Knowing

I hadn’t laughed this hard during an office visit in a long time…  A young, contemporary woman from Russia , first-time mother, brought her baby in recently with an ear infection.  Now you all know how I explain things in detail and tell you what to watch for and when to return and so forth and so on… I see your eyes glazing over.  Anyway, I’m almost through my standard ear infection speech and out of the blue she interrupts with, “What about fish and onions?”

Then, “What? Why are you laughing at me?”

Okay, maybe you had to be there to get the comic effect right, but when I regained my composure and asked her to explain her startlingly out of place comment, I figured she would tell me that when she was ill as a child in Russia, her mother would grind fish and onions then spread the paste on her chest or something.  But no, she was just wondering if and when she could feed the baby fish and onions.

It’s fish that has me going today, and about knowing.  Some years ago the committee on allergy and immunology from the American Academy of Pediatrics (AAP) recommended that parents delay the introduction of certain foods, like fish and shellfish, into their child’s diet.  Food allergy reactions had become so common that our experts were looking for some way to reduce the risk, and considered that maybe the earlier a person was exposed to the provocative proteins, the more likely they were to react to them later.

Although many of us pediatricians questioned this policy vigorously, believing there was insufficient data to make such a recommendation, when the AAP makes a recommendation it’s more like a decree, especially for something associated with life-threatening possibilities like food allergies.  I mean you can’t really go against the flow on that one, too risky, even if you don’t believe it is correct.  You just don’t know.  Consequently we all started telling parents to delay introduction of foods like peanuts, fish, eggs and so forth.  As it turned out, a few years later the same experts looked again at the data and realized that delaying introduction of provocative foods didn’t change the statistics at all; kids were still turning allergic, big time, so they withdrew the recommendation and went back to square one.

Sometimes you just don’t really know, not for certain anyway.  And it works both ways.

For example, the “Back to Sleep” campaign.  Some of you may not realize that until recently generations of babies in this country were always put to bed on their tummies facing down, not on their backs like now.  Over a decade ago the AAP committee on Sudden Infant Death Syndrome (SIDS) decided that since parents in nearly every other large country put their babies to sleep on their backs facing up, and all those places had substantially lower rates of crib death than we did, American parents should start putting their babies to sleep on their backs too.  Well, big controversy!  Strong feelings expressed on both sides, with many doctors squarely against alterting an established cultural practice based on absolutely no understanding of the cause of SIDS.  But they did it anyway, and amazingly within a couple years the rate of SIDS in the USA had dropped remarkably.  Thousands of lives saved, thanks to a hunch.  (We still don’t know why, but it sure did work out well!)

This comes up all the time in medicine, both as broad guidelines and with day to day decisions in the office.  Sometimes you just have to lay out the facts and make a decision based upon reason and experience, even if you’re not totally certain.  That’s actually the easy part.  The hard part is knowing what you don’t know.  Doctors who get that part are the doctors you want taking care of you.

I’ll give you a notorious example from pediatric history.  Most of you know about jaundice in newborn babies, when the skin turns yellow due to a buildup of a natural substance called bilirubin.  Some jaundice is quite normal, but if it gets out of control it can be harmful.  We can measure the level of bilirubin and use that level to decide how aggressively to treat the condition.  So here’s a scary fact; when I finished training in the early-1990′s, if a baby developed a bili level of 20, we would bring the baby back into the hospital and essentially exchange all of its blood for banked blood!  That’s right, a complete transfusion.  Can you imagine?

Then a smart doctor got to thinking about this situation, researched it thoroughly and found out that there was no evidence underlying the practice of transfusing babies with bili levels of 20 or above.  It was just a doctorly practice that kind of got handed down over the years and nobody questioned it until he did.  He titled his paper, “Vigintiphobia,” from the latin, meaning “fear of the number 20.”  Suffice to say we’ve become a lot smarter about newborn jaundice since then.  (No that wasn’t me.  I’m still trying to figure out where belly-button lint comes from.)

That’s really the key; knowing what you don’t know, or more accurately stated; respecting what you don’t know.

Life-lessons come when you least expect them right?  Back in medical school as I prepared for graduation and the next level of training, I was interviewing for pediatric residency at various institutions.  One day I arrived to a little office hidden deep within a big old university building.  The space was filled with hundreds of books, floor to ceiling, piled everywhere.  A professorial physician emerged from behind stacks on his desk and I remarked about the impressive number of books he had.

Although I was there to be interviewed that doctor dispensed a little casual wisdom.  He replied, “If you learn nothing else in the coming years as you prepare to treat patients, remember this; for every medical library we have, ten more libraries could be filled with what we don’t know about the health and the human body.”

And I never forgot it.  

I meet with expectant parents often, and they ask me all sorts of questions trying to decide if I’m the right pediatrician for their baby.  “Do you support breastfeeding?”  “Are you cautious about antibiotic usage?”  “Do you have weekend office hours?”  But they never know to ask the most important question; “What do you do when you don’t know the answer?”

And the response would be, “I realize I don’t know and work hard to find the answer.”  That’s the kind of doctor my patients deserve.

So…. anybody have any ideas about that lint?

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