July 30, 2010

A Baby with Diarrhea

The mother that called me wasn't in a panic, and that's usually reassuring to me. She told me that her 3-month-old baby had diarrhea for 3 days. At that age, with nursing well-established and generally consistent growth, they can usually weather a brief illness without too much difficulty.  But I asked the usual questions. He didn't have fever or a rash. He didn't seem to be in pain, he wasn't unusually irritable. In fact, he was nursing as usual, seemed happy and playful as usual, and was having a lot of wet diapers, as usual. But he was having diarrhea in small amounts a dozen or more times a day.  It started 3 days ago, and nobody else in the family was sick. Did they change what he was getting? I wondered if they had started to introduce a baby formula to which he was having some sort of reaction.

"No formula," his mother said. "Except...," she paused here with a giggle. “Well,” she said, “we were in McDonald's and the baby was hungry and he kept looking at us and seemed to be grabbing at our food.  So we took a little piece of cheeseburger, kind of mashed it up, and fed it to him.  He really liked it!  We were careful not to give him a lot though.  Everybody knows that kids shouldn’t eat too much fast food.”  The diarrhea started the following day.

“Oh,” I said.  “Uh…did you give him anything at home?”  I had a feeling about what to expect.

Well, he liked the cheeseburger so much that we wanted to see what else he’d like.  We were having spaghetti, so we gave him some of that.”

Sauce of some sort with that?”

Of course.  Who eats spaghetti plain?”  Not 3-month-old babies at their house, for one.  Within the last 3 or 4 days, the baby, who had never had solids before, had at least a little bit of cheeseburger, pasta, marinara sauce with meat, mushrooms, at least 2 different kinds of sausage, several breads with and without butter, and just about everything else the parents ate.  And, the mother pointed out, “He really liked the ice cream.”

Usually, the first solid food we introduce to babies is rice cereal. Sometimes it's as early as 4 months, sometimes as late as 6 months. Much later than that is still compatible with life, of course, but the nutrition seems to be less complete, the child doesn't learn the skill of eating, and the maturation of the digestive system is delayed. Aside from This Island Berkeley,this_island_earth_1954 perhaps, places where nursing is the exclusive source of child nutrition extending well beyond a year are usually places of great deprivation.

The recommendation of starting with rice cereal has some sense behind it. You may know people who have reactions to wheat or just trouble digesting it. But though possible, this is much less likely with rice. It's reasonably inexpensive, and readily available in the supermarket, fortified with iron. It can be mixed with breast milk, formula or water. It cam be put into a bottle or made thick enough to stand on a spoon.
The iron is important. Formula in this country is fortified with iron. Breast milk has little iron, but what it has is especially absorbable to the baby. Even in Red States, babies don't generally get a lot of beef or related high-iron foods until they are walking. As the first year goes by, the store of iron-rich red blood cells inherited from the baby's mother are gradually used up.  By 9 months or so, these are all gone, and babies whose diets are low on foie gras don't have a lot of concentrated dietary sources. That's why we test every 9-month-old for iron (hemoglobin level, actually) at their well-child visit.

Here's what happens, as every parent knows. The first time a spoon of cereal goes in their mouths, babies scrunch up their faces and scrape the stuff off their tongue and out of their mouths. Never having had anything like this before, they wonder why you are putting a spoonful of what could be sand in their mouth.   It had never occurred to them that food could come in some form other than liquid.  They get the idea eventually, of course.  This process, often requiring patience and persistence, is important. It's not the nutritional value of the cereal that's so essential. It's the learned skill of manipulating solid food in your mouth to get it to go down the right way without choking. We've all had that horrible sensation, and we've had a lot of practice. For a baby, this is a skill for life. Still, rice cereal is bland and not every baby likes it. 

This is a good spot to tell an absolutely true story, which I freely share with many first-time parents who struggle with teaching a baby to eat.  In my graduating class at medical school, there were about 100 graduates.  Every one of them—with no exceptions—was on solid food.   At this point, most of these exhausted and frustrated parents look at me and wonder if they picked the right doctor.  Every one of my medical school classmates, I assure them, learned to eat solids at some point between being 4 months old and medical school.  Though I couldn’t say exactly when.

I’m happy to report that the baby with diarrhea didn’t have a dreaded infectious gastroenteritis.  Or if he did, it just happened to resolve at the same time he stopped getting his meals at a drive-though window.  Do you want fries with that?

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July 27, 2010

Mystery Diagnosis--The Streak


Sometimes it’s easy to figure our why parents call when they do.  If a child is sick, most parents have no problem recognizing this.  Most people are empathic enough to sense when a person has difficulty breathing, or is in pain or distress of some sort.

Sometimes, this is a language problem.  It’s probably not a great idea to speak loudly about a movie that bombed at the box office while going through airport security.  And it always gets my attention when parents tell me that their baby had a hard time breathing last night.  True, a complaint like this is one that will usually get a doctor’s attention.  But if you take advantage of this too often, the doctor could decide you are just crying wolf, and gradually take your complaints less seriously.  

Today, a nice couple came in to the office with their baby.  They had been up all night and said that the baby was having trouble breathing.  I sat up.  Maybe I didn’t really sit up, but instead slouched a little less than I usually do.  After several minutes of interrogation-like questioning, it was clear what the baby’s real problem was.  He was having trouble breathing…through his nose.  This can be a real nuisance for a nursing baby, since they can’t really nurse and breathe at the same time with a stuffy nose.  Still, from the doctor’s point of view, it’s a long and reassuring distance from having trouble breathing.

There are also parents who are generally less anxious.  I try and fail to contain my surprise when a child is brought to me with severe symptoms that have been going on for a long time.  Every doctor has cases like this, some tragic.  For pediatricians, a typical example would be asthma.  Several times a year a child comes in whose parents say that she’s coughing.  For how long, I ask.  ‘Maybe a year,’ they say.

I don’t fault these people.  If the kid was really in trouble, they would have sought help right away.  For some, coming to the doctor is a logistic nightmare consisting of taking time off from work, getting the kid transported, parking expenses, and lots of other incidentals.  (As an aside, it’s easier if the kids actually like going to the doctor.)  Besides the general pain-in-the-neck quality to doctor visits, there’s a natural inclination—often correct—to believe that medical problems that aren’t too bad will probably get better on their own.  Even though I am often sent unusual and difficult cases, many times I have to tell parents that I don’t know what is causing the symptoms they report.  

This brings up an extremely important but subtle part of good medical education and experience.  Some people believe the smartest doctors can diagnose the most exotic problems.  That’s certainly a great and useful skill.  But in primary care practice, especially pediatrics (and, I suspect, geriatrics) where the patients often can’t answer your questions, it’s often most important just to be able to tell worrisome or not.  So though I didn’t know exactly why the baby was congested, I had no idea why the baby was fussy last night, and I didn’t know if the fussiness would happen again tonight, I was confident that the baby was generally OK and would continue to thrive despite having a stuffy nose.

This ability to assess some kind of worry-worthiness grading system seems to be in all of us.  Obviously, some are more anxious than others, and they will grade a threat-level higher than others.  

So it’s not bad parenting that led to the call I got about 4:30 this afternoon.  A mom called and said that her daughter, 6, had a rash.  How long had the rash been there?  At least a month.  I asked more questions, and they decided to come to the office and let me take a look at it immediately, which I did tonight.2010-7-20 lichen striatus-Kayla vertArrows  

Memory is a funny thing.  Sometimes a visual image will stick out like a stone in your shoe.  It’s pretty common for people to say that they know they’ve seen something before, but have trouble placing just when or where.  And I wish I knew why people can look so familiar but I just can’t come up with a name.  This happens to me locally all the time.  Someone will stop me in the supermarket, for example, and say, “Hi Dr. Wolffe.”  I return the greeting but don’t even recognize the person.  Then from another aisle comes grandma with the kids, and I’ll know exactly who they are.  I’m so focused on the children when they are here in the office that sometimes the adults look familiar, but without the kids they are sometimes hard to recall.

The mother said that this girl hadn’t been sick, and this developed over some period of time—she wasn’t really sure how long.  Maybe it was a week, maybe several weeks.  The girl said that it was itchy, but it hadn’t been scratched and she wasn’t scratching it in the office.  It was a little flaky, possibly a little red.  It didn’t hurt.  It had been there for at least a month.  It did feel a tiny bit raised, dry.  Mostly, though, the impression I got was that it was lighter than the surrounding skin and wound like the Andes from her upper arm to her wrist.

The first level of diagnosis, for me, is figuring out if I have to worry about it.  She had it for a month, for goodness sake, and the kid was none the worse.  She was happy and playful in my office.  I looked the kid over, and she was fine.  It’s certainly true that there are diseases that appear to get better and then return.  But most of the bad things generally just get worse, or at least don’t get better.  

The next question for me is if I know what this is.  I didn’t know.  But I knew I had seen it before.  But where?  What was it called?  I think that I am a reasonable diagnostician because I have real difficulty putting this aside and catching up with all the work I really have to do.  I eliminated the rashes that cause light streaks on the skin, but are there since birth.  I crossed off the ones that hurt or itch a lot or come from trauma of some kind.  And the ones that are very smooth or very rough or whorled like a cowlick.  So the diagnosis gradually came to me, but I hadn’t seen it in so long that I couldn’t be sure.  I excused myself from the exam room, and went to the computer in my little office.  It wasn't helpful.  I went to a reference textbook.  I looked up what it was…and I had been, well, close.  This was Lichen Striatus, a bizarre thing that preferentially appears in girls (no one knows why), of age 3-6 or so (no one knows why), usually affects a single extremity (no one knows why), and goes away by itself after some weeks to months (no one knows why).  No one knows what causes it.  It doesn’t seem to do any permanent damage, and generally needs no treatment.

(This is a good example, however, of the incremental information value of an analog book.  I was thinking right, and knew what kind of rash it was.  My first guess was indeed Lichen Striatus, but I couldn’t remember the right name.  I kept thinking, ‘Lichen…something.’  Honestly, I confabulated a last name for this disease.  I looked in the index for ‘Lichen Linearis.’  Seriously.  There is no such condition, and perhaps if my Latin training had been a little more thorough—or I had paid better attention—I would have realized this.  I had unintentionally taken a word from a real but unrelated problem called Lichen Planus Linearis (which I didn’t think this was), and stuck it in the empty spot, like a medical MadLibs game for doctor geeks.  I looked it up on the computer—but could not find the misnamed disease.  It was only when I went to the textbook and leafed through the index section starting with the word Lichen that a bell really rang for me.  Then when I saw the textbook pictures, I knew I was right.  This is the difference between going to the library to find a book on the shelf and getting the book, fully scanned, online.  Sometimes what is most valuable isn’t what you’re looking for, it’s what’s next to what you’re looking for.)

I forgot to ask the mom why, today, she called to have the child seen.  I’d be interested.

July 23, 2010

Headache in a 5-year-old

Molly, 5, had an eye problem. It was pretty common, and her eye doctor recommended that she wear a patch on one eye several hours a day. She didn’t mind this, and she and her parents picked out all different designs for the patch that might suit her mood or fashion requirement. Usually, the patch is worn over the stronger eye in order to force the weaker one to get more exercise. 

So when her mother told me that she had a headache, my first guess was eyestrain. It's a common cause of headache at almost any age. But still, 5-year-olds don't often complain of headaches.

Her mother was sympathetic. She told her child that she'd get some medicine for her that would help her feel better, and went to the cabinet where they keep the acetaminophen. It was only a few steps away, but Molly started crying. She said that it was still hurting. Mother repeated that she would give her some medicine that would help. Molly said that it wouldn't help. Mother said, calmly, that she thought it would and that after the medicine they would lie down in the bedroom together until she felt better. Molly said that it wouldn't help and that it was going to get worse and it was getting worse right now and she didn't know what was going to happen and that it was still getting worse and medicine isn't going to help and nothing is going to help and she was really scared. Molly was screaming by now, continuing to express her fear and pain. Mom had picked her up, of course, and was doing her best to settle her.
She did the best thing she could think of, and took her into the bedroom. They lay on the bed together, with Molly in her mother's arms. Soon, Molly fell asleep and was better a few hours later when she awoke. When mom told me the rest of the story, I told her I wanted them to come to the office so I could speak to Molly in person.
Fortunately, Molly is smart and talkative and likes me as much as I adore her. She told me that her eyes didn't hurt when this happened. Her mother told me that there really wasn't a family history of migraine.
Though in my training I received a little exposure to migraines, even now this is generally thought to be uncommon in children. I have a feeling that isn't right. I have diagnosed migraine in children as young as 5, and there is often a family history. Their symptoms are usually just like adult symptoms. I wonder if these kids have headaches or stomach aches from even younger ages, but lack the expressive language to tell us. In this way they suffer without relief, and their doctors never get the clues they need to make the diagnosis. I would guess that a toddler with a headache is pretty cranky. So I wonder if some emotional or behavior problems in these younger kids--who knows? maybe babies, too--could be resulting from this kind of invisible problem.

But Molly didn't fit an identifiable migraine syndrome. She didn't have any problem with her brain that I could find. 

I asked if she would get headaches when she was outside in the bright sun. Her mom said that she didn't have one when they went to the local county fair the previous weekend. They were outside all day. They went to the petting zoo--but she didn't go in. Her brother, just 2, had no hesitation and had fun with the gentle animals. In fact, the closer she got to the fence around the petting zoo, the more upset she had become. She even was scared to see her brother near the animals. I asked her mother about other things she was afraid of. 

The list was long. She was scared of just about any animal that was live, any bug of any kind but especially spiders, snakes, dark places including closets and under the bed. I asked Molly, and she was open with me. She said that she was afraid of being separated from her family, she was afraid that something bad would happen to her mother, to her father, to her brother, to all of them together, and to herself. She was afraid of strange and new places, new foods. She was afraid of snakes. 

Now, with a little more insight, I asked her about the headache. She said it had hurt. This time I asked her more about what she was feeling during the headache. She said that she was very afraid that it wasn't going to get better. She was afraid that her mother wasn't going to be able to help her and that would make her mother feel bad and it would be her fault.

It's always concerning to me when a 5-year-old complains of a headache. I think Molly had a headache, and I'm not sure what caused it. But though it's not in my textbooks, this is what a panic attack looks like in a preschooler. When I told her mother this, she was able to think of a couple of other unusual meltdowns that seemed to come out of nowhere. They weren't for the usual reasons, when a parent says that the child can't have ice cream for dinner or has to turn off the television. They weren't about defiance, they were about worry. And each time, her mother felt powerless to stop them. In many ways, these events might look behavioral. They include crying, perhaps screaming, maybe pounding fists or feet.

It's the panic attack that made her reaction spiral out of control. Her mother had the right treatment for a headache. Some acetaminophen, closing her eyes in a dark quiet room. But I had to give them something that could make the panic attack less traumatic for the child—and maybe for the mother, too.

Panic_in_year_zero_1962_poster I gave the mother a pair of questionnaires I give to parents to help me evaluate anxiety disorders in children. The responses were convincing.

Though Molly had a clear anxiety disorder, she had some big potential advantages as I considered her treatment options. She was smart, she was verbal, and she wasn't afraid of me. The first two points would enable her to cooperate in her treatment in important ways. The last one would, I hoped, enable her to accept my guidance without her anxiety interfering. I discussed treatment options with her mother. She, too, thought that Molly's particular trust in me was worth exploiting to help her. 

Often, with generalized anxiety that includes aspects of the diagnostic subcategories (such as social anxiety disorder, separation anxiety, phobias, and so on) medication is a reasonable approach. But we had these advantages, and her mom and I wanted to try and take advantage of them. We could always revisit a medication option if other approaches didn't work.

I could have sent her to someone really good at Cognitive Behavioral Therapy. In 5-year-olds.
This approach is designed to help patients recognize their dysfunctional thoughts, and manage them in a rational way. Though the technique is well-known in adult psychotherapeutic circles, it's not so well developed for kids. And certainly not with preschoolers. 

In the bigger picture, however, the effects of Cognitive Behavioral Therapy, I think, can be thought of in the same general pool with meditation, yoga, prayer, and clinical hypnosis. They all help people (nothing works for everybody—each helps some people) get relief from thoughts and feelings that are painful or harmful.

What her mother decided was to let me try to teach her self-hypnosis. 

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July 18, 2010

Vaccine Refusal and Ethical Issues

All the families who bring their kids to see me know that, in general I’m a supporter of childhood vaccination. On balance, the risk to your child of a devastating or lethal disease with known and terrible effects seems to dominate the risk of vague eventual possibilities of problems that are either unproven or completely debunked. This post is not about why you should vaccinate your baby. Though you should.

I’m in a pretty privileged position. None of my patients comes to me just because my name was on the list from the insurance company. A parent picked me, researched me, got my name from a friend or coworker. Sometimes, I’m gratified to say, they get my name from a nurse in Labor and Delivery or from one of the lactation consultants or midwives. Some of my most difficult cases come to me on the recommendation of my pediatric colleagues who have practices of their own.

So it’s what is generally called a self-selecting group. They are here because they want to be here. When parents expecting their first baby come to interview me, many don’t know my views on vaccination. Perhaps it’s a result of being located here in Berkeley, but I don't get parents who have heard that vaccines are harmful, and want to learn my professional opinion. I get those who say they want me to be their child's doctor because they have read or heard about me, but have made up their minds about vaccines. I wonder what they really want from me. If they don't want my medical expertise, they why are they coming to me? How can I help them? I hope that I will always provide the best care I can, but I was not trained in and do not know how to provide some reduced level of care.

What prompted this observation is a comment I read on one of the informational websites for physicians. A very smart academic doctor pointed out that when we treat families who refuse vaccinations, we are really being asked to provide substandard care. He argued that if we send these families elsewhere, we have lost the opportunity—perhaps many opportunities—to educate them and help them appreciate the value of this intervention.

It makes sense to engage with these parents. Most of them are extremely well-educated and literate. I would love to give them literature on the subject, cite references, tell them my own horror stories to counter the ones they heard from the internet, the parent group, or in the check-out line at the local organic market. I'd love to tell them that one of the local Montessori schools was closed twice in the last year by the Public Health Department for being a center of major pertussis epidemics. But I get the sense that they are not interested in receiving this information, or perhaps just not from me.

The parents of every child make essential health decisions every day. They manage the diet, activity, and safety of their children. Hopefully, they balance protection with freedom, and find a way to let the child ride a bicycle but still make them wear a helmet. I don’t think I’m the only one who is shocked when driving in a parking lot and a toddler is walking along without holding a grown-up’s hand, while they walk far behind, texting. That’s not OK! I keep my mouth shut when this happens, but I mutter unflattering things as long as my car’s windows and doors are closed.

But I am required, as much by my own standards as those of my state licensing board, to practice at very least at the standard of care. If the kid needs an antibiotic, I prescribe an antibiotic. For this reason, doctors shouldn’t be complacent with the nonvaccinating parents. It seems like a strategy of engagement is a reasonable way to go.

But I'm scared. In the past couple of weeks, I saw in my office a pair of former preemie twins. They are now about 6 and 8 pounds or so, and just got out of the intensive care unit. They are over 2 months old. Having unvaccinated kids in my office would seem to put them at substantial incremental risk. What is my responsibility to them?

That's not the only reason I have problems seeing unvaccinated kids in my practice. I feel so strongly about the importance of a meaningful doctor-patient relationship that I'm unclear about my role in their care. If I prescribe a medication to help your child breathe but you don't give it to your child, and instead use what your homeopath recommends, why did you consult me in the first place? If HIB vaccine could save your baby's life (or brain) but you refuse it, how much trust do you really have in me, my judgment, my training? It's better to bring your child to an advisor you really trust, whose expertise you respect, who can provide the care you really want and value.

I have absolutely accomplished one of the goals I set out for myself when I started this practice. I have patients and families that I know and who respect my guidance. This is probably a logical point at which to note that this doesn’t mean slavish obedience! I expect my own doctors to give me their very best professional advice, and in return I promise them—though this is unspoken—that I will take it seriously and do the best I can. I haven’t always followed what they suggested. Occasionally, I thought they were wrong, or didn’t understand all the aspects to my situation or complaint. Most often I just couldn’t do what they wanted. I couldn’t afford it, couldn’t spare the time, couldn’t make it work for me in some important way. But it has never been because I thought they were stupid, uninformed, or malicious. It wouldn’t say good things about me if I continued to go to a doctor like that.

So if I recommend that you let me painfully inject into your baby something you believe to be poisonous, toxic, or unproven, or if by recommending this your belief is confirmed that I am little more than a meretricious shill for the Big Pharma cabal, why would you want me to see your child?

Sometimes, when the prospective parents are interviewing me but before they storm out of the office, the reason comes out. I’m not really going to be their baby’s doctor. I’m the safety net for the naturopath, homeopath, or chiropractor who will really be managing the baby’s care. Then, if something goes wrong, they can bring the baby to me.

car seat
So the first ethical problem I have with treating families that don’t vaccinate is the fundamental nature of their request. They have asked me, with their full consent, to provide substandard care. When asked about this, a physician said that it was like the family refused to use a car seat for the baby. They ask the pediatrician, however earnestly, ‘What’s the best way to hold the baby while driving?’ Not only isn’t there a good way to hold the baby, but it would be unethical to do the research which could tell us if holding one way is 100 times more potential lethal than using a car seat but holding a different way is only 92 times more potentially lethal than using a car seat.

This is a line from a common translation of the Hippocratic Oath: I will prescribe regimens  for the good of my patients according to my ability and my judgment and never do harm to anyone. There isn’t much about doing less than my ability because the helpless baby has parents with...issues.

But the second ethical problem is obvious. Though it doesn’t come up in Hippocrates, it’s a central tenet in medical ethics. Autonomy. The patient has the right to make decisions about themselves and their treatments. With children, it’s generally understood that this means that the parents get this autonomy. When exactly this ends, by the way, is unclear. Legally, kids who are 18 acquire most of the medical rights of adults. This is confused, of course, if mom and dad are still paying for the health insurance. And, varying state by state, teenagers of a certain age can ask for and receive contraception or contraception counseling. Sometimes psychological services. Babies...not so much. Our society makes an implicit assumption that a baby’s parents have the best interest of the child at heart. Luckily and almost always, that’s true. The parents who choose not to vaccinate aren’t trying to hurt their baby, they are trying to protect it in the best way they know. Given this complete and unquestionable lack of malice, don’t they deserve the autonomy we all expect?

And one more thing. If a parent came to my office obviously intoxicated, I wouldn't let them drive home. Maybe I’d call a taxi, maybe I’d drive them home or call someone to pick them up. I would intervene in some way to protect them, their child, the community of unsuspecting and unwarned drivers on the road who all agree to follow some shared set of rules that protect them all. I don't know how to resolve this ethical dilemma between their autonomy and my responsibility. When they decide not to vaccinate, it's not like holding the baby without a car seat—it’s loosening the straps a little bit in every baby's car seat. What's my obligation to them?

So I think there’s a third ethical problem: my responsibility as a physician in the community, perhaps as a citizen. It would be wrong to cry out, ‘Fire!’ if there was none. But do I have an obligation to cry out if I see one?

July 16, 2010

Anxiety—College Boy Problems

handicapped sign
Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?

An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.

He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.

But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.

He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.

Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.

This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.

Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.

Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.

Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.

Let me be explicit about some of the ethical issues associated with this case.

1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality?  Does the doctor have an obligation to do more than educate, inform, and offer help?

2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?

3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?

July 13, 2010

Anxiety--College Boy

Peter was at college here in Berkeley, and needed a physical exam form filled out for a summer job he had applied for. He came in with his parents. I asked them if they were worried about anything in particular and they said that he had been very healthy. But they wished he'd get out more. Maybe be a little more...outgoing. He looked very relieved when his parents left the room.

"Gosh," I said, "I thought they'd never leave!" He smiled briefly. I asked how college was going, if he had a major.

He said, politely enough, looking at the floor, "It's going OK. Don't have a major." Didn't I recall that he was interested in Economics? "Yes, but I didn't get a good feeling from those people." Meaning, I took it, from those in that department. How about people in other departments? I told him I thought there was a lot to be said about finding a group where you feel like you fit in. "Maybe, but I don't fit in." Still no eye contact.

"You haven't made a lot of new friends?"

"None, really."

"Are you in touch with your friends from high school?"

"I had two friends in high school but they are going to college in Hayward [Cal State]." It is a sad fact of suburban life that the logistics of socialization are often very cumbersome for children. (This is very different from my experience growing up where public transport was great and cheap.) But he was 21, not 14. What about borrowing a car from his parents? "I don't drive."

"Why not? Didn't they have driver education in your high school?"

"Yes but I stopped taking it after the first day. It was just too dangerous." But his mom and dad drove, I pointed out. "But I won't drive with them at night. Anything could happen. No," he added for emphasis, "I definitely don't want to drive."

Most 16-year-olds have, at least in their minds, cut from magazines the photos of the cars they want to have. A car, or access to one, or even without access but having a driving license, meant adulthood, liberation from the control of their parents, freedom. Most American teenagers have much clearer dreams of owning their own car than they have of owning their own home someday. I think that this is less prevalent among those growing up in urban settings. (A wealthy high-school classmate of mine had his own car, but I don't know where he drove it (let alone parked it) and neither I nor most of my other classmates were envious.) But this is California, where having a car or wanting one is or should be considered an essential developmental milestone, like walking or potty training. When he said that he didn't want to learn to drive, whatever alarms were not already ringing for me started to go off. "What about going to Hayward on BART?" [Bay Area Rapid Transit--a not very extensive system, but fast and reasonably comfortable and clean.  And ] I knew he lived in a town with a station.

"That goes under the Bay!" he explained as if I has somehow been misinformed about this fact.  But it didn't between Berkeley and Hayward.

At some point, I stood up to wash my hands and examine him. I went to put my stethoscope on his chest, but stopped. "Gosh, Peter. Have you been gardening? Working with paint solvents?" His hands were red, very dry-looking and irritated. He denied this but said that he washed his hands a lot. Mine were not so raw, and I typically washed them 20 times a day, sometimes more.

"I know. I'm a bit of a germophobe."

He was attending college locally. So I asked him if BART was uncomfortable for him, why wasn’t it a problem taking the public transit bus to school?  He told me that he walked to his college campus, about 3 miles or so from his home. He admitted that not using public transportation was a real barrier to making and sustaining new friendships at college.

Continuing in this line, I was worried about what would come next. As I would ask any patient his age, I asked if he was dating anyone. I assumed that this would be logistically difficult for him, given his transportation constraints. He said he wasn’t in a way that concerned me. Sometimes I get a disappointed response, when the college kid wished they were dating somebody. Sometimes it’s a blissful yes they are. He looked at me at me with an odd expression of confusion. Now I was confused about why he was confused. I asked him to clarify what he was thinking.

He told me that he wasn’t dating and convincingly claimed not to know why people did. Let me be really clear here:  I asked about just dating, nothing more intimate. Yes, he knew classmates in high school went on dates or wanted to and talked about it.  He knew they did in college. I asked if he knew how his parents met. Like most of us, their relationship started with dating. But he didn’t really see why people did this. There were so many obstacles that he pointed out. Getting together in a certain place and time, which is a key part of the definition of a ‘date,’ is very difficult if one of the people has to be within walking distance of their home. Holding hands seemed unappealing to him, and kissing appeared positively unhygienic. I asked if he would like someday to have a family of his own and a mate. He said that he would but he didn’t know and couldn’t picture what kind of a person that would be or how he would get to there from where he was.

I spent about an hour with him, much of it trying to figure out the level of isolation to which he was willing to subject himself.

I told him he had anxiety. I recommended many things, including trying some medication. I was willing to work with him in any way that I could. He was willing to commit only to think about these choices, or if he wanted to do anything at all. So deeply did he see his perspective as an accurate view of the world that he didn’t see it as a problem in his life. I asked about continuing to live with his parents, and he didn’t see a problem with that, or limiting for school or work to a walking-radius around his parents’ house in Berkeley. Gently, I tried to point out that it might be difficult to meet somebody under these circumstances, but he was blind to this. He didn’t try to reconcile his dream of having a family with his disinterest in looking for somebody with whom to start that family.

July 7, 2010

Anxiety—College Girl

Not feeling well for a weekend, getting through a really busy spell in your work, maybe just being exhausted and not getting a good night's sleep. Those are common reasons why people stop their regular daily exercise routine. It's not like they make a decision that the exercise they've been doing isn't a good idea, or even that they hadn't been enjoying it. But somehow the routine is broken. It's really hard to get started again. When you do restart, what came easily when you stopped is really difficult. It will take time to work up to your former level of fitness.

I got unusually tired and wasn't feeling well. My closest friend called and told me she had cancer.  Suddenly, the effort that was required to keep this up just didn't seem so important. A series of moving patient encounters, together with a surprising amount of encouragement from readers both locally and around the world combined to get me off my lazy behind. My 2-month sabbatical from this blog, I hope, is over.

anxiety acres
Jessica came to my office by herself last week.  She was 18 now, and starting college.  She’s been seeing me since she was a girl, and though I knew we got along well enough, I never got the feeling that she was entirely comfortable.  This visit might be the first time I saw her without her mother.  She had always been thin, but my perceptive assistant noted to me that she had lost about 10 pounds since the last time she’d been in the office.

She said that she wanted me to take a look at something on the skin of her leg.  It had started as a bump a few weeks ago, about the size, she said, of a ‘mosquito bite.’  Maybe it was a little itchy at first, but she didn’t remember it being very annoying.  After some time, she wasn’t exactly sure how long, the bump went away and an area of the surrounding skin on her leg was red.  It wasn’t painful or bothersome.  Over the last couple of days, the redness has decreased and there was a very small amount of skin peeling.  When I asked, she said that it looked like it was getting better.  It didn’t hurt, itch, burn, bleed, ooze, or interfere with anything she did or wore.  I asked to see it.  A little above her knee was an area about the size of a quarter with some faint pinkness and a few skin flakes.  I asked if I could touch it, and found that it wasn’t warm, firm, soft, raised, or bumpy.  She said that it didn’t hurt when I touched or pressed on it.  There were no other such lesions on her.  I was not very worried about it, whatever it was originally—and told her so.  She should call right away, however, if it didn’t continue to improve a little every day. 

I will inject as an aside that I believe the rapport that a patient—even a little kid—has with her doctor can be really important.  It is very hard to establish that relationship with 6-minute visits.  There are lots of other impediments established by current care standards.  If you see a different doctor every time, if the doctor never seems interested in other symptoms you might be living with, if you’re made to feel like just another hot-stamped drop-shipped cog delivered through optimized just-in-time-supply-chain management into the inflexible assembly line of efficient health care designed to achieve least-common-denominator-acceptable outcomes for your particular diagnosis code in order to achieve maximal reimbursement from a 3rd-party-payer at whose toll-free-number you cannot ever reach a human, then you probably won’t really feel relaxed with your doctor.  My patients of all ages, I hope, know that’s not how I work.

So when I told her to call right away if it didn’t improve, my hand was not on the doorknob.  I didn’t even stand up to go.  I simply asked her, “What else hurts?”

“Nothing much,” she said thoughtfully.  “I mean, you know, except for the stomach aches.”  I resisted the urge to smack myself in the head.  Only gradually had I come to realize that bald as I am, a good smack might leave a red mark that could last an afternoon.  Somehow, it was not as satisfying to smack myself on, for example, the ankle.  I didn’t say or do anything except pay attention.  “Sometimes they’re really bad.”  With that her eyes filled with tears and so did mine.  The exam rooms are stocked with tissues, but only one box.  We shared.

She had been having abdominal pain for at least several months.  It was very worrisome for her.  She was afraid she had an ulcer caused by her anxiety.  Anxiety?  Forget the mosquito bite—what happened to the abdominal pain? 

About an hour later, I had learned that she had a couple of jobs that she couldn’t keep because of her anxiety about many, many things.  She had no problem with the academics of college but being in a classroom was a problem and if the classroom were filled with busy, social, chatting, comfortable peers it was an awful experience.   She had sought professional help for this, I was relieved to learn.  But the medication she was prescribed wasn’t helping her—and she was afraid of bringing this up.  I offered to make that call, but she declined for now.  She felt hopeless about the anxiety because the medication didn’t work.  She said that she was worried that her abdominal pain could be something serious.  Right after she said that, she said that it’s her fault because she probably has an ulcer that’s caused by her anxiety.

Here’s what I told her.  Neither the anxiety nor the abdominal pain were her fault.  This I backed up with a short neurophysiologic explanation of how the amygdala communicating with the prefrontal cortex can give the uncomfortable sensations associated with anxiety.  I told her that though it does indeed seem like she has an anxiety disorder, people with anxiety disorders can get just as sick as people without. 

I explained the curious history of peptic ulcer disease.  For more than 100 years, an entire field of medical knowledge was based on the belief that it was somehow caused by intense or anxious or angry or unstable personalities.  Idioms like Type-A Personality entered the daily lexicon largely based on this medical belief.  It was all crap.  Ulcers are usually caused by a bacterial infection in the stomach, which is typically successfully treated with antibiotics and Pepto-Bismol.  (Even happy little kids can get ulcers, by the way, though this is quite unusual.)

I told her that it would be a medical error to assume that her anxiety had been the cause of her symptoms.  It didn’t help, of course.  But I suggested an alternative way of looking at her pain.  Suppose there were some reasonable explanation for the pain and other symptoms that she described.  Maybe when the pain was bad, she would become worried about it and if it were something serious.  This, I pointed out explicitly, would be just how people without an anxiety disorder would think about it.  If the pain continued, a person would be increasingly worried.  As the worry increased, their senses would be focused on the pain, observing it carefully for changes.  With this concentration, continued pain would be sharply perceived and the worry would just continue in an accelerating spiral.  She had not looked at it that way.  Besides, I said, I would really like to relieve that pain if I could.  She deserved and needed the workup I would do for any young woman with chronic abdominal pain.

I informed her that though she might not have been helped by her treatment so far, there are many other treatments available.  None of them works with everybody, but all of them work with some people.  There’s at least a dozen medications she hasn’t tried.  Has she tried a workbook?  She said she had one but she didn’t want to do it because it might not help.  She had not seen that she was too anxious to try an anxiety treatment.  Maybe yoga, maybe hypnosis, I suggested.  She hadn’t thought of those.  I didn’t promise to make her better.  But I promised I would try and I wouldn’t give up.  I don’t know if that will be enough, but it’s all I had to offer.  Well, that and calling the shrink.  For now, I’m working on the stomach aches.

By complete coincidence I have had a series of patients with anxiety issues.  Maybe there were more of them out there than I knew about, and maybe I wasn’t asking enough or the right questions.  With teenagers, I screen everyone for depression.  I get the feeling that’s not enough.  I’ll write more about these young people.

The poster pictured above, stolen from the internet, is from a movie I have not seen.   It’s apparently being shown as a double feature with Libidoland, by the same filmmakers.  Not sure what to make of that.  The tag line for Anxiety Acres is:  “When Casey moved Kevin to the country, she hoped he’d find peace and quiet; instead he found new things to worry about: zombies, hitchhikers, and chocolate cake.”  Who doesn’t worry about zombies, hitchhikers, and chocolate cake?