I Told Your Child How Babies Are Made

14 years and I finally had someone who wanted to know.

When I am seeing early adolescents for well child visits I frequently start my discussion about sexuality with the question, "Have your parents told you where babies come from?"  Most laugh a little and say they already know and we move on to deeper discussions of the topic.  Every few months a patient will tell me that they haven't learned about it yet.  So I ask if they want to know.  For the first time I had someone who said yes.

I told the adolescent about the fact that babies are made from genetic material from each parent.  (I used basic medical terminology that I won't repeat here because I don't want this page to get flagged as inappropriate content.)  And then I gave a brief description of the basic way the genetic material from the father gets to the genetic material from the mother.  The patient said, "Oh, that makes sense."  The patient then went on to tell me their erroneous thoughts about what the process entailed - the same things I have heard from other kids whose sole knowledge about the process comes from watching PG13 TV shows.

To the parent, I'm sorry if it upset you.  Though I suspect maybe it is a relief that now you don't have to be the one to have "the talk."  Patient education is one of the things I like about being a primary care doctor.

Why are you REALLY declining the HPV vaccine?

It is not evil to vaccinate your child against a sexually transmitted virus.

The Gardasil vaccine has been on the market in the US for 5 years now.  I suppose as pediatricians we realized up front that some people would have a moral issue with this, not sure the message they are sending to their child.  I am OK with that and happy to talk about it.

Please don't lie to me and tell me that you heard there were terrible side effects so you don't want to immunize your teenager.  There have been great studies recently showing that Gardasil definitely causes a sore arm and some people pass out after they get it (we are talking teen age girls getting shots here).  It is no more harmful than any of the other vaccines which you have already quite willing given your child.

But what message are you giving your child by vaccinating against a sexually transmitted infection?  I get it - you don't want your child to have sex until they are married.  Guess what?  I don't want your child to have sex until she is married either - and I told her that during our visit.  So if you vaccinate your child for an STI are you telling her that you think she might have sex with multiple partners anyway?

Let me tell you what I am likely to tell your child.
I don't think you should have sex until you get married.  A lot of people may try to pressure you to do things, and the choice is yours, but please don't let anyone pressure you into doing something that you don't want to do.  If you choose not to have sex until you get married you protect yourself 100% from getting a sexually transmitted infection before marriage.  However, what if the person you choose to marry did not wait to have sex until marriage?  They could be a wonderful person who repented and is fully worthy - and they could also have HPV.  Better to protect yourself.

That is what you can say to your child too.  Getting the HPV vaccine is not a signal that you think your child will have premarital sex.  It is a way of protecting your child from the potential consequences of someone else's bad choice.

What Not to Say

http://www.nytimes.com/2011/06/12/fashion/what-to-say-to-someone-whos-sick-this-life.html

This is a great article in the NYT about what not to say, and what to say, to someone who is seriously ill.  And, I would add, to their family members.  The author went through cancer treatment.  His suggestions are spot on.  All the things I want to say to people but feel too polite to say.

I recall a time when I was in the hospital quite ill and in a lot of pain.  Five days into the hospital stay a newly consulted specialist walked into the room and said, "You look miserable."  I wanted to cry and hug her.  That was what I really wanted to hear, an acknowledgement of how I felt.  If you had asked me how I felt I would have said, "I'm hanging in there."  Which I was.  But it was miserable.  I try to remember as a physician that if I can't do anything else, I can always acknowledge a patient's suffering.  "This is such a miserable experience, I am sorry you have to go through this."

Compassion is the best medicine.

Why I Will Not Phone in Antibiotics

Dear Parent on the other end of the phone,


I am so sorry that your child is not feeling well and you are leaving on vacation tomorrow/out of town/can't afford another copayment/sick of coming in to the office.  I realize that having a miserable/feverish child makes your life hard and makes you feel stressed.  I know that you are sure the ear pain/sore throat/pain with peeing must be an ear infection/case of strep/urinary tract infection.  And I know you are very unhappy that I will not phone in a prescription for antibiotics for you.

Unfortunately not ever fever and ear pain is an ear infection - many of these kids have normal looking and functioning ear drums when I examine them in the office.  Most of the sore throats we see do not test positive for strep.  Most of the pain with peeing in young children is not a urinary tract infection.

I will not prescribe an antibiotic "just in case".  This makes your child more likely to have bacteria that are resistant to the antibiotics that we commonly use to treat infections.  And what if your child has a reaction to the medication?  Aside from a bad allergy, getting diarrhea or a yeast infection or a rash is still not a pleasant thing from a medication your child didn't need in the first place.

There is also the possibility that your child really has a bacterial infection and needs an antibiotic - it just isn't the infection you think.  What if that ear pain is a swimmers ear rather than a middle ear infection?  What if the ear pain is caused by a strep throat infection?  What if that pain with urination in your teen is a sexually transmitted infection, not a urinary tract infection?  I can only tell by talking to and examining the child.

I am sorry that your employer has contracted for a high co-payment insurance plan, or your insurance company doesn't cover out-of-area care.  I am happy to speak to you and problem solve, to suggest over the counter medications and other ways to make your child feel better.  I will even advocate for you with your insurance company the best I can.  But I will not phone in antibiotics.

I am used to the anger, the pleading, the threats to file a complaint.  I will try hard to be patient when I talk to you on the phone.  But I will not compromise my standards of giving your child the highest quality medical care I can provide.   If that means I need to examine your child to determine the best course of treatment then I will let you know that.  And I won't back down.

Sincerely,
Dr. Beeler


ALB

Heal Thyself - or rather, Just Let Thyself Heal

The human body has amazing powers of self restoration.

I have known that for years.  Little cuts don't bother me, I don't think every little cut needs a bandage.  (My kids on the other hand do.  Thus the rule fun band-aid if it is bleeding, plain brown band-aid if there is no blood.)  I'm not bothered when my kids eat stuff off the floor.  Or occasionally out of the trash can.  Coughs, colds - no big deal.  I have even refused to pick up a child from school who had fallen and bumped her head.  She sounded fine, I told the nurse to send her back to class.  More often than you realize your body has prevented horrible disaster through the efforts of the many healing substances in your blood.  And don't get me started on how much DNA your body repairs due to sun damage.

This is not at all to say I am opposed to modern medicine.  I am a physician, and I also marvel at what we can do.  Being a pediatrician, immunizations stand squarely above everything else as the most amazing medical advance.  They have saved millions of lives through preventive medicine - the best kind of medicine there is!  People don't even realize their life was saved because they never got sick in the first place.  Preventing infection through immunization is something that we take for granted these days, but something our grandparents marvel at, and something our great-grandparents would have begged to have the privilege of doing for their children.  But I digress.  I started this to talk about what the body can do for itself.

As part of my husband's cancer treatment he had bone, muscle and skin from his leg removed to rebuild the site where the tumor was removed.  It was painful.  I mean, really painful.  He was on large doses of pain medications and would cry in pain if they were allowed to wear off.  After a few weeks of this I became concerned.  Why is he not healing?  Why is this taking so long?  And why are his doctors not worried, just tell me to keep giving pain meds?  We could get the pain under control with large amounts of medication. (I always teased him they were Elvis amounts, but not up to Michael Jackson amounts of pain medication.  Sorry if I offended anyone but when you are at the pharmacy every few days picking up more opiates you have to take a step back and laugh a little.)  The doctors just said, "It takes time.  Sometimes months."  So just when I resigned myself to months of heavy duty painkillers and the long wean that would follow, the pain improved.  I'm not saying we could suddenly stop all medications.  I'm saying his pain could be controlled with long acting medication alone and didn't need break through medications.

Where a large piece of bone, muscle and skin were missing, healing was happening.  Whatever had been so irritated or swollen and painful before was quieted, returned to a more normal state.  He started to be able to walk, even walk faster than me, though off balance and needing a walker.  Skin grew over the large surgical site.  Red, bumpy skin, but none the less an effective barrier to keep out contamination and keep in moisture.  Even more amazing, the site where the bone, muscle and skin were grafter healed beautifully.  It was never really painful as the nerves to the area were severed in the surgery.  But the skin grew pink and healthy, well perfused.  It is amazing to see how the surgeons know how to connect things, then stand back and let the body heal.

It helps me remember that as a physician I can't heal anyone.  I can prescribe an antibiotic but the body still has to return the site of infection back to normal, removing dead tissue and rebuilding.  I can set a broken bone but the body has to reconnect and realign the pieces of bone.  All of my interventions are mere tinkering, pushing things in ways that allows the body to heal itself.

That low back pain, that cold that is 5 days along, even that little pus pocket you drained yourself - most of the time these will get better on their own.  So next time your physician tells you "This one just takes time to get better, there is nothing more we need to do", what she is really saying is, "All things are in alignment for your body to heal itself.  Just give it time."

The Third Chair - life on the other side of the stethescope

My husband was diagnosed with cancer 4 months ago.  With apologies to the Grateful Dead, what a long, strange trip it's been.

Since he is still in the throes of treatment I am not yet ready to process this experience into a thoughtful analysis.  Instead I will share with you a jumble of my impressions of life as the physician spouse of someone dealing with the medical system.  And just my impressions of life caring for someone with cancer.

• I felt guilty when the doctor said, "It looks like cancer" - did I miss something?  How could I have not caught this earlier?  I do feel that I pushed when I felt things were not being followed up when I thought they should.  In retrospect the diagnosis to surgery time was pretty fast, though it felt agonizingly slow when going through it.
• When we interact with health care personnel I feel a need to tell the history, even though I know I should let my husband speak.  He frequently defers to me when I do sit back and try to shut up -- but have I just trained him to do that by my eagerness to speak?
• I feel a little guilty when we are treated very nicely by the hospital staff, like getting a private room.  Part of me wonders if they are just doing that because I am a doctor, part of me knows I wouldn't refuse even if that was the reason we got the good treatment.  I do feel better when I look around and notice other people being treated as well.
• I can't stop being a doctor and just be a spouse.  I make recommendations for treatments - please put dextrose in the IV fluids, please give Reglan.  I question treatment options, especially if it seems no different than what we've already tried.
• And then when I reach the limits of my medical knowledge, and my husband still has that "Please help me" look on his face, I feel guilty and frustrated.  I feel like a failure sometimes when we have to go to the hospital for non-routine treatment because I feel it means I failed at management. Is that the "doctor as god" complex, having a hard time admitting that I can't do it all?
• When he is inpatient I have dichotomous feelings - frustrated by having to wait for other people to act (at home I give the meds when I feel they need to be given), yet safe because if something is not going right there is someone else to turn to (if he vomits the med someone else can figure out what else to give).
• One of the big surprises is how many employees I see in the hospital and clinics that are parents of my patients (did I mention I'm a pediatrician?).  I smiled when the Gastroenterologist came out of the OR to tell me that the PEG placement had gone well and mentioned that "half the endoscopy staff said to treat your husband well because you are their pediatrician."

The one big advantage I have over other people going through difficult medical treatments is that I feel at home.  The geography and language of the hospital are not foreign to me.  I understand the hierarchies - I'm not afraid to ask someone where they fit in the team.  The ebb and flow of shifts, the difference between what can be accomplished during a day shift and a night shift.  This allows me to act as an interpreter for my husband, to try to ease his anxiety.  No, the nurse can't just change that medication from oral to IV, you must wait for the night float resident to answer the page and give a new order.  Yes, they will still take you to the OR for that procedure, even at 6pm.  I know which alarms on an IV I can fix and which I can't.

I am still deep under water with my head down, swimming hard to get through this as I carry my husband along.  But now when I look up, sometimes I can see a bit of light dancing on the surface of the water.  Then I have hope that end of the hard times is near, we will come to the surface and enjoy a large gasp of fresh air that will wash over us with wonder.

1 more round of chemo, 13 more radiation treatments to go.

ALB