expertise required to prescribe the drug. Using these criteria, let us examine 7 medications that your pediatrician should never prescribe under any circumstance.</p><p><span style="font-weight: bold;">Promethazine</span>:</p><p>Pediatricians commonly use this medication for the treatment of nausea and vomiting that often accompany viral intestinal infections. Unfortunately, it doesn't work very well and it frequently produces drowsiness, dizziness and confusion: symptoms we'd like to avoid in a child whose mental status must be monitored as an indicator of dehydration. The intra-venous use of this medication has resulted in tragic events requiring the amputation of limbs due to the caustic nature of the drug, and is now prohibited in many hospitals. Fortunately, we have a much more effective medication at our disposal with a far better safety profile; which makes one wonder why some doctors still cling to Promethazine.</p><p><span style="font-weight: bold;">Cough suppressants</span>:</p><p>The common cold is the most common ailment in childhood. It is natural to want to provide some relief to a child whose cough is keeping her from sleeping. Unfortunately, the cough medications we have at our disposal have not been shown to be effective in children and may cause unacceptable side-effects. Over the counter cough medicines almost universally include the active ingredient, Dextromethorphan (DM), whereas prescription versions may employ Codeine. Both these drugs are derivatives of opiates. Respiratory depression and behavioral problems have been observed in children taking these products, and in infants, overdoses have resulted in deaths.</p><p>In October 2007, the American Academy of Pediatrics proposed to the Food and Drug Administration that the following warning be included on the labeling of cough medications:<br />"This product has been shown to be ineffective in the treatment of cough and cold in children under six years of age. Serious adverse reactions, including but not limited to death have been reported with the use, misuse and abuse of this product." Inexplicably, many pediatricians continue to routinely prescribe these medications even to infants.</p><p><span style="font-weight: bold;">Dexamethasone eye drops</span>:</p><p>This is an example of a medication that can be extremely efficacious, but which pediatricians should not prescribe because they lack the requisite expertise to use it safely. Dexamethasone is a steroid that is utilized for its anti-inflammatory properties. These eye drops are a powerful tool for a variety of conditions but require a careful eye exam by an ophthalmologist prior to their use. If applied in the midst of some eye infections, Dexamethasone-containing drops can exacerbate the infection and lead to irreparable eye injury. This medication is best left to the eye specialists.</p><p><span style="font-weight: bold;">Nystatin with Triamcinolone Combination Cream:</span></p><p>Sometimes the sum of the parts is less than the individual parts. Nystatin is a useful topical antifungal, routinely used to treat diaper rashes that have an overgrowth of yeast. Triamcinolone is a potent steroid cream that is effective in treating a variety of inflammatory conditions of the skin, including eczema. The problem arises when these two medications are combined. Doctors, wanting to add some anti-inflammatory effect in the treatment of a yeast rash, or uncertain as to whether the rash is the result of a fungal infection or due to plain inflammation, mistakenly instruct parents to use this product in the diaper area. The potency of all steroid creams is multiplied when applied to skin that is occluded by dressings, plastic wraps, or diapers. When applied under cover of a diaper, Triamcinolone can lead to ulcerations of the skin, which often intensify as a well-meaning parent continues to apply ever more cream in a frantic but futile attempt to alleviate the worsening rash. Only thin applications of far weaker steroid creams might be applied to this extremely delicate area of the body, and only after the careful consideration of potential risks and benefits.</p><p><span style="font-weight: bold;">Cefaclor</span>:</p><p>A few decades ago, Cefaclor was one of the only oral preparations of a family of antibiotics known as the Cephalosporins, which are commonly used to treat a variety of childhood infections. This particular medication, however, has a much higher rate of allergic reactions compared to other drugs in its class, including a particularly severe complication known as Serum Sickness-Like Reaction, in which children develop rash, fever, swollen, painful joints, and other troubling symptoms. Furthermore, many bacteria have become resistant to this drug. In a large study published in 2003, out of 19 antibiotics tested, Cefaclor was the least likely to kill the most common bacterium implicated in ear infections, sinus infections and pneumonia. Academic medical centers have stopped using this medication some 20 years ago, but some doctors in the community just can't break the habit.</p><p><span style="font-weight: bold;">Albuterol Oral Syrup</span>:</p><p>Albuterol by inhalation, either in an aerosol or inhaler form, remains the most important rescue medicine for the treatment of asthma attacks. When the medication is inhaled, it travels directly to receptors located on the walls of the respiratory airways, signaling muscle fibers to relax, thereby reducing bronchial constriction and improving the flow of air in and out of the lungs. The inhaled route maximizes the amount of medication delivered to its intended target and mitigates common side-effects, such as jitteriness and an accelerated heart rate, that are produced when the drug enters the bloodstream. When the oral formulation is used, the medication must first be absorbed from the intestinal tract into the circulation, by which it then travels throughout the body, with just a fraction of the ingested dose eventually finding its way onto the receptors of the airways. This is a highly ineffective delivery system that magnifies the side-effects while minimizing effectiveness. Albuterol oral syrup is often used not for asthma, but as a type of ersatz cough medicine; a practice that is a relic of the past.</p><p><span style="font-weight: bold;">Anti-Diarrhea Compounds</span>:</p><p>Diarrhea is a common occurrence in childhood, most often the result of a viral gastroenteritis; what is commonly referred to as the "stomach flu". At times, it can be the result of bacterial dysentery. The key to the treatment of this usually self-limited but bothersome condition is to provide hydration and nutrition. Guidelines from the American Academy of Pediatrics and the Center for Disease Control and Prevention discourage the use of anti-diarrhea compounds due to their lack of efficacy and the potential for serious side-effects, including severe cramping, and temporary paralysis of the gut, which can lead to a concentration of bacteria and their toxins in the setting of dysentery. Unfortunately, many pediatricians are either unaware of, or choose to ignore these recommendations.</p><p>At its best, the practice of pediatrics incorporates scientific evidence, critical thinking, best practices, and accepted standards of care, while embracing humility and a deep compassion; ever cognizant of each child's unique constitution and the cultural values of his family. Too often, we doctors fall far short of this objective, particularly when we are rushed, when we don't take the time to listen patiently or examine carefully, or when we fall into the ruts of habit, not questioning what we think we know.</p><p>Sir William Osler, a renowned 19th century physician who practiced at a time where many of the treatments were ineffective and fraught with hazards, wrote, "One of the first duties of the physician is to educate the masses not to take medicine": an admonition that retains a clear ring of truth even in the 21st century. All medications have potential side-effects and, particularly in children, a wise philosophy is to use the fewest medications with the most favorable safety profile for the least amount of time.</p><p>Many childhood illnesses are self-resolving conditions that doctors should manage by providing comfort to the child and by counseling parents, rather than blithely dispensing prescriptions designed to subdue symptoms without a conscientious attempt at identifying the true nature of the underlying condition. We doctors must do better. The best parents can do is to become informed consumers of health-care, and never hesitate to question their doctor.</p> </div> <div id="article-resource"> <p style="font-style: italic;">Dr. Palmieri is a board certified pediatrician and the author of Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. His interests include patient safety and how cognitive errors lead to errors in diagnosis and treatment.</p><p><a target="_new" href="http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_2?ie=UTF8&qid=1306890395&sr=8-2">http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_2?ie=UTF8&qid=1306890395&sr=8-2</a></p> </div>Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com6tag:blogger.com,1999:blog-5332168372257738092.post-11322741350107055892011-05-20T14:24:00.000-07:002011-05-20T14:25:39.984-07:00A good example of bad medicineHere's a physician from Louisiana who embodies many of the criticisms that I lay out in my book. He is, to be sure, an extreme example; but not an isolated case.<br /><br />http://www.lsbme.louisiana.gov/Blog/DocViewer.aspx?decision=true&fID=70957Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com3tag:blogger.com,1999:blog-5332168372257738092.post-53610147679950577612011-05-09T10:11:00.000-07:002011-05-09T10:12:31.623-07:00False positive blood tests are common... and they can cause further unnecessary testing, or needless treatments. <br /><br />http://today.msnbc.msn.com/id/42829175/ns/today-today_health/Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-52127305721493703872011-05-03T11:59:00.000-07:002011-05-03T12:00:14.349-07:00Narcotic overdoses in children are commonA new study shows that young children are frequently overdosed when receiving narcotic pain medication.<br /><br />"Specifically, 61.1% of children aged 2 months and younger who were prescribed a narcotic drug received an overdose quantity. Additionally, 35% of infants aged 3 months to 5 months received an overdose, as did 17.1% of infants aged 6 months to 11 months and 8% of children who were a year or older."<br /><br />http://health.gresnews.com/ch/Diseases/cl/University/id/283631/Overdose-Risk-for-Young-Children-on-Prescription-Pain-DrugsAnonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-46822659654523759292011-05-02T07:39:00.000-07:002011-05-02T07:42:04.497-07:00CT scans and the risk of cancerCT scans are frequently ordered in children for the evaluation of abdominal pain. Often these scans are unnecessary, yet they expose children to significant doses of ionizing radiation. This article looks at the lifetime risk of cancer as a result of these scans.<br /><br />http://www.kmx.cc/resource_pages/Second_Thoughts_Schenkman.pdfAnonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-72618194198391935562011-04-26T11:15:00.000-07:002011-04-26T11:52:03.821-07:00Wrongly AccusedThe abuse of children at the hands of their parents is a tragic reality that all pediatricians confront at some point in their careers. I have had to serve as an expert witness in a trial where a young girl contracted gonorrhea when her father raped her, and in a military court martial in which a 4 month old baby had her leg broken by her father, who happened to serve in one of the branches of the military. In the last two decades there has been a strong move to train pediatricians, and other professionals that deal with children, in recognizing evidence of child abuse, and to suspect the possibility of foul play in any instance where injuries or symptoms seem unexplainable.<br /><br />Unfortunately, this renewed effort can lead to false accusations when the individual that raises the question of child abuse lacks the knowledge and skills necessary to confirm or dismiss the suspicion. I have seen two children in the past month, whose parents were wrongly suspected of abuse, not because of a preponderance of evidence but as a result of simple ignorance on the accuser's part.<br /><br />The first child was a boy that for the last two years has been incontinent of stool. At school and at home, the child defecates in his underwear, apparently unable or unaware of the passage of stool. A teacher referred him to a school psychologist who sent the family for counseling. Despite this, the child continued having problems. The principal then got involved, accusing the family of sexually abusing the child. The child's pediatrician was apparently Missing In Action, going along with the recommendation for counseling, but not offering any additional advice. The child was finally brought to the Emergency Department when the mom was threatened by the principal that if the child was not examined immediately for sexual abuse, she would notify the police.<br /><br />The child turned out to have severe constipation leading to encopresis: the spontaneous seepage of stool. This is the most common cause of incontinence of stool in children of this age, yet this child had not received the care he needed. The family spent countless hours in needless counseling and faced intense pressure from a host of professionals that failed this child.<br /><br />The second child I saw was a 6 year old girl who had started with intense anal itching, that then spread to vaginal itching. She was seen by her pediatrician who immediately suspected child abuse. No further investigation into other possible causes of vaginal symptoms was sought. After one month of excruciating itching, with the family being investigated for possible abuse, the child came to the ER where she was found to have pinworms.<br /><br />What is stunning in both cases is that these children had very common conditions, but immediately, almost reflexively, symptoms that involved the anus and genitals were deemed to be indicative of abuse. Thereafter, all thinking came to a halt. In my book, I discuss the case of a child whose parents were accused of abusing their child who ended up having a life-threatening disease. <br /><br />Pediatricians should be ever vigilant of the possible abuse of children, but we should approach this possibility as we would any other problem in medicine; thinking of alternative explanations of the symptoms, analyzing all evidence objectively, re-thinking our initial impressions, and keeping an open mind. None of this is possible if we latch onto a judgment in a knee-jerk fashion, and if we don't have the knowledge to recognize rational explanations for the symptoms presented.<br /><br />We have a duty to protect children from harm. But we also have a responsibility to exercise diligence in our practice. Otherwise, it is we physicians who end up harming the families we care for.Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com0tag:blogger.com,1999:blog-5332168372257738092.post-80073167767560107142011-04-19T12:43:00.000-07:002011-04-19T12:48:01.041-07:00Book review by Dr. Harriett HallMy book received yet another excellent review, this time by the skepdoc, Dr. Harriet Hall. Dr. Harriet Hall is a retired physician and columnist for Skeptic magazine: one of my favorite publications. She also contributes to a web site that encourages a strictly scientific approach to medical care.<br /><br />Here is the link:<br /><br />http://www.sciencebasedmedicine.org/<br /><br />Today, Suffer the Children reached the ranking of #4 in Children's Health, and #5 in Personal Health on Amazon.com.Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1tag:blogger.com,1999:blog-5332168372257738092.post-81685766257909098032011-03-16T16:23:00.000-07:002011-03-16T16:24:18.189-07:00Introduction to Suffer the Children:<br /><br /><!--[if gte mso 9]><xml> <o:officedocumentsettings> <o:relyonvml/> <o:allowpng/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:trackmoves/> <w:trackformatting/> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> 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name="Bibliography"> <w:lsdexception locked="false" priority="39" qformat="true" name="TOC Heading"> </w:LatentStyles> </xml><![endif]--><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} </style> <![endif]--> <p class="MsoNormalCxSpFirst" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">On August 7 1963, in a small hospital on Cape Cod, First Lady Jacqueline Bouvier Kennedy brought to the world a baby boy more than five weeks prematurely.<span style=""> </span>Weighing 4 pounds, 10 ½ ounces, little Patrick Bouvier Kennedy was hastily transferred to Boston Children’s Hospital, where, despite the best medical care available at the time, he died at just two days of life.<span style=""> </span>Less than three decades later, a baby girl born at Loyola University Medical Center in the Chicago suburb of Maywood, would become the world’s smallest surviving human with a birth weight of just 9.9 ounces.<span style=""> </span>Headed by neonatologist Dr. Jonathan Muraskas, the team of doctors and nurses who took care of tiny Madeline Mann would save an even smaller infant at the same hospital in 2004, weighing in at only 8.6 ounces: the weight of a typical paperback book.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">I got to know Dr. Muraskas quite well during the three months I spent in the Neonatal Intensive Care Unit at Loyola, both as a medical student and as a pediatric resident.<span style=""> </span>Tall, with a casual ambling gait and a propensity to erupt in a boyish grin, his easy-going style belies his meticulous attention to detail; details that make the difference between life and death to the tiniest of patients.<span style=""> </span>Fortunate as I was to have him as my professor, I am most indebted to him for caring for my own prematurely born son who, at 4 pounds 6 ounces (“a huge baby” by Dr. Muraskas’ standards) was smaller than little Patrick Kennedy.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">The scientific and technical advances in the field of Neonatology in such a short span of human history would have boggled the mind of the President who ambitiously issued the challenge, within a decade, “of landing a man on the Moon and returning him back safely to the earth”.<span style=""> </span>In fact, in the forty years following Patrick Bouvier Kennedy’s death, the field of Pediatrics has had countless successes.<span style=""> </span>In the 1960’s childhood leukemia was nearly universally fatal; three decades later the five year survival for the most common type of childhood leukemia approached 90%.<span style=""> </span>Devastating infectious diseases such as polio, smallpox and diphtheria were so utterly vanquished that many otherwise reasonable people, apparently afflicted with an odd and dangerous form of selective amnesia, now openly embrace misguided anti-vaccination efforts.<span style=""> </span>The fields of genetics and molecular biology have advanced at a dizzying speed, leading to a vastly improved understanding of mechanisms of disease and the development of novel treatments for a whole range of metabolic conditions.<span style=""> </span>Advances in pediatric surgery have approached the miraculous with operations performed on the fetus while still in the womb.<span style=""> </span>Surgical correction of congenital heart disease on infants once plainly referred to as “blue babies” ushered in the era of open heart surgery, not just for children, but for adults as well; operations once thought too dangerous to attempt. <span style=""> </span>Organ transplantations in children have crossed the experimental threshold and are now performed routinely, to the extent that any procedure can be considered routine in a child. The care of children with developmental and behavioral problems, though ever a challenge, is a far cry from the institutionalization and neglect of years past.<span style=""> </span>And even the poorly understood condition of Sudden Infant Death Syndrome has become much rarer, thanks mostly to the decidedly low-tech solution of placing infants to sleep on their backs.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">One might infer that the remarkable achievements of the last four decades have translated into improvements in pediatric care at all levels. Witnessing these breakthroughs, parents have understandably come to suppose that their own children might become the beneficiaries of all this recently acquired knowledge, and not just in the unfortunate case of their child needing sophisticated treatment for a life-threatening condition.<span style=""> </span>Parents believe, as I did early during my pediatric training, that pediatricians - and I use this term in the loose sense to mean any professional who provides medical care to a child - routinely use knowledge and skills acquired during an arduous education, following scientific axioms, engaging in thoughtful reflection and incorporating incontrovertible logic in order to arrive at a rational therapeutic plan that is always in the child’s best interest.<span style=""> </span>It pains me to say that this is far from the truth.<span style=""> </span>In reality, my profession is often marred by physicians who have long forgotten or abandoned what they learned during their training, replacing scientific tenets with a hodge-podge of erroneous beliefs obtained from dubious sources, adopting a smorgasbord of unproven methods carried out in a glib, thoughtless way, minimizing intellectual effort while appeasing parents to avoid any confrontation, with the goal of arriving at a treatment plan that is convenient (and hopefully profitable), regardless of what is in the best interest of the child.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">This last statement may sound far-fetched to those outside the profession, and impertinent to those within.<span style=""> </span>Yet, there is a torrent of evidence attesting that physicians frequently mismanage the most common conditions that bring children to medical attention.<span style=""> </span>Antibiotics are routinely prescribed inappropriately to treat viral infections.<span style=""> </span>There is an undue reliance on laboratory and radiologic testing often leading to erroneous diagnoses and unnecessary treatments. <span style=""> </span>Asthma, the most common chronic illness of childhood, is mishandled with such stunning regularity that a movement to effect a type of remedial education of primary care doctors is now underway. Even the use of over the counter medications such as acetaminophen and ibuprofen is bungled.<span style=""> </span>And these are the easy lay-ups, the very bread and butter of pediatrics. When faced with problems outside their constricted comfort zone of practice, physicians resort to unnecessary referrals to specialists, raising not just the costs of a financially overburdened health care system, but needlessly arousing anxiety in family members.<span style=""> </span></span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">A curious consequence of the frequency with which poor medical care is encountered is that rational practices are supplanted by the irrational, much as weeds taking over a garden.<span style=""> </span>An alternate reality is thus created making it virtually impossible for parents to distinguish reasonable recommendations from patently bad advice.<span style=""> </span>Thus, many believe it is sensible to alternate acetaminophen with ibuprofen to eliminate fever (it is not), that amoxicillin is no longer useful to treat ear infections (it certainly is), and that colic is cured by changing an infant’s milk (hardly the case).</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">These problems are not unique to pediatrics:<span style=""> </span>this country is suffering a generalized malaise when it comes to quality of primary care medicine; there is a peculiar paradox whereby stunning technological and scientific achievements are contrasted by banal blunders.<span style=""> </span>I limit my discussion to the medical treatment of children in this book because it is what I know best from first-hand experience.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">As a board-certified pediatrician working in a variety of geographic locations and practice types for over fifteen years, I have witnessed how the sausages of pediatrics are made:<span style=""> </span>an unsavory and sometimes frightening spectacle.<span style=""> </span>I have also beheld the near sublime:<span style=""> </span>inspiring professionals whose encyclopedic knowledge I can only envy, whose dedication to their patients’ welfare we should all admire.<span style=""> </span>To avoid misrepresenting myself as a paragon of pediatrics, I must confess that in my career I have repeatedly fallen prey to illogic, I’ve sometimes provided questionable advice, and I’ve made some mistakes that continue to trouble me despite the passage of years. These personal shortcomings and the realization of the ease with which physicians succumb to the irrational have been part of the impetus driving me to analyze and better understand why physicians, presumably intelligent creatures, so often end up making poor decisions.<span style=""> </span></span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">In a kernel, physicians commit errors not simply because of a lack of knowledge or inferior intelligence, but as a result of easily recognizable human fallibilities projected on the backdrop of a complex inter-relationship of patient, doctor, and family members. In some cases we fall victim to predictable but nonetheless difficult to avoid cognitive errors and mistakes in logic. The therapeutic alliance between families and physician can be hampered by mis-communication and opposing agendas. To top it off, our decisions are sometimes swayed by financial considerations if not shameful conflicts of interest. </span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">But it is the very casual, almost slovenly approach to the care of children - not really listening to parental concerns, haphazardly examining patients, and locking onto decisions very early in the process of evaluation, sometimes even before entering the exam room - that is the most pervasive problem.<span style=""> </span>If airline pilots flew with the glib disregard for procedural principles that doctors display when treating children, planes would be dropping out of the sky every day.<span style=""> </span>Luckily, many of the problems that bring children to the attention of their doctors are self-limiting, and resolve often in spite of rather than as a result of the care prescribed.<span style=""> </span>This is why, if armed with a good bedside manner, some of the least competent pediatricians manage to appear exemplary.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">Behind closed doors many pediatricians will readily acknowledge that our profession is suffering from a general laxity of discipline, though few would admit it in public.<span style=""> </span>Professional decorum dictates that doctors should balk at criticizing their colleagues, if not out of a sense of fraternity and respect, for the more practical ends of avoiding the legal perils of defamation, and to maintain a steady flow of referrals from those very doctors whom we would never entrust with the care of our own family members.<span style=""> </span>Even Sir William Osler, arguably the greatest physician of the twentieth century, cautioned with almost biblical somberness, “Let not your ear hear the sound of your voice raised in unkind criticism or ridicule or condemnation of a brother physician”.<span style=""> </span>This admonition, however, might have been limited to the act of criticizing specific doctors by name, because Dr. Osler held no punches when criticizing, in general terms, the class of physicians who sunk to poor standards.<span style=""> </span>“For the general practitioner a well-used library is one of the few correctives of the premature senility which is so apt to overtake him”, he quips, and one can almost palpate his frustration as he repeatedly admonishes doctors to take their time, listen to the patients, question their initial diagnoses, to reflect, and to engage in life-long study.</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-align: center; text-indent: 0.5in; line-height: normal;" align="center"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">*****</span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">The purpose of this book is two-fold.<span style=""> </span>First, I hope to raise the public’s awareness of the sub-standard medical care that children are too frequently subjected to, while shedding light on some of the common myths on children’s health (often promulgated by doctors).<span style=""> </span>Second, I will offer suggestions on how pediatric care can be improved, from revising aspects of medical education, revamping the infrastructure of primary care delivery for children, and fostering behaviors that will strengthen the physician-parent partnership.<span style=""> </span></span></p> <p class="MsoNormalCxSpMiddle" style="margin-bottom: 12pt; text-indent: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: "Times New Roman","serif";">There is a wide chasm between the quality of care we physicians are capable of providing and what we are actually delivering.<span style=""> </span>Bridging this gap should be a societal imperative, especially when we consider that the poor care we deliver unnecessarily inflates medical expenditures.<span style=""> </span>So while many children undergo unnecessary diagnostic studies and are started on questionable treatments, many others don’t have access to basic care.<span style=""> </span>Good pediatric care is cost effective.<span style=""> </span>With the resources currently available we would be able to provide quality care to all children in this country if physicians, in collaboration with parents, exercised discipline and adhered to accepted standards of care.<span style=""> </span>But first we must admit there is a problem.<span style=""> </span></span></p>Anonymoushttp://www.blogger.com/profile/12816365588182303777noreply@blogger.com1