How comfortable are we with uncertainty?  I struggle with this question every day.  I treat children with abdominal pain.  Some of these children suffer with crohns disease, eosinophilic esophagitis, and other serious problems.  Some children struggle with abdominal pain from anxiety or social concerns.  I see all kinds.

But kids are tricky and sometimes I can’t pinpoint the problem.  Trudging forward with more testing is often the simplest option since it involves little thinking.  And some parents perceive endless testing as ‘thorough.’

The question ultimately becomes:  When do we stop?  Once we’ve taken a sensible first approach to a child’s problem and judged that the likelihood of serious pathology is slim, when and how do we suggest that we wait before going any further?  This requires the most sensitive negotiation.  It’s about finding a way to make a family comfortable despite the absence of absolute certainty.  This is easier said than done.  Parents can unintentionally advocate for themselves and their worries by insisting on the full court press.  Alternatively they may refuse invasive studies when absolutely indicated.

All of this is for good reason: You can’t be objective with your own kids.

Pediatrics is tricky business and managing parental uncertainty is perhaps my biggest preoccupation.  As I’ve suggested before, sometimes convincing a family to do less represents the most challenging approach.

Image: iStockPhoto

 

Is there anything wrong with this child? This is the question that runs through my head several times per day.  And it’s one of the most important questions any good pediatrician or family doctor should ask.

Like most doctors, I see children when there is a concern that something may be awry.  Be it the appearance of a baby’s stool or the way they cry, parents are designed to assume the worst.  This is probably good.  Fear, after all, keeps babies safe (usually).

So sometimes they need to know that there’s nothing to do.

I see it all the time:  Freshly minted pediatricians often assume that when parents appear, they want to leave with something.  Antibiotics and a laboratory requisition.  Nobody leaves without a prize.

In my world the classic example is uncomplicated infant reflux presenting with frequent spitting (the happy spitter).  While the parents on the surface appear may appear in need of a fix, my reassuring diatribe on the natural course of uncomplicated reflux almost universally ends up with in relief.  Despite their initial posturing, I’m impressed with the number of parents who prefer to avoid medications.

When there’s nothing to fix it’s improperly assumed that there’s nothing to do.  Some of our hardest work involves helping families understand what doesn’t need to be done.

 

Yesterday I ate at one of my favorite Italian restaurants.  I had eaten there many times before but the experience this time was different.  After ordering I received a vacuous bread basket with precisely two pieces of bread.  At the end of my meal I was offered two biscotti…and no more.

Only the manager could offer an explanation:  As a means of containing costs the decision had been made to capitate biscotti and bread distribution.

I was disappointed.  I had been eating here for years.  When Colic Solved was released, my publication party was held here.  After all those anniversaries, New Year’s celebrations, and birthdays, I’m shortchanged on cookies?

It’s remarkable how a great experience can be shadowed by something so small.

Then I got to thinking:  Perhaps I’m a two biscotti physician.  Like this restaurant there are times when I don’t finish well.  I may do a phenomenal job with assessment and diagnosis only to delay a callback on biopsies or x-ray results.  Perhaps I get it all right but fail to get the detail right on the home health orders.  Are there small pieces missing in my encounter that represent everything a parent remembers?

I know that there are and I know there are things I have to work on.

There’s a lot we can learn from a restaurant.  I don’t want to be a two biscotti physician.

 

I received a press release today from a friend in the Bay Area.  Investigators at UCSF have published a study in the New England Journal of Medicine showing that less chemotherapy can be effective at treating some childhood cancers.  The paper was the result of an eight year clinical study in children with neuroblastoma.  In this particular population, researchers were able to reduce chemotherapy exposure by 40% while maintaining a 90% survival rate.  You can read about it here.

The press release sparked a brief email exchange between me and my friend.  Who might be interested in writing about this study and is there any way to get it to spread?  What would make it sticky in the eyes of the public?

Here are a few ideas:

Figure out who cares? Sure it’s niche news but there are people who would think this is pretty darn important.  Think organizations centered on parents of children with cancer, adult survivors of childhood cancer, pediatric hematology-oncology physicians, pediatricians and allied professionals in pediatric medicine like nurse practitioners and hematology-oncology nurses.  Networks form around these groups.  Find them and seed them.

Make a video. Offer powerful, visual content beyond a press release.  A four minute clip with the principal investigator, Dr. Matthay, would be simple and offer dimension to what is now something restricted to print.  The Mayo Clinic has done this really well.

Make a Cinchcast. Some people just like to listen.  Cinch offers a simple micropodcasting platform that can run off of your iPhone.  Grab your phone and find Dr. Matthay.

Find for a story.  For the mainstream media, stories carry the message.  Perhaps a family that underwent the lower dose arm of the study or potentially a family that had suffered the effects of higher dose chemo would potentially create a human connection.

Hammer your COG (Children’s Oncology Group) hospitals. Off the top of my head both Boston Children’s Hospital and Seattle Children’s Hospital maintain very busy blogs.  Gracious mention by these two institutions alone would have you off to the races.  The dozens of other COG children’s hospitals with their blogs, Facebook pages and Twitter accounts should add to the burst.  For the latest listing of hospitals in the social sphere, visit Ed Bennett’s great big hospital list.

One tweet can go a long way. A simple Twitter request to me, Wendy Swanson, Kevin Pho, Rob Lamberts, Jenn Dyer, Gwenn O’Keefe to name just a few would disperse to some 35,000 followers.  I’m guessing that this would make its way into the right hands and you’d land a couple of blog posts.

Dig your well before you’re thirsty. Have your network in place before you need it.  COG, UCSF or the institutions harboring these powerhouse principal investigators should think about what kind of networks they’ve built to support important messaging like this.  These are the networks that make stories move.

CureSearch, for example, the funding arm of COG, has a dynamic Facebook page with over 6,000 fans.  These followers would die for this information.  Unfortunately at the time of this post I can see no mention of the study on their wall.  Again, video and audio are likely to get more mileage than a press release.

So how would you put out the word on this study?  Should it be pushed at all?  Or are some stories just not born to spread?

 

My daughter was sick this weekend with a terrible stomach virus requiring Zofran (anti-vomiting medication). Under normal circumstances I would call in the prescription into save our pediatrician a Sunday morning wake-up call. Our state medical board, however, is coming down on doctors who prescribe medications without proper documentation (i.e., what every self-respecting pediatrician does when stuck with their own sick kids on Sunday morning).

So I made the call.

The nurse screening the calls was an acquaintance and seemed to think my call to the doctor about vomiting was some type of practical joke (I’m a pediatric gastroenterologist). Once beyond this I was connected to the on-call doctor who was able to offer some valuable insight on medication options in my daughter’s case. There were some things I hadn’t thought of. While the discussion is the same one I’ve had countless times with patients of my own, you lose your objectivity when it’s your own child.

At the risk of sounding trite, I’m glad I called.

Originally published on my old blog, Parenting Solved, in 2006

 

Many times when faced with a clinical dilemma a parent will turn to me and ask, “What would you do if this were your child?”

When faced with this question I never quite know what to say.  And each time I feel a little on-the-spot.  But why is that?  Aren’t I comfortable recommending for someone else exactly what I would do for my own child?  After all, what have I got to hide?

Here’s the problem: the decisions we make as parents involve our values, tolerance of risk, level of concern and frustration, prior health experience and religious belief to name but a few.  There’s no way to fully tease those things from the parent sitting across the room.

Perhaps it’s the intensity of the fact that my child would or could be in the same situation that bothers me.  When I disclose what I would do myself as a dad, it’s intimate.  The decision I make for my child says a lot about me and my fears and concerns.  When I disclose that I’m biasing their decision with the things that are important to me.

When I get this question, what I really hear is, “I can’t really weigh the options so help me out.”  And I do.  With my answer they believe that I’m telling them what I would do.  But in fact it’s nothing more than an exercise to help them understand what they really want.

When I’m in an exam room I’m a pediatrician, not a father.  But the art of what a great pediatrician does involves understanding the mindset of a parent. Through this understanding I can frame my recommendations in such a way helps parents make the best decisions for their kids.

 

I see it from time to time. The doctor with a voice who’s uncomfortable with transparency. They post and comment under the cozy blanket of putative anonymity. But it’s bad policy. Here’s why doctors need to be outed in social media:

Anonymity is a fantasy. It’s remarkably difficult to achieve. With small thoughts you can hide – in fact, no one cares who you are. If you offer anything worth hearing people will ultimately find out who you are. And the plaintiff attorneys will always sniff you out.

You need a reality check. Anonymity gives us phony security and opens the door for us to say the things we wouldn’t normally say. There’s no editorial influence more powerful than knowing that my patients and my boss are listening. While an incendiary rant may serve to vent frustrations and drive traffic, it just fuels the perception of doctors as cynical, frustrated folks. And we don’t need help with that.

We need the press. If you spend any time in the health infosphere you’ll see that physicians are the ones left behind. If docs want a seat at the health dialog table they need to raise their hands, speak up and be accountable for their point of view. Speaking from behind a curtain doesn’t help the cause.

“Trust me, I’m a doctor.” Or are you? Medical credibility begins with credentials. The web is lousy with poseurs and your ability to be taken seriously as a medical expert depends upon your ability to first admit who you are and what you do. If you can’t stand on your name and credentials, perhaps you should stay seated.

Privacy is privacy. Pseudonyms don’t absolve you from protecting the privacy of your patients. If you are compelled to tell stories, it’s the identifying details that need to be laundered, not your identity.

So let’s go public. Online medical personalities went out of fashion with Flea. He taught us that much like the great and powerful Oz, a fiery front is only a temporary cover for the man behind the curtain.

Related links

• The hardly anonymous Dr. Nick Fogelson talks about anonymous
  doctors.
• Dr Ves on physician anonymity

 

I can spend 20 minutes interviewing a parent about their child and still not really understand them. During a consult, my interview centers on the objective elements in a child’s history. When evaluating a child for abdominal pain, for example, I have a panel of questions that cover what I need to know to generate a starting hypothesis.

But none of it helps me understand Mom.

Understanding where the parents are at is critical to both understanding a child’s problem as well as pitching a plan of care. Whether it’s revealed to me or not, parents often come to me with an agenda. If my plan doesn’t meet with their view of the situation, it’s going to be much harder for me to help that child get what she needs.

So at the end of my interview (usually when washing my hands) I launch one or all of the following questions:

• Is there anything you forgot to mention?
• What’s your biggest concern?
• What do you understand about what’s going on with your child?

Despite having a few years under my belt I’m always amazed at my inability to predict what’s worrying a mother. This is why I ask. And trying to get at what a parent understands gives me a jumping off point for the education part of the visit.

The experts call these open-ended questions. In medical school I thought the open-ended question was academic nonsense. Now it makes my life a whole lot easier. It gives me what I need to know when helping a family navigate their child’s problem.

From what I understand these questions are equally helpful with adults.

 

When I was a medical student I carried around a little black notebook. It held my lists of differential diagnoses, workups, and other key clinical pearls. In the middle of clinic when I needed to know the workup for rickets I had it right at my fingertips. I had dozens of lists and differentials, many of which saved me on rounds or during busy ICU shifts.

I still keep lists and cheat sheets. But now I keep them on Evernote. Evernote is an application that allows the digital capture of notes, images, PDFs, etc in one place. The iPhone app is phenomenal and syncs with Evernote on my Mac (or PC).

Here are 8 ways I use Evernote to make my medical life simpler:

1.  Workups. Can’t remember the workup of a baby with cholestasis or the latest evaluation for autoimmune hepatitis? I do liver for a living and I sometimes can’t keep it all straight. An Evernote list is perfect place for differentials. And the lists are right on my phone – if I catch wind of something new during a seminar or lecture, I can update my list on the spot. I encourage students and residents at Baylor College of Medicine to record their differentials and workups as they learn them. What you hear on rounds today you won’t remember in two months.

2.  Names. I just can’t seem to remember the names of all those wonderful ladies in medical records. So I keep them on a list that I peek at just at before going to complete charts. Disingenuous? No. Smart, yes.

3.  Capture papers, PDFs and peripheral stuff.  Evernote is a great place to keep journal articles, images and other stuff for reference.  And all of it is retrievable on your iPhone or Blackberry.  For a great screencast detailing how to use Evernote this way, check out this great video by fourth year medical student Ryan MacDonald.

4.  Patient plans. If you keep up with 33 Charts you’ll know that I use dry erase boards in my office to help patients understand differentials and plans. Many times I snap a picture into Evernote and refer to it at the end of the day when completing charts (no patient information attached, Evernote isn’t HIPAA compliant).

5.  Special dosing. Sure we’ve got Epocrates and other great apps for medications, but there are still situations where you need to remember special dosing protocols. For example, 2-3 times a year I use methotrexate for crohns disease. I keep my recommended dosing schedule and monitoring protocol right in Evernote. This week I had to start subcutaneous vitamin B12 on a boy with short gut syndrome. I recorded the protocol that our PharmD and RD uncovered. Next time I’ll have it at my fingertips.

6.  Grab that poster. At meetings I have used Evernote to capture pieces of poster abstracts. Conclusions, graphs, or any other type of content you want to take with you. And your photographed words even become searchable on your iPhone.

7.  Capture ideas. Inspiration strikes at strange times. Book ideas, blog concepts, potential articles come and go in my head. A lot of my clinical ideas come when I’m … in clinic. I’ve gotta get ‘em down before they disappear.

8.  Stop wandering in parking lots. I travel a lot, Houston has a big airport garage, and I’m getting older. This is bad combination. So I never leave the garage without noting my garage, level and zone. I can even snap a picture of the location or ask Evernote to retrieve notes based on my location.

And I’ve only scratched the surface. If you have any great medical uses for Evernote, let me know in the comments below.

Other links of interest

• 14 Practical Ways to Use Evernote – Pithy summary by Guy Kawasaki
• Noteworthy Blog – Evernote’s blog with lots of tips and links
• Twenty Ways Surgeons Should Use Evernote – This one speaks for itself

 

I recently had dry erase boards installed in my office exam rooms. I didn’t give it much thought but felt on a whim that it might help with diagrams and things. As it turns out, the result has been dramatic. Parents are crazy about them.

Here’s how I use them:  After my history and physical I summarize the 4-5 key points of a child’s story in the upper right part of the board. I then generate a small differential diagnosis in the lower right side. In the left upper side I list off what I think we should do. I also use self-scribbled schematics of the upper intestinal tract and colon to illustrate key ideas.

I used to stare patients, talk and use my index finger for ‘air diagrams’. Now I scribble in a way that parents can see. I can see parents thinking as they look, ask questions and process information. While I have no data to support it, I would be very surprised if retention were not improved. White boarding also helps me organize my own head when discussing care with a parent. At the end of the visit I transcribe my brainstorming into my EMR. Here’s my favorite part: I encourage families to photograph the board with their smartphone. They love it.

Perhaps it’s the visual thinking that appeals to patients. Perhaps it’s the perception that I’m spending more time with them.  Everybody tells me I look like House M.D. I’ve never seen House.

Carlos Rizo at Innovation Cell has written about how small changes in healthcare can have a big impact. I think he’s right. Here’s an example that was discovered purely by accident (call me the accidental disruptor).

If you’re thinking of doing this in your clinic, spend money on quality boards.  My 4×3 Quartet boards are big enough to hold my ideas.  And stick with the the traditional ink Expo markers.  I find the low odor markers to be a bit dry.