Intangibles.

I was trying to explain something important to my son Louis the other day.  See, Louis is kind of a know-it-all, especially about sports.  He’s 13 years-old, has a memory like a vice grip, reads everything and knows all the data and stats you could imagine.  But as much as he knows ABOUT sports, he hasn’t actually PLAYED much.  So I think when guys like him debate me into statistical oblivion over some “who’s the best blankety blank ever” topic, I feel pretty secure talking about the “feel” for the game or that “intangible” winning attitude, even if my memory for stats and names and stuff like that isn’t so good.

So what I was trying to explain was that Tim Tebow, this college quarterback coming up in the draft, is going to be a great quarterback in the NFL despite what Louis and all the sports pundits say about him.  See a lot of people believe Tebow has some “mechanical” faults with his football throwing motion and footwork that won’t translate well from the college game to the pros.  But I think he’s just a winner, pure and simple, and if it ain’t broke, don’t fix it.  He’ll be a star.

Anyway, I’m trying to make my point about Tebow having great intangibles and being a winner when I thought of an analogy to illustrate my point.  “Remember that movie we rented, long ago, Chariots of Fire?  Where that gold medalist distance runner had that awkward running style but in the middle of a race his mouth would open and his head would tilt back and he’d become so possessed by the spirit of the Lord that his body would push above and beyond toward victory?” 

So I’m reminding him about this movie and I’m talking to him about intangibles and faith and spirit when I notice he’s got that trying-to-recall-something look, and as I’m about to make my final point his eyes suddenly clear, he gets this quizzical expression and says, “Wait.  I don’t get it.  Wasn’t that movie called Blazing Saddles?”

“Uhhh… actually yes, Louis, that WAS the movie we rented, Blazing Saddles, I saw Chariots of Fire with your brother.  So, what’s mom got for dinner tonight anyway?”

Burn Your Sins Boys!

Although a lot of people expect their doctor to figure out what’s wrong with them by doing a physical examination, in reality doctors figure most of it out by listening; simply listening to what the patient says.  That’s why we ask so many questions… well, unless you’re a dermatologist I suppose, in which case you just walk in, look at the patient’s skin, and ask the patient to be quiet.  But for the rest of us doctorly-types it’s mostly about what you patients tell us.  And although I love using electronic medical records and a variety of digital resources, I am certain that no technology will ever replace listening as the most important skill needed for making a correct diagnosis.

We call this question and answer part of the doctor visit “taking a history.”  It’s an art form really, to do it right, and a fun challenge that usually leads to me understanding what is wrong with the patient, or helps the patient and parent realize what is going on.  And sometime a careful history yields quite unexptected results.

Like this… A second grader was brought in by his father this week.  Dad was worried his boy might have a throat infection or asthma.  The boy’s school sent him home the other day noting that the child developed trouble breathing while coughing a lot, then he turned very red in the face.  The father informed me that it is “a Lutheran school where they apparently burn incense,” but that’s all he knew about the incident, and all the school told him.  Well that didn’t sound right, I mean I knew this kid all his life and he’d never shown even a hint of asthma, so I asked a few more questions and here’s what the young sinner told me;  “We were in first period, at chapel, and you know that place where the priest stands, that’s where the teacher was and we all had to write down a bunch of times what we shouldn’t be doing in class, then he took all the papers and put them into a can and then he lit the can on fire with a flame, and all this smoke came out and everyone in the front row started choking and coughing, and I turned all red so they made me leave and called my dad.” 

I wrote a prescription out immediately: One pea-shooter, use as necessary, avoid eyes.

Save the stump

Did I tell you this one yet?  About the belly button?  It’s been so long since I posted I’ve forgotten.

There have been a lot of scrumptuous little newborns in the office lately.  I love newborns; they’re quick and easy to examine, usually perfectly healthy and they bring their parents who are almost always gratifyingly eager to hear what I have to say; they smell nice and look cute and most of all remind me of my chihuahua, which I absolutely adore and treat like a baby.  In fact, when I watch parents fawning over their little babies it occurs to me that that is what I look and feel like when I’m with my little  pooch.  I just love this dog.

My real kids are teenagers and we all know there’s nothing too cute about our species at that stage of life.  So I hadn’t had that “new baby” feeling for quite some time.  Most of you know I keep reptiles as pets.  Lots of snakes in my home, lizards and tortoises too.  But they’re more cool than cuddly. 

We found this little dog a couple years ago; a stray, on the street, skinny and cold and beat up.  I walked in the door with this pitiful little creature on Thanksgiving morning and I’m not kidding, the first thing my wife said was, “Can we keep him?”  And after a reasonable search for his prior owner, we did, named him Pavo (which is “Turkey” in Spanish), and I tell you… if I would have known how much happiness a little brown dog would give my wife I’d have found one years ago!

Well, me too.  It’s like having a baby, all the good things about having a baby I mean, and it stays that way.  I got all those nice warm-baby-in -the-house fuzzies every day now.  I could go on and on about him, about his playfulness, his reliably eager greeting every time I come home from work, some of the silly things he does… but I know that’s a bore… and I’m off track…

Something about belly buttons…   So I walk into an exam room to find another young couple and their newborn, first child, and right off the bat mom tells me that the baby’s umbilical cord stump – that leathery thing that hangs from the belly button on newborns until it withers and falls off – had indeed fallen off the day prior. 

I was reminded of another couple, from Bosnia or Turkey or somewhere I can’t exactly recall, who jumped out of their seats to stop me after I removed their baby’s cord stump and moved toward the trash with it.  “Wait!  We need that!” they blurted.  “Really?” I asked, handing it to the father who carefully wrapped it in tissue, “What for?”

The father explained that in his culture it is customary for hopeful parents to retain the umbilical cord stump and deposit it somewhere they want their child to follow.  Like if they aspire for their child to attend a fine university, they secretly bury the stump somewhere on campus at Harvard or some other school like that.  Or if they want her to be a world traveler they might toss it into the ocean or something.

Interesting right?  I hear stuff like that all the time in my practice, we get such incredible ethnic diversity amongst our patients.

Anyway, I’m telling this little story to the young new parents the other day and the mother is kind of getting into it; “Hey that’s really neat, I like that, what did you do with it honey?” she asks her husband.  And with a sheepish look and apprehension in his voice he answers with impeccable comedic timing, “I threw it in the garbage.”

I should have seen that coming.  Oops.  Not sure where that will lead, but no point speculating.  I’m sure she’ll do fine.

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?

XYZ

While waiting for my tire repair at the bike shop recently an eager salesperson approached and said with enthusiasm, “How about a test ride!”  She stood proudly over a device that looked more like a sculpture than a bicycle.  “On that?” I asked.  “What is it?”  The frame was slender and elliptical, the tires so narrow they’d slip into any grate, and the pedals… well, there were no pedals actually, just little clips for little clippy bike shoes.  I lifted the entire unit up with my pinkie, it weighed much less than my Chihuahua, and had a price tag beyond what I paid for my kid’s braces.  I appeared skeptical and answered, “I’m kind of old-school.”  Undaunted, she pointed to a row of gleaming new bikes with lower but still exorbitant prices and said, “Old school? No problem, those are all made of steel.”

“Listen,” I started scornfully, “see that bike over there, the one with the squishy seat, actual pedals and milk crate strapped to the rear, that’s my bike, and it does everything I want a bike to do, which is get me from here to there, and burn me a few calories on the way.”

I mean that’s the point right?  The harder I pedal the more I sweat, the more I sweat the better I feel, the better I feel the more donuts I eat and donuts make me very happy.  It’s a simple equation really.

But there are drawbacks.  I’ve been biking to work lately.  I get up early and ride to the gym each morning, do some work-out stuff (more donuts), hurriedly change into my backpack-wrinkly clothes and dash to the office.  One morning last week I saw about a dozen patients before noon, and during my final encounter the father of the patient informs me that my fly was open.  Did you catch the part about this being my LAST encounter of the morning?  HELLOOOO!  Couldn’t someone have clued me in earlier?  How embarrassing!

Okay, so you’re wondering how I make the leap to pediatrics and parenting right?  Well I’ll tell you.  On the morning in question I was rushing and everything was crammed into my locker at the gym, I put on whatever I dug out first and bingo, the zipper got overlooked because I was out of sequence.  I was out of my routine.

See… it’s all about routine.

There are few things more important to success in parenting than consistency and routine.  From early on parents get a lot of mileage from this simple principle.  For example, I always suggest that parents of infants develop an organized and directive approach to their interactions with their baby.  As young as two months babies are capable of learning from their parents repetitive behaviors, like putting them down to sleep in the same place, with the same blanket, singing the same song, at the same time and in the same relationship to feedings, and doing the same with feedings, and nursing, etc.  Parents who behave in this organized manner are likely to have infants who do likewise, with predictable nap, bed and feeding times, readiness for weaning and so forth later in infancy.  And we all know how helpful it is to have babies and toddlers with predictable schedules.

The power of routine in parenting works at all ages, from preschoolers agreeably obeying the limits their parents set on television time to older kids arriving at the table hungry and more likely to eat because snacks are always restricted in anticipation of a consistent dinner time.

And vice versa, as parents who do not behave toward their kids in an organized, predictable manner are more likely to have children who behave in disorganized, unpredictable ways, i.e. without routines, making independent sleep and bedtime, family meals, homework and so forth more challenging than they could otherwise be.  I’m not pontificating here, believe me, I’ve already made the mistakes with my kids, and it was my zipper after all that needed examining.

One of my favorite guidelines for parents is “do now what you plan to do later, and don’t do now what you’ll have to change later on.”   Develop favorable  routines with your kids, you’ll never regret it.

But speaking of dressing, I’m reminded of the day I went to sign Louis up for kindergarten.  He had long before learned to dress himself and insisted on doing so without our assistance, so there were days he’d go to preschool dressed very oddly, wearing backwards shirts or extra hats!  The questionnaire was focused on development and school readiness of course, and one question asked, “Does your child dress him/herself?”  So I wrote my answer, “Yes.  So don’t blame us.”

Look, up in the sky, it’s….

According to many parents my name is invoked in a variety of circumstances at home.  For example, many fathers advise their preschoolers that “if you don’t eat your broccoli I’m going to take you to Dr. Sagan!”  Not uncommonly a child will tell their parent an office visit is needed, like the little girl who, while sitting in the bathtub looked between her legs and exclaimed, “Uh oh mommy, there’s a hole there, better go see Dr. Sagan!”  And of course I am often referred to in the heat of battle, “I’m not brushing my teeth and I don’t CARE what Dr. Sagan says!”

But today a mom told me one I really liked.  She said I’m quite the celebrity in their home.  She has three young kids, I’ve known them all since birth, and as she pointed to them in turn she said, “This one is Superman, this one dresses like Spiderman, and this one runs around with them shouting ‘I’m Dr. SAGAN!!!'”

I’m working on my superhero uniform now… could use some ideas for the insignia across my chest.

Summertime, and the giving is easy…

Swedish Covenant Hospital, like every business and community hospital, is struggling during the recession.  But instead of simply cutting costs on all fronts, our CEO insists that Swedish Covenant will weather this financial storm through growth and service.  That way, when the economic storm is winding down, we’ll be better off in every way, and so will our patients.

That impressed me.  Similarly, on a family level, and from a parenting perspective, this is a good time to let our kids know that despite the pinch we’re feeling, it is still important to be unselfish and caring, and if possible to help those less fortunate.  As our president says, it’s a difficult but teachable opportunity, a worthy life-lesson for our kids, who may someday say that “even when my parents were struggling they managed to help others whenever possible.”

And on a family level, times are really tough.  

A bunch of my patients’ parents have lost jobs this year.  I had a mom tell me last week that she’s “got a bit of seniority, but they’re letting more of us go and if I lose my job it’ll be the food lines for my kids!”  I got a father in my practice who sells the world’s most expensive sports cars to the most wealthy local families; He may be closing his doors for good soon.

So many sad and frightening real-life stories.  Most of us work real hard and the recession has hit almost everyone.  A little positive, optimistic spin won’t hurt, and I really feel this falls into the “modeling behavior” category as parents.

Our children see us cutting back, cancelling trips, dining out less often, shopping less, maybe they sense our worry or hear their parents discussing or arguing over finances.  I want my kids to hear about the situation in words and concepts they understand, and to know that while there is real fear and good reason for it, amidst the fear there is hope, and despite the fear there is still room for giving, still room for service.

So, we look for ways to serve, and here’s an easy one for you, real simple…

For every response to this blog one can of food will be donated by Swedish Covenant Hospital to the North Park Friendship Center, a nonprofit dedicated to alleviating hunger and poverty in this area.

C’mon now, I see all the visits this blog is getting… give that Reply button a click, click it to give.  Thanks.


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