The Power of Slow Medicine

I discovered the power of slowness even while being rushed to see more patients faster. Luckily, I have a good way with most children, and they aren't usually scared of me. But there's no practical way of examining a child within a minute of walking in the room. Like the rest of us, children get territorial about their personal space, and will be upset if you violate their boundaries. So the key to a cooperative examination is getting the child to invite me to share their space with them. This takes time and patience. I will often use a prop of some sort, such as my tie or a toy or stuffed animal to engage the child and get them to reach out to me. It's a subtle dance which can take more than a few minutes, especially for anxious children. The first part of my definition is literal: slow visits.

Slow visits allow the patient or parent to ask all their questions, to get comfortable with the surroundings. In medicine, there's something known as the 'doorknob question.' The patient is in the room with the doctor, and their visit is finished, and just as the doctor turns the knob to leave the room, the patient asks a really important question like, 'Oh, and doc, should I be worried about this chest pain I keep having?' I think there would be fewer doorknob questions if doctors weren't always reaching for doorknobs. The removal of time pressure in the visit allows the patient to express their anxiety, and gradually open up about important issues. It also allows them to explain complex related problems, like family or financial situations that might have an important impact on whether they will be able to take their medicine or follow the doctor's advice.

The goal would not be simply providing the minimal acceptable level of care. Having an expert doctor who knows who you are is like having a chef who knows how to take advantage of that local seasonal produce. It takes more skill to cook something fresh than to heat something in the microwave. Having uninterrupted access to your physician can keep you from unnecessary treatments and save your insurance company money.

When I see a sick child, I have a luxury that I didn't have when working in a busy clinic. In the clinic, it wasn't clear when or if the parent could bring the child back. So to be safe, we would sometimes prescribe medication on the assumption that the diagnosis would eventually require it. Because my current patients have open access to me, I will often choose not to treat the child at all. I tell the parents to call me right away if the child gets worse. If I don't hear from them, I'll call the next day to check up on the child. Often, my patient will get better on their own and won't need any medication at all. This system only works because when parents call, they talk directly to me. I know the situation and can evaluate the need for treatment at that time. If it were a doctor covering for me, this might be a problem. Either the covering doctor would be extra cautious and prescribe medication or possibly not take it as seriously because they wouldn't know the whole history. If the parent is even more removed from the doctor, by calling a call center, they often can only get a response by selling the person answering the phone on how awfully sick their child is.

About two months ago, I got a call one Sunday from a mother of two preschoolers. Both had fever and seemed to be in pain. I met them at my office, opened the office for them and treated them. I was later told by their insurer that Sunday visits aren't a covered service. The person I spoke to on the phone in the claims department suggested that I do what most practices would do on Sunday--send them to the emergency room. It didn't seem to matter that the ER would be way more expensive, slower, and scarier.

I wonder if slower, more customized, more personal care would end up costing less. I think there might be fewer tests, fewer ER visits, fewer prescriptions, better compliance with the doctor's advice, and a lot more medical problems might be caught early. That could result in better health outcomes, lower cost of care, and more satisfied patients. I suspect there aren't enough doctors who practice this way to do the research to prove it.

I practice slow medicine.

Next Post: Slow Medicine and the Telephone Paradox

My Child Hates Me

Hitting Mommy

"You will not be punished for your anger, you will be punished by your anger.” --Hindu Prince Gautama Siddhartha, the founder of Buddhism, 563-483 B.C.

A sensitive and intelligent mother started the visit by saying that her 3-year-old said, "I hate you." There had to be a lot more to the story, of course, so I said, "that must be very hard for you." Mom started to cry.

"She hits me," she said, very seriously as if confessing.

"How long has this been going on?" I asked. She said that her daughter has been hitting her and only her for about 6 months. Though she hasn't been hurting anyone else, she's been more difficult in preschool and quicker to fight over toys and play turns. She said that the child hits as hard as she can, with obvious intention to hurt.

It wasn't always like this, mom said as I started to examine her 6-month old baby. There used to be times of cuddling and laughing, and now it seems that the toddler is angry all the time. With gentle questioning, this mother admitted that her daughter still has happy times with dad, who is working long hours but is a big help when he's home. She admitted worrying about the future of her daughter, worrying if she will be violent as a teenager or adult. This made her very sad.

I felt sad for her, too. I told her the quote above, to help share my perspective--as on most child behavior issues--through an empathic view of the child. Siddhartha could easily have had preschoolers in mind. They don't want to be angry! It may seem like the child spent a lot of energy on her anger, but it wasn't a fun place to be for her. So I knew that she wasn't enjoying feeling or expressing this aggression, especially against her mother. And toddlers don't do things they don't enjoy for reasons of principle.

It should be obvious that the child's aggressive behavior towards mom started soon after the baby was born. When I pointed this out to the mother, however, she was surprised. She tried to retrace the calendar in her mind as a way of proving that it had nothing to do with the new baby. She failed, and realized it had everything to do with the baby.

This is not an unusual story, and many kids (as well as many dogs and cats) can get pretty resentful of the new baby.

Mom was surprised, however, because she said she had followed my advice from before the baby was born: make time to be one-on-one with the older child, so they know you are still interested in them and their priorities. She said she did this as much as possible. Depending on what time her husband came home, and the baby's nap schedule and feeding schedule (which varied every day), this could be a couple of hours or none. Sometimes the dad came home after bedtime, and he wouldn't see his daughter at all that day.

Now all the pieces fell into place. This 3-year-old had VPS, and a bad case of it. Vanishing Parent Syndrome, a problem that often arises as a complication of Concrete Thinking. (NB to the reader with OCD: Concrete Thinking is real, look it up. I just made up VPS.)

First, the problem arose because the parent has made a subtle but serious error in empathy. Mom was trying as hard as she could, and made as much time for the child as possible, but the kid is only 3 and cannot appreciate her mother’s sacrifice. It is perfectly understandable and natural for the loving parent to make the assumptions she did. But it's an error. Would you take your 3-year-old jogging? No, she wouldn't be able to keep up. Would you take her to a college lecture? No, because it wouldn't be reasonable to expect her to pay quiet attention for so long. Concrete thinking means that the child has a limited capacity to imagine herself in somebody else's shoes. Her ability to think abstractly in the future, which is to say imagine herself doing something tomorrow or next week, is absent.

So let me apply empathic analysis, a methodology I came up with to help work through challenging child behavior issues. Maybe she can't put herself in my place, but I can put myself in hers.

From the 3-year-old's point of view, these one-on-one sessions with mommy and daddy are great. But because she can't plan tomorrow or the next day, she is trapped into reacting to whatever is happening right now. She doesn't remember the hours spent with her yesterday--they might as well have been ancient history. Even if you remind her, she can't grasp the feeling it gave her yesterday when you were with her. Thus, it doesn't soothe her or relieve her need any more than the drink of water you had last week can relieve your thirst right now. In the same way, your promise of spending time with her tomorrow is of no value to her today. In this case, there wasn't even that promise. Maybe there would be time tomorrow, maybe not.

For the child living in the moment, as would be developmentally normal for a child this age, these times with her parents seem arbitrary and unpredictable. Though nice when they happen, they start and end for inconceivable reasons. The child has no confidence that these times will ever happen again.

When did this start? It's a mistake to think that the child has formed a conspiracy theory to explain it, with the newborn baby as the evil leader. Earlier, I said that I helped mom see that the problems started about the time when the baby arrived. But the baby didn’t do anything—it was the behavior of the parents that changed. The baby is an incidental artifact to the situation from the child’s point of view. It's the parents that this child depends upon, and it is their actions alone that she reacts to. So it's perfectly reasonable that a developmentally normal child will try one thing or another to regain the attention that she has inexplicably lost. Maybe it's refusing to go to sleep or eat. Maybe it's giving up the potty and going back to diapers. Maybe it's hitting mommy. She's creative, inventive, and needy. She has now learned that the hitting thing works, in a big way. Mom puts down the baby and talks directly to her--maybe not in the tone she hoped for, but at least, like a desperate salesman, she's got her foot in the door. The attention of her parents is the single most valuable thing in her world, yet her parents dole it out like worthless crumbs.

This mismatch between the priorities of the child and the priorities of the parent is a set up for relationship friction. Each party doesn’t understand why the other can’t see reality in the clear bright light of truth.

This sweet preschooler couldn’t jump up to her mother’s perspective, but maybe I could get mom to kneel down to hers. What I had to do was come up with a system that the child could rely upon, that the parents could live with, and that would still include the baby. I needed to work with the tools I had.

The child didn’t know numbers and couldn’t read, but did know colors. So I told the mother to get a big desk calendar at an office supply store. Every day had a plan. On weekends, daddy would go for a walk to the park and leave mom at home with the baby. Every weekend morning, even in a cold, drenching rain. This is crucial—the child thinks concretely, so she can’t abstractly imagine her own wet discomfort trying to play in the rain (and she might, in fact, enjoy it). So get over your petty adult comfort preferences and take her to the park, at the same time every weekend morning. If you go and she says she wants to go home, that’s OK, but that still means isolating dad and her from mom and baby and giving her one-on-one time with dad. These are orange days, and every weekend day must be colored orange. On green days, mom would do laundry when the baby was sleeping in the afternoon. And laundry was their special time to be alone together. The child was given special helping tasks and made to feel important and useful to mom. She knows a baby couldn’t do these things! By the time dad came home, mom would have specific things she could tell him about all the helpful things she did. On blue days mommy would go to the store with her and the baby. But before going to the store, she helped mommy make a list of things to buy. She helped take things off the shelves and put them in the cart. A baby couldn’t do that!

Every day, at bedtime, the child would put a dinosaur sticker in that day on the calendar. That was the end of that day. Goodnight, dinosaur!

Though the child had limited ability to picture the next day, this became a bedtime ritual. When the next day was green, she was reminded of the important job she had helping to sort light from dark wash, or adding the dryer sheets.

I can’t emphasize enough that for this plan to work, it needs to be cast in steel. It isn’t the tasks that change the toddler’s behavior, it’s the dependability. When she feels confident that she can count on the plan happening, she won’t feel the need to experiment with new and inventive attention-getting techniques. The plan is designed to build confidence, so it doesn’t matter if it’s only an hour a day of parent time. It matters a lot if the parent doesn’t follow through. That will erode the child’s confidence in the parents even more, with predictable increases in problems. So the key success factor here is the commitment of the parents to do what they contract to do.

Her parents told me that she’d sometimes ask to start the laundry first thing in the morning. When reminded that they have to wait for the baby to be asleep, she’d talk very quietly and sometimes sing softly to the baby to help initiate this process.

She stopped hitting mommy.

I need to add this caveat. There are kids this age who are aggressive, even hurtful. Not just with mom and dad, but with peers, strangers, grandparents. I’d guess that in the last 10 years, I’ve seen 1 child like this for sure, maybe a couple of other, less clear cases. This aggression and oppositionality can sometimes be perceived at a very early age. It’s not normal, and it obviously is going to have an impact on this child’s life. It seems to be caused by brain chemistry, not some external influence. The child should be carefully evaluated.

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 19^th 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.

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.