February 28, 2009

Teenager, Failing and Depressed

Once you make it to your late teens, your parents occupy an odd place in your life. You’re still dependent on them for many basic things, but you don’t want them interfering in your affairs. Parents often have a more difficult time with this separation. They know that they are providing many things, and they feel that it’s appropriate to receive something in return. What, exactly? Love and affection, respect, courtesy all must be earned, and cannot be bought with room and board. Those of us who have been in the working world and have worked for mercurial bosses know that we don’t respect people just because they are in some kind of supervisory position. (At Harvard Business School, they taught about leadership by showing the movie Twelve O’Clock High—a fabulous movie to see for any reason and an effective teaching tool for this, too.) I’ve known him and his family for about 10 years.

His mother called me last night, worried. She said that there was a major blow up with J, and he said he needed to ‘go for a walk.’ He left the house several hours ago and isn’t answering his cell phone.

About 5 years ago or so, when he was 12 or 13, his parents divorced. He was the only child who seemed to be reasonably OK with this at the time, since he wasn’t getting along so great with either one at that moment. But he started getting a little more introverted at the time, until one night he took off. His parents were naturally very concerned, and the local police found him some hours later nearby. He said at the time that he just needed some privacy, and he didn’t know why everyone made such a big deal out of it. His parents brought him to me. He explained that he just needed a break from things going on at home. I worked out a plan with his parents. I gave him my home and cell phone number. I told him that if he needed to get away again, he should call me at any time, day or night, and I would come at get him and take him to Denny’s or someplace where I could call his folks and let them know he was all right, and then he and I could talk and work out a strategy that could help him. He found this helpful, he said. It was like a relief valve.

In general, I think every teenager should have at least one, maybe several, safe adults. Adults who can let them vent, or just accept them when their parents have pushed them into a corner. It could be lifesaving.

When his mother called back, he had returned. He wouldn’t talk to her but she suggested me and he agreed to come the following day.

He sat in the room with me. I told him that his mother had called me, and I told him everything the mother had told me. He said that he was in a deep hole academically. Though he was a senior with excellent grades, and his college applications were already out, he has not been doing his school assignments and is in danger of failing several classes. I asked how that could be possible given his record. He started to cry. He had been cutting class, not handing in his work, not participating in class when he was in class. I didn’t press the issue, which I thought was tangential, even though he and his parents thought it was the center of the problem. He knew that eventually there would be a reckoning, specifically when his midterm grades were given to his parents, but he couldn’t deal with this. As the semester went on, and he got further and further behind, it seemed more and more impossible ever to catch up, so he had no choice but to let this crash happen even as he saw it approaching. His grades came out, his parents confronted him, he admitted not doing the work and lying to them about it, and his parents grounded him for a long time, to learn a lesson about lying to them and to get him to focus on his work.

I told him I wanted to change the subject. I asked and he told me that he was also neglecting his friends, even spending less time with and attention to his girlfriend. He said, “I’m not doing any of the things I used to enjoy. They just don’t mean that much to me any more.” He wasn’t doing new enjoyable things, either. All of this coincided with his academic slide.

He denied feelings of overt sadness, and denied thoughts of self-harm. I explained that weeping 17-year-old young men have a hard time convincing me of their blissful happiness. Indeed, what he described so eloquently is called anhedonia, a state of indifference to pleasurable activities. It’s a sign of depression. I told him that I didn’t think the academic problem was making him depressed. It wasn’t his fault, I said. The depression had caused the academic problem.

We needed a plan. First, let’s try to treat the depression. I discussed medication with him, and we agreed on a prescription. It offered the best chance of relief in a reasonably rapid time frame. Next, I offered to intervene with the school, but he said this wouldn’t be necessary. He was already negotiating a make-up schedule for the work he missed. Next, a frequent schedule for follow up. Though I suggested he try to find a therapist he can trust and talk to, I wasn’t going to wait for that to kick in. Whenever I start someone on medication, I see them at least once a week. So he’ll be back next week with a progress report. Finally, I told him I would call his parents and ask them to un-ground him. He is punishing himself for this mess much more painfully than anything a parent can devise. And at his age, a major source of support is his friends. Now, at this troubled time, he needs them more than ever. His parents should embrace their help.

I discussed with him explicitly what I would like to tell his parents when I called them. We agreed on a plan. When I spoke to his mother, she was OK with the plan. I’m awaiting a call back from his dad.

J told me that he felt much better after the visit. I think it’s because at least there’s now a strategy to get through the crisis. It won’t be easy—he has a lot of work to do. But his parents are behind him and I’m behind him.

Newborn Won't Gain Weight

A new baby, especially a first baby, comes as a reward for the inconveniences of pregnancy. New parents feel a rush of exhilaration and relief when the baby is finally there. As every parent knows, however, each achievement of parenthood merely punctuates a transition to another challenge. Maybe you just got your kid through high school. Now what? For good and caring parents, the sense of responsibility doesn't have a natural endpoint.

When I first saw this baby 17 days ago, I appreciated the excitement for first-time parents. Mom was about 40, and she told me there was some in-vitro fertilization involved [IVF]. She didn't have to spell out the details, and they didn't matter too much now that the baby was there. But I knew there was a back-story of frustration trying to get pregnant, wanting to be a parent but thinking it might never happen, having a picture of yourself with a child and thinking that might never come to pass, lots of indifferent intimate medical examinations and blunt clinical discussions of frightening risks, and, of course, the money. Now that the baby was in her arms, it was all worth it.

Now, it's my turn.

The baby looked great. Robust and healthy at a little more than 8 pounds, he did everything right. He moved right, acted right, had all the right reflexes. His heart and lungs sounded perfect. It was really fun to hold him. When I checked his hips he started to cry. The parents looked at me suspiciously, but I picked him up right away and quietly talked some sense into him as I walked around the hospital room. Obviously appreciating my point of view, the baby quieted immediately. The new parents were duly impressed with my persuasion skills.

A couple of days later, they were in the office. By now the baby was a little yellow. That didn't worry me too much, since somewhere over 50% of babies get a little jaundice. It usually peaks at about day 3 of life, but sometimes it's day 5. I sent the baby for a test and the level was moderate. That means not high enough to worry about, but high enough to test again in a day or two. The next level was at a high enough threshold to initiate some phototherapy. I know it sounds like every parent's dream: make your baby better by taking lots of pictures. In fact, it has probably been used for centuries. What was told to me many years ago is that it became standard therapy for jaundiced babies in the 19th century. Picture the hospital at the time—big wards, like barracks, in which cots with mothers were lined up. After giving birth, the babies were taken to other big rooms filled with cribs. There was no air conditioning at the time, of course, and disease was suspected to be spread by bad airs (miasma). So hospitals were typically put at the top of a hill (for better ventilation) and fitted with large windows. It was noticed at the time that the babies near the windows were less jaundiced than the babies near the center of the room. Some rudimentary experiments confirmed that the natural light reduced the visible jaundice in the baby. We understand the mechanism of how this works a little better these days. It turns out that the chemical bilirubin, which is the yellow pigment, is not very water-soluble, but is oily. So just like salad dressing, the oil doesn't want to mix with the water. In our bodies, watery stuff is typically blood and other fluids, and oily stuff is skin and fat. That's why our skin is fairly waterproof, and generally keeps our fluids on the inside from leaking out. The light changes the chemical structure of bilirubin slightly, but enough to make it more water-soluble. This helps it get out of the skin and into the bloodstream, where it can be digested and disposed of. It's the reason baby poop is so yellow. Our technology hasn't done better than sunlight. I ordered a bili-blanket for the baby, which is a small electric blanket that produces, instead of heat, an absolutely otherworldly greenish glow that would make any visitor to Roswell New Mexico proud. But I still advised the parents to find a sunny spot in their home, and as long as they could keep it warm enough, let the baby have some nice sun exposure. This regimen only took a few days to lower his bilirubin levels sufficiently to have the medical equipment company retrieve the blanket. The parents were relieved that this jaundice issue was over.

With every visit, I always asked how the breastfeeding was going. Apparently, it was going extremely well. Mom didn't have too much discomfort, and the baby was doing perfectly. I observed several feedings and the baby was doing everything he should, latching on beautifully, sucking and swallowing. It didn't surprise or worry me when, at about 5 days of age, his weight was down about 8% or so from his birth weight, to 7 pounds 10 ounces. That's normal I assured the parents. Babies are born with extra fluid, and this helps them get through the first few days until the mother's milk comes in. As they lose this weight, they typically get pretty hungry, and cry aggressively and often. These signals, too, help with the natural production of the mother.

I was seeing the baby every 2-3 days, because the baby was jaundiced and because he hadn't started to gain weight yet. He was still 7 pounds, 10 ounces. When the baby was 5 days old, I didn't think twice about his mild weight loss. He didn't keep losing weight, but when he was 10 days old and hadn't gained even one ounce, I had a harder time reassuring myself and the parents that all was definitely well. Then the baby was two weeks old, he was still 7 pounds 10 ounces, and had not gained a single ounce from his lowest weight. My decision process got difficult. Ironically, I would have had a sadder but easier set of choices if the baby didn't look great. I could have done all kinds of blood tests, looking for signs of infection or rare metabolic diseases which could interfere with the baby's weight gain. I could have admitted the child to the hospital for regimented feeding. It's not breastfeeding-friendly, but it could be crucial diagnostically to figure out if there was something wrong with the baby. I didn't tell the parents this step was now on the not-so-distant horizon. I didn't like any of these options, but would do them if the baby showed any signs of a problem.

Now I was seeing and weighing the baby every day. This was extremely hard on the parents, especially the mother. It's typical enough for new mother to worry if the baby is getting enough, and to conflate their breastfeeding issues with their own sense of success as a mother. Here in Berkeley, breastfeeding is equated with parental adequacy. People breastfeed their kids pretty much through college, it seems. This culture of breastfeeding dogmatism has had both good and bad effects. It's great that breastfeeding is now widely acceptable socially and openly. People talk about it and there's lots of resources available to help with it. Research does show benefits to breastfeeding, for both mother and child. Whether these benefits outweigh the need for therapy resulting from your mother attempting to nurse you at your prom, is unclear. The bad part of breastfeeding as a cultural necessity is the pressure it puts on the mother. The dogma implies that breastfeeding comes naturally to good mothers, and that successful breastfeeding is simply a matter of caring and motivation. In fact, lots of mothers and babies find it to be a little tricky, though many problems can be overcome. There are lots of variations in babies and breasts, so there is no single method or position or technique that works for everybody. Still, it is sad for me to feel the overwhelming sense of failure and inadequacy that some mothers feel when nursing isn't going as easily as in the brochure. This is a contributor, at the most vulnerable time, to postpartum depression.

But this baby was feeding like a champ. His mother was getting all the right signals, and doing all the right things. So why wasn't he gaining weight?

The next day the parents told me that the baby had started to become a little fussier than usual, not sleeping as much, and was harder to comfort.

I decided that I certainly could wait any more and had to take some action. First, I sent her to a lactation consultant. A good lactation consultant, I like the IBCLC certified ones (http://americas.iblce.org/registries.php ), can be a huge help and knows much more than I do. So even though I couldn't see anything wrong, I wanted to get some expert help. (Another resource is www.breastfeeding.com . Their lactation consultants are at http://www.breastfeeding.com/directory/lcdirectory.html .) I also wanted to get some formula into the child.

Formula isn't poison. It had a couple of serious medical uses in the current situation. First, it provides a known volume and known calorie input for the baby. I needed to find out if he was taking in the volume needed to support himself and thrive. If he was, I needed to know if he was absorbing and metabolizing the energy content of what he was getting in an appropriate way. I told the mother to give him formula every other feeding. At the time of the formula feeds, I wanted her to pump. This had the additional advantage of helping figure out how much she was producing. The pumping, though not as effective as a nursing baby, would help to maintain her milk supply. This was important because I was hopeful that we would soon return to exclusive nursing. And of course, we weren't going to waste that milk. I told the mother to freeze it so that dad can do some feeding when she's sleeping.

At first, mom was even more frustrated. The baby didn't want a bottle, and would spit up after bottle feeding when he didn't after breastfeeding. I told her to be patient, and that like all of us, when we're hungry we're not as selective.

Twelve hours later they were in my office. Mom had a great meeting with the lactation consultant, who was concurring with my assessment that the baby is a great nurser. She was optimistic that this would all work out fine. With the new regimen of formula every other feed, used for just 24 hours, 7 pounds 11 ounces. The baby gained an ounce!

Today, 24 hours later, is Saturday and the baby is 17 days old. He still looked a bit scrawny, a little yellowish. We did another bilirubin test today. His parents said he spent a better night, with less fussing and more time awake and alert but not crying. Maybe he was just less hungry. Today he was 7 pounds, 12.5 ounces. It’s a great day.

February 23, 2009

Toddler Makes Friends with the Doctor

This was a great day and a great visit.

I had my first visit with a 16-month-old girl today. Her mother interviewed me a week or so ago. When her mother called today, I told her that I was surprised I passed the audition.

I didn't think she'd pick me as she looked for her new pediatrician. My practice is very grounded in practical science, and in general I am reluctant to intervene unless necessary. This is a luxury of good access to the physician and a willingness to see patients whenever they need it. It's a luxury of good follow-up. So I don't routinely give a prescription to every kid with a cold. This parent liked that, but I know she would have preferred a doctor who was ambivalent about vaccination but a cheerleader for something more alternative. It took a lot of humility for her to return to me with her child when it would have been easy to find a practitioner here in Berkeley who could meet every litmus test for alternative medicine. But her daughter had a cough for a few days. When she called, I suggested she bring her daughter in today.

During the interview last week, the girl was exploring the toys I have in the office. They are there for a reason, after all. She was reluctant at first, and didn't know what to make of the balding giant with the tie. It is an anxiety-provoking situation at her age. I saw she was not comfortable, so I took the basket of stuffed animals, turned it over, and let them all fall into a big pile on the floor. I laughed when this happened.

Today it was the first thing she did. She knew just where to go and didn't ask permission. She picked up the fabric basket and dumped out all the stuffed animals. She really laughed. Then she put the basket over her head. For the first 10 minutes or so, I sat on the floor and did silly things with her. When her mom and I were talking, she would sometimes seem bored, so I got up and fetched her a new toy from another room. Her mother looked a little concerned when the floor was covered with toys. I reassured her that this is exactly what will help the child be comfortable.

Eventually, of course, it was time for the exam. As I approached, the child backed away into mom's lap. I kept talking to her in a soft voice. I offered her my stethoscope to handle and check out, just to make sure it was OK and nonthreatening. I picked up a stuffed dinosaur. First I listened to the dinosaur, then her mother's leg, then the dinosaur. Back and forth right in front of her just to show that neither her mother nor the dinosaur minded even one bit. Back and forth she followed the movement as if she were watching a tennis match. Then I made a quick stop on her chest--just for a moment--and then back to the dinosaur. Then a longer pause on her right chest, dinosaur, left chest, dinosaur, right back, dinosaur, left back. I took off the stethoscope and handed it to her. She gave a big smile and put it on her ears. I took out my little otoscope and handed it to her. She knew right away! She put it in her own ears and I held on briefly to give myself a quick view. By this time she was laughing a lot and I as able to use one of those opportunities to get a good look at her throat. I felt her neck and we were done.

That was the first time in her life, her mother said, that she ever had a doctor visit in which she wasn't screaming throughout. Her mother said she'd start screaming when they approached the doctor's building.

I've seen doctors examine children who are screaming. Sometimes that's what has to be done and there's no way around it. But I've never met the 1 to 3-year-old who lets a non-parent adult get right into their space and poke around the way a doctor does. I have sometimes read exam notes that say that a kid's heart sounds were normal or their lungs were normal when the only exam was while the child was terrified and wailing. It takes practice and patience, and both only come when the doctor is willing to take the time to let the child come to him.

Medically, a child's uncooperative demeanor is a potentially serious confounder of physical exam findings. Crucial and subtle observations, such as sounds of the heart and lungs and abdomen, are easily eclipsed by the glare of screaming. Indeed, the gestalt of the child is an essential observation of the skilled examiner (ie does the child look sick?). Is the child in distress from the illness or from the situation? The good doctor needs to know these things and figures out how to get the information needed. It may look like play, but I take it very seriously and work very hard at it.

Just as with adults, some kids are a lot more anxious than others. But just as with adults, it's a lot less stressful to have a doctor you like. I believe that this results in better care. The exams are better, the communication is better. Even the communication between 16-month-old and pediatrician.

The kid had a cold, I thought. No need for medicine, I told the mother. Some home-made nose drops might help with the congestion. Nothing for the cough unless it gets to be a problem. And of course, call me anytime if you're worried or if she's not better in a few days. The only time the child was upset was when she was leaving. Her mom and I agreed to make another playdate soon.

The photograph: photographer Arnold Eagle is most famous for documenting the Lower East Side, a tenement area of New York City. In the 1930's he took a series of photographs he called One Third of a Nation, referring to children living in poverty. He made up a book from the prints of this series, and gave it to his wife as a gift. There are no other copies beyond the one that was in my collection.

February 16, 2009

All he needs is tough love, an ADHD story

His mother said that she was getting a very hard time from her parents. Her father said that if she left her son with him for a week, he wouldn't misbehave any more. He told her she was a weak, ineffective parent who just wasn't strong enough to give this boy what he needed. She asked me if the child's medication was really necessary, since her father didn't think it was.

You don't need to be completely freudian to hear the echoes of a mean father used to treating his daughter with judgemental negative feedback. I didn't ask how his comments made her feel. How would that help? We are all adult children, and many of us get treated like children by our parents--and sometimes act like children when we are with our parents. It's the pattern we know from a lifetime of practice, induced by the pavlovian stimulus of a critical parent or maybe just the smell of your mother's cooking.

I try to enable the parent of the child I'm treating. When they are supported and strong, their children are more likely to be supported by them. It's a team approach. I'm all for indulgent grandparents, of course, but the ultimate victim here is my patient, and don't ever mess with my patient.

I would never, ever medicate--indeed, treat--anyone unless I thought the treatment would be helpful to them. Medication is often not needed for behavior problems. And every medication has its risks, side-effects, and costs. We don't yet have the technology to predict which person will respond best to which medicine. For any of the psychoactive medications, and this includes many which are not primarily targeted to the brain (prednisone, for example) some of the effects on emotions and behavior can be surprising. And it's hard to know what the optimal dose might be for any given person. So medication isn't ideal.

Let's look at this from the kid's point of view. Every day, this boy is getting in trouble at school. He's being sent to the office almost daily. His teacher doesn't like him, the teacher in the schoolyard or the lunchroom doesn't like him. Most of his classmates don't like him. He interrupts so often that even the 2 boys he calls his friends don't want to be with him on weekends. He doesn't understand why no one likes him, and has asked many times why this is. It's not better at home. He's constantly being punished for something, grounded for something he doesn't remember doing. The groundings seamlessly dovetail from one to another. In this way, the child sees that being grounded is normal for him. So he knows very clearly that he is being treated differently and not as well as his siblings. From the moment he wakes up in the morning, he is criticized and corrected. There are no compliments, there are no treats. Every reward his siblings get, he misses for something that may have happened days ago. He is a beaten dog, kept on a short chain at home and a shorter one at school. It's not surprising that school isn't fun and he believes he might as well spend his time sitting in the office, alone.

What if there were a way to pluck him out of this spiral of failure and criticism, this pre-fairy-godmother-cinderella life of loneliness and hopelessness? What if we had a way to help him restrain his impulsivity and give him the ability to pay attention to the teacher for a substantial part of a lesson? When this happens, there's an upward spiral. He does well on assignments, proudly brings home good grades. His teacher tells him, in front of everybody, that he's doing a good job. His parents are proud of him and tell him so.

Fill in the blanks: an angry, lonely kid who doesn't like school or home growing into a teenager who.... Sure enough, studies show that the kids with ADHD who don't get treated have higher rates of substance use, school failure, and, maybe, prison. Or, with some help, a kid who gets to like school and succeeds like every other kid to go on to work, college, life. Who's better off? Do you really think that it's an even trade-off between the 'benefits' of not being treated and being able to live like everybody else?

Many parents lecture me on the risks of medicating their child. But what, exactly, are the benefits of not medicating? How loving a parent are you for leaving the stumbling blocks in front of your child, for crushing his self-esteem? I want to hear what the benefits are.

This patient came to me after mom had run out of his medication for 6 weeks. Some parents ask if it's OK to take a break from the medication, presumably so they can be reminded of the benefits of not medicating. This parent didn't ask. He needed his life back, and I was happy to prescribe it.

February 15, 2009

New mother, Breastfeeding and Feeling Fragile

I just left a brand new mother in the hospital, going home today with her baby. She's doing fine, the baby's doing fine. So why did I spend 2 hours with her?

She had been reading a book about breastfeeding. It was very thorough and complete. Yet it didn't mention the issue she was having with painful engorgement on one side but not the other, and the problem she was having draining the engorged side. That wasn't the bad part. The bad part was the message the book conveyed that if it's not going according to the chronology in the book, then either you have incompetent breasts, an incompetent mother, or are doomed to failure.

Again and again when I see the beginnings of postpartum depression, it rears its ugly head in the camouflaged form of off-the-cuff comments by beloved relatives and friends. And book authors! Something is said along the lines of "...I did it this way and it worked beautifully" or "most women have no difficulty with...."

Though mammarily-challenged, I keep getting the impression that women have breasts their entire adult lives but never learn how to work them as a device until they have a baby. Imagine how difficult it would be to learn to walk, if even though you've had legs your entire life, you only now, suddenly, had the ability to use them. Books are helpful, and friends can be supportive. But, I told the mother today, they don't have your breasts and they don't have your baby. Both the baby and mother are still, at day 4 of life, trying to figure out a working system that keeps both happy. This is an iterative process, of course, so it's logical that an optimal outcome can come about only after many trials and many errors. She expressed her frustration with the baby failing to latch after 3 tries. I think it was Mark Antony who said, "I thrice presented him a kingly crown which he did thrice refuse." So maybe Julius Ceaser only got 3 chances, but not the baby! I told her that the baby might be hungry, but he wasn't going to starve in the next hour or so. So maybe he'll nurse on the 5th try or the 25th. The baby was just figuring it out much like mom was. I told her that the baby would be OK and she shouldn't be so hard on herself.

There is no one right path to parenthood, or motherhood, or successful breastfeeding.

She felt better having voiced her insecurities, and I didn't wave them away. I did, however, give her permission to use her own creativity with her baby. I gave her permission to give herself a break and then try again. It was 2 hours well spent.

Sometimes, with mothers in whom I see a risk for postpartum depression, I'll see them once a day, every day, in the office and then phone them every evening. I've had good feedback about this method. I also use the Edinburgh Postnatal Depression Scale.

But sometimes, what works best is my home phone number. And that one time when they're really upset when I show up at their house. It's only me, but they're not alone.

Breakthrough with a Two-year-old's anxiety

Some time ago, I looked for but couldn't find the origins of the phrase 'terrible twos.'

I could not find who invented the terrible 2s. I think it's a great year. Finally, they are talking just enough to let you know what they want, sometimes. They are interested in everything and going everywhere. This is often inconvenient, but it's a wonderful thing to see in terms of their development. They often explore and are willing to put themselves in harm's way just for the thrill of your raising your voice and yanking them back to reality. They are busy discovering new techniques to meet their most important goal: getting the parent to play with them.

With that said, however, I got a call last week from a woman whose English was as bad as my Spanish. We had enough overlap to make an appointment. She brought her 2 year old for what she had called a check-up. As soon as they walked in the office, I know that no check up was going to be getting accomplished. They opened the door to the office, walked in, and the child started screaming. Not crying--that happens sometimes with very anxious children--screaming at full capacity as if in pain. The other kids in the office were startled. My medical assistant didn't know what to do. The child took one look at the student who was following me around that day and increased his volume higher.

I ushered out the other patients.

I asked mom to follow me into the room with the sofa. He never left her side, of course. I asked the mom, over his shrieks, if my student could observe and she was gracious about this. I observed the child for about 5 minutes, during which he played with none of the toys that are in all of my exam rooms. He simply stuck to his mother, screaming.

I told the student--something I almost never do--I'm going to need your help. She nodded OK. I told her to avoid all eye contact with the child, no matter what. Then I picked up the large basket of stuffed animals and puppets, and without warning, dumped the entire contents onto the floor in the middle of the room. He stopped, was silent and watched what might happen next. I picked up two hand puppets and told the student to pick up 2 also. She got the cow and the frog. Ignoring the child, she and I played with the puppets, moving their mouths and making animal sounds for at least 10 minutes. He left his mother and came to get a closer look. I took off one of the puppets and gave it to him. Then I sat on the floor and played puppets with him. After a little while, he would smile and laugh with certain puppet actions. I retrieved a Thomas and James train from the other room. He liked these a lot and I sat on the floor with him as we rolled them back and forth between us. I showed him my otoscope, which he liked holding--who doesn't like a flashlight?--so I let him hold it as he looked in my mouth and I in his. I let him play with my stethoscope, then back to Thomas, then back to the stethoscope. I let him listen to some of the stuffed animals. I said it was my turn, even though he didn't understand any English, and he let me listed to his heart and lungs and abdomen.

The whole exam took about 70-80 minutes, most of which was playing with him. When he left the office, he said goodbye and gave me a hug.

His mother told me that he had been very traumatized by the previous place they went for medical care. I'm proud to say that she also said that she had never seen him allow even as much exam as I got and that this represents a major breakthrough for him.

I got that sense as well, I'm glad to say. I grow increasingly convinced that rapport with a child cannot be established in minutes, and this is even more true for difficult children or those who have been hurt in the past. Our medical care delivery paradigm has been optimized for the shortest possible visit, and this will only exacerbate the trauma children (and adults!) experience when they go to the doctor.


I subscribe to a fabulous listserv for pediatric bioethicists. We've been having a spirited discussion of the ethics of the recent octuplet birth.

It's an ethical stew. It's easy to see that this mom is, in my opinion, psychologically troubled, likely with narcissistic personality disorder or another personality disorder which prevents her from getting a realistic grasp on the implications of her actions. What many people see, including me, is that there's a real risk that many or all of her children will end up in the care of the state, and that her given rationalization--that she will finish school and support her 14 kids working as a childcare expert, sounds frankly delusional. Meanwhile, she'll user her school loans to support her family. I have to think this is against the rules for school loans, and besides, it shows a serious disconnect with what this childcare is really going to cost.

That said, the professional ethicists seem to be struggling on certain issues.

  1. Access to care issues. There's a lot of discussion about the woman's rights and the physician NOT having the right to deny a procedure to her that he would do for someone else. This is an understandable slippery slope. If doctors get to decide who is fit to have a procedure, it is easy to imagine all kinds of discriminations coming into play--race, influence, and money, just to name a few. Should doctors have the power to decide who benefits from their skill and who doesn't? With assisted reproductive technology (ART), should it only be for the rich? For the poor and infertile, should they be limited to adoption? That doesn't sound fair. If we think access to ART should be needs-blind, how many tries? Many attempts can cost $100,000 or more. Should the public pay for that?
  2. What is the doctor's role in this? Is the physician simply a nonjudgmental technician, performing a task for which he is contracted? Does a doctor leave his or her common-sense at the door and simply work for the patient? (There seem to be some other relationships like this. Lawyers, I think, have well-defined situations in which they have to do what the client requests even if it's not a great idea.) At some point, this doctor made a decision to go ahead with this for reasons, which are obscure at the moment, that must have included monetary compensation and public relations for his own gain. It would be hard to conceive of the doctor's thought process resulting in a conclusion that the patient would be better off after the procedure. In general, doctors are guided by the Hippocratic concept of primum non nocere (above all do no harm) (it may not be from Hippocrates, by the way, it might be from 17th century doctor Thomas Sydenham, who might also be the first doctor actually to state that doctors should always do what's best for the patient). It's not really clear if helping her get 8 children incremental to her extant 6 is truly acting in her best interest, even if she says it is. Clearly, the doctor has a lot to answer for here.
  3. If a patient came in to a doctor's office, and asked for disfiguring surgery, should the doctor do it? Even if the patient offered a substantial fee in cash? Every doctor makes these kind of judgements to some extent or another. Even in my practice, people come in and ask for a specific treatment, such as antibiotics. But if it's not the right thing for them, I refuse. (I try to be polite about it!)
  4. Who's the patient? This is often a problem with ART/IVF cases. On the one hand, the fertility doctor in this case seems to have acted on the belief that his patient is the woman. While reasonable enough, the result of his work was the birth of 8 more patients. Who looked out for their best interest? Our society generally assumes that the interests of a mother and her unborn child are the same. Cases like this one might call that assumption into question. A woman goes to a doctor, asks for a procedure. Clearly, she's the patient. But at some point that gets complicated when the 8 babies come along, and then they become patients too (notably, they are not patients of the IVF doctor). As doctors, we're required to report parents to Child Protection when we suspect possible neglect of children. In this case, we may have invented a scenario in which a doctor facilitated the mother doing something which will almost certainly result in neglect of some sort. Shouldn't somebody besides this delusional mother be looking out for the well-being of these babies? They are the only innocents here.
  5. Who looks out for society? While happy to acknowledge that the children's welfare is paramount, the cost of caring for this family will be millions. It'll be well over a million even before they leave the hospital. Will we donate to enable the disturbed fantasy of this troubled woman? Or will we simply pay for her insanity out of tax dollars? Should the cost of this whole issue even be discussed as an ethical problem? In bioethics, there's a frequent topic of allocation of scarce resources. If we're all in a lifeboat together, should somebody get more than their equal share of water? What if healthcare resources are limited (as they seem to be)? Should such a disproportionate share be allocated to this one person? [There are many ways to analyze this issue, but here's a really thorough discussion, from the Veteran's Administration--warning: it reads like a good bioethics textbook.]
My opinion: This is very sad on many levels. Those children are struggling now and will struggle their whole lives. No matter how liberal or conservative you are, every child needs the undivided attention and affection of a parent. It's hard to see how these children will get this basic need unless they are placed in multiple adoptive homes. Believing what I just said, the doctor who made this happen has a lot to answer for. When I trained in Utah, there were many very big families. Mostly, they had the stability and longevity to find a way to make a big family work. The level of psychopathology in this mother should have been obvious and have induced grave reservations in any health professional contemplating assisting her in realizing her delusions.