Public Health and Pediatrics

Bloomberg's folly- the war on soda

The old prisoner slowly rose from his chair; a lifetime of crime had made him careful.  With a slow, shuffling gait he brought his tray back over to the cafeteria line where he placed it on the rack to be washed.  As he looked into the window where the prison trustees took the trays and began to clean them, he noticed a new face.  A young face.  One with innocence etched all over it.  He wondered what might have brought him into such a horrible, cruel place. 

 He normally didn’t mix with other inmates; he didn’t particularly care about their problems or what led to their incarceration.  The less he knew, the better, and he almost turned to amble out the door when something stopped him.  His humanity, perhaps?  Or maybe just his curiosity.  Regardless, he looked at the young man with this mix of emotions and something pushed him to ask the kid what he might have done to come to this state in his life.

 “What brings you to this place?  This is the worst prison in New York.” 

 “I don’t know, man.  A few months ago I was just out for dinner with my girlfriend and the next thing I knew I was hauled away by the police.  And here I am, doing 5 to 10 for something everybody does!”

 “What’s that?”

 “Ordered a 32 ounce soda.”

 “Damn,” thought the old man, “I’d better steer clear of this one.”  He moved away from the youngster warily, not wanting to upset him any further.  ““I’ll bet he puts salt on his French fries as well.”

Dr. K

Too fat or starving? Which is it?

I’m confused. 

On one hand I read that there is an obesity epidemic that threatens our very way of life, or at least our life expectancy.  Predictions abound that the “bulk” of us will be overweight in a few years.  Public health experts warn that this concern is reaching down into the pediatric age group as well.  This article states that “fully” one out of seven low income kids is obese.  Clearly this would appear to be a public health problem.

On the other hand, there also appears to be a hunger epidemic in America.  The news is replete with stories wherein children are going hungry on a daily basis.  Some estimates are that one in five children is struggling with what is known as “food insecurity” (however that is defined…).  Is this a true representation of the state of nutrition in our nation’s children, or does it imply something else?

Can both of these epidemics be true?  I don’t pretend to be able to provide an answer to the obesity problem, but I do know that if the hunger epidemic truly exists, then federal programs such as free school lunches, SNAP (food stamps), and WIC are monumental failures.  Digging into the weeds of the statistics of hunger, one finds that it is more likely that the true “hunger rate” is between one and two percent. 

It is interesting that two avenues of progressive thought seem to be vying in a paradoxical battle for control or dollars.  There are the forces that dutifully preach that the obesity epidemic must be curbed, and some of the means to curb it could mean dictating what may or may not be eaten or what medical care will be paid for.  Then there are the opposing groups that bemoan the fact that millions of children are going to bed hungry every night, and that we must pony up for even more governmental food programs.  I wonder who is going to win this one.

So which is it?  Can both scenarios be true?  Are too many poor kids too fat?  Or are too many poor kids starving?  Maybe if the fat kid would split his milkshake and Whopper with the hungry kid, then both problems would be solved…

 Dr. K

The blog muse- why Johnny can't read, or write, or spell, or...

My wife is a source for many of my postings; in fact, I refer to her as my “blog muse”, especially when I am struggling with writer’s block.  When I am striving to come up with a topic I will often text her and she will reply with some anecdote from work that brings a problem sharply into focus.  In her capacity as a librarian for an intermediate school for children in grades 4-6, she provides me almost daily with a rich substrate from which to develop topics concerning children and the field of pediatrics.  She came home the other day with an insight that is laced with common sense, yet profound it its way.

 

Much has been written about the poor performance of our education system.   Evidence of this can be found everywhere.  I am often driven nearly stir crazy by stories of lazy, incompetent, and abusive teachers and administrators.  I am not apologizing for them by any means.  Many on either side of the political spectrum debate the pros and cons of teachers unions, charter schools, poor teacher preparation and many other education issues.   

What my wife has learned in dealing with a school system that has its share of incompetent educators is that the most reliable predictor of student success is parental involvement.  Simply put, the kids that have a parent involved at home and a vested interest in how well a child is learning are the kids that will be successful.  There is a wonderful monogram , published by the Michigan Department of Education, that ties parental involvement and academic success together. It bears close reading.  Again, it states the obvious but necessary point that is often missed nowadays.  Parents must be involved.  It seems that the disintegration of the family in our society has many ramifications.  The lack of an adequate education of the next generation seems to be one of them.

It has been said that “no…success can compensate for failure in the home.”  It would also seem that no amount of education reform can compensate for failure in the home either.

Dr. K

A requiem for the medical profession, Part III, or how does Al Hrabosky make this blog post?

For a glimpse into what the future holds under Obamacare, one might not need to look any further than the nation of Hungary, where diabetics who don’t adhere to government decreed treatment plans will not have the more modern treatments offered them.  According to the article:

“Diabetics undergo a blood test on average every three months and those who score high levels of glycemia more than twice a year could be turned away from treatments with analog insulin -- more efficient but also more expensive -- and left with the less efficient human insulin, under the new rules.”

This is enough to drive the Mad Hungarian even madder.

Why does this matter?  A number of reasons come to mind.  To wit, from the article:

“Currently, all diabetes treatments are subsidized by the state, which hopes to reduce health spending with the new rules.”

When the government pays the bills, they will make the rules.  This appears to be the harbinger of things to come when the U.S. government recommends the use of clinical guidelines; guidelines that initially will be held out as suggestions or best practices, but will eventually held as strict mandates that will preclude the use of clinical judgment in the instance of recalcitrant cases.  Guidelines may work for a certain percentage in the middle of the bell curve, but woe to the doctor and the patient on either end of that curve.  I predict physicians will eventually find themselves sanctioned or financially penalized if they stray from these mandates.  An interesting blog post here from the esteemed DrRich emphasizes this point.  As the story from Hungary shows, the patients as well will be punished for non-compliance, at times for circumstances beyond their control.

At the end of the day, what I fear will happen is that patients will be herded into a style of medicine that is completely beholden to what is most cost-effective for society, and not necessarily what is best for them.  Physicians will be more akin to robots on an assembly line and will provide a cookbook approach towards their clients (can’t really call them patients anymore).  This approach will be so unappealing to the current cohort of physicians that they will opt out and leave the field of primary care to the nurse practitioner set that is being trained under the guideline-centric ethic of the medical care of the future. 

With this as the underlying trend in healthcare, is the Hungary experience a realistic expectation of what is to come? 

 

My Magic 8 Ball says: “As I see it, yes”.

Dr. K

 

 

I (not me) now take a break for a non-pediatric/public health rant...

I’ve finally had it.  Lost it.  Completely.   I’m afraid Henry Higgins was right about the English language.  In America, we haven’t spoken it in years.  What has finally led me over the brink is the improper use of pronouns, specifically I and me.  These two pronouns are frequently misused, and I think it is due to an overcorrection that has occurred in our society over the last thirty or forty years.  When I was a young child, I remember saying something to the effect of: “Me and Billy are going to the store.”   My mom would dutifully correct me by saying “That’s ‘Billy and I’, dear.”  No doubt this sort of correction was going on all over the country with millions of little kids, not realizing that we were using an object pronoun me when we should have been using the subject pronoun I.  What I think we heard was that it was altogether wrong to use me in any part of a sentence.  What this has lead to is the incredible overuse of the pronoun I in contemporary society until it will be impossible to change.  Indeed, there is this inordinate fear of the word me that this author notes: 

"In the old days when people studied traditional grammar, we could simply say, "The first person singular pronoun is I when it's a subject and me when it's an object,' but now few people know what that means. [. . .] The misuse of I and myself for me is caused by nervousness about me. [. . .] But the notion that there is something wrong with me leads people to overcorrect and avoid it where it is perfectly appropriate. People will say, 'The document had to be signed by both Susan and I' when the correct statement would be, 'The document had to be signed by both Susan and me.' (Brians, Common Errors in English Usage).

Perhaps most of us are afraid to sound like that 5 year old of yore, even when it is most appropriate to use me.  Do we figure it sounds more sophisticated when we incorrectly use I when me is called for?  Once you start to take notice you will find that this improper usage is rampant in our society.  Music seems to be a bastion of incorrect me/I usage.  Maybe you’ll never think of that Eric Carmen favorite “Hungry Eyes” in quite the same way again…Pay attention next time when you are at a party or listening to someone give a speech.  You’ll be surprised at how often this rule is broken.

This problem is ironically more common in native speakers than those who learn English as a second language.  That is likely because the ESL learners actually study grammar, an art lost in most schools these days.  I remember having drills in English class about this and other fine points of the English language.  Maybe they don’t teach that in school anymore.  All I know is that if you don’t get it by now, me don’t know what to tell ya…

 

A requiem for the medical profession, Part II

In another development that at first glance might not seem very momentous may help hasten the end of the medical profession as it is currently constituted.  The Medical College Admissions Test, or the MCAT as we knew it fondly, is undergoing a transition that will be complete in 2015.  In addition to genetics and cellular and molecular biology there will be a new behavioral and social sciences section. An article in the US News and World Report states that “The intent of this addition is to assess a student's ability to understand, empathize with, and communicate well with patients of all cultural and socioeconomic backgrounds—an aspect of practicing medicine that's become more important as the nation becomes increasingly diverse...”  Bonnie Miller, senior associate dean for health sciences education at the Vanderbilt School of Medicine, feels the MCAT's expanded measures of science and social awareness will better reflect the skills needed by doctors in a rapidly evolving medical climate.

"The proposed changes in the MCAT are much needed," she says. "Physicians of the future must be critical thinkers who can manage complexity in diverse settings, from ethical dilemmas within families to the operations of integrated health systems…The proposed changes will better align the MCAT with the measurable traits we seek." 

Now as I attempt to decipher what this actually means, I wonder if those in medical education deem the physician of yore, or even the one of today as  inadequately equipped to deal with the needs of tomorrow’s or even today’s patients. 

As Dr. Doug Perednia notes in his “Road to Hellth” blog, this appears to be an attempt to craft a new breed of physician.  The new course taken by the medical education establishment apparently desires to construct a new kind of touchy-feely physician that is ready and willing to be able to handle the ethical dilemmas that might arise from this brave new world of healthcare, one who is able to deftly navigate the intricacies of the “operations of integrated health systems”. 

What ethical dilemmas, one might ask?  Oh, something akin to what the esteemed DrRich has written about, that is the new ethics of medicine.  The dilemma of how to appear to be an advocate for the patient yet have as true motivation what is most cost-effective for society.  It will take a great deal of psychological and sociological gymnastics for today’s current docs to get on board with this sort of program, so it inevitably must be sought for in the medical school admissions process. 

“Operations of integrated health systems” is likely another word for a guideline-driven, Accountable Care Organization-heavy system that will be notable for its reliance on a cookbook approach towards medical care, and the requisite empathy and cultural awareness needed by the purveyors of medical care to sell this mess to every patient in the nation.  In reality, what I want when I am ill, and what anybody else truly wants in that same position, is a physician who is well-trained in the science of medicine and to use that training to inform me of my condition and how to best ameliorate it.  Our nation is apparently not prepared to continue to train this sort of doctor.  

With this to look forward to, no wonder so many docs are getting out.  Would the last one out turn the light off when she leaves?

  

 

 

 

 

A requiem for the medical profession, Part I

As I look around the medical landscape in the spring of 2012, there is not a lot out there to engender confidence.  There have been darker days I’m sure, but none with the sense of foreboding that is pervasive amongst many physicians these days.  There are three movements in particular that seem to presage a 3-pronged attack, as it were, on the physician of today.  Each taken separately may not have much significance, but taken together could spell the end of the physician model as currently constituted.  This post will focus on the first development as outlined in a recent article from the Journal of the American Medical Association this past week.

The article, by Ezekiel Emanuel and Victor Fuchs, proposes decreases in the time spent in pre-medical school training, medical school, and residency programs.  I am not going to speak to the first two items on the list (as decreased time spent in these endeavors may have merit), but the proposal to drop a year from primary care residency programs is at least short-sided and likely detrimental to the trainee and his/her patients when the resident leaves the program.  As the article states, “The third year of internal medicine or pediatric residencies or the research year in surgical specialties could be eliminated without compromising the clinical quality of trainees.”  Also, “the third year is not essential to ensure competent physicians. This residency year is mainly engaged in supervising and teaching interns, in taking electives, or in some cases conducting research.” 

In my experience, the time spent supervising and teaching interns was one of the most valuable aspects of my training.  Emanuel and Fuchs infer that much of what is seen in residency is rote and repetitive in nature, as “changing the structure of training would force medical leaders to eliminate unnecessary and repetitious material…”  Again, in my experience, there was and continues to be great value in the necessary repetition of cases and workups.  I didn’t learn how to manage a new diabetic in DKA on the first go round, and I suspect that even after the fourth or fifth time I was still learning the nuances of the illness.  Likewise for the training of interns; there is much to be said for the educational value of teaching someone else.  It served as an acute learning tool for me; one had to be on their game every day in morning report, on rounds and while on call to be able to answer the questions that would invariably come up.  Most of what I learned as a pediatric resident was during my second and third years of training.  There would have been a large gap in my knowledge and competence had the third year been scuttled.

What might be the reasons behind such a proposal to decrease residency time?  Emanuel and Fuchs state that this shortened time frame would

• “enable physicians to recognize their limitations as well as their competencies; (as I stated above, one less year of training certainly would have enabled me to find my limitations quicker once out in practice…I’m not sure this is helpful to patient care)
• “enable physicians to use evidence more effectively to improve care; (laudable on its face but could be construed as a call to encourage physicians to not individualize patient care and force a “one size fits all” approach to medicine)  
• “enable physicians to become comfortable with group decision making, standardization of practices (see second bullet point above), task shifting to non-physician providers, and outcomes measurement.” (this might be the crux of the issue, to take doctors down a notch and remove them from their traditional role as the ultimate authoritative decision maker in the health care team.  If they feel less confident in their training and skills then they may be more likely to look towards a team approach that may have other motives (think financial) than what is best for that specific patient.)

Looking at the broader picture, what does this mean for medical education in the future?  What I suspect is going to happen is that medical school and residency training will be further and further shortened until the line between a doctor and an advanced practice nurse is so blurred as to not be distinguishable whatsoever.  I also suspect this has been the agenda all along of those who will be paying for medical care in the future under a single payer system.  Cheaper medical costs, but at what cost?

Dr. K

New York City Department of Education??? Get a rope...

The New York City Department of Education recently released a list of subjects not to be placed on city-issued tests.  “The forbidden topics were recently spelled out in a request for proposals provided to companies competing to revamp city English, math, science and social-studies tests given several times a year to measure student progress.”  For a full list of the topics, see here.  Some of the topics include:

• Gambling involving money and in-depth discussions of sports that require prior knowledge.  (This would apparently render useless the time Johnny has spent filling out his March Madness bracket.)
• Vermin (rats and roaches) and politics (clearly the Department didn’t catch the redundancy here)
• Bodily functions (such as thinking, obviously)

This is not necessarily a right-left political issue; it would appear that this bureaucratic edict is an equal-opportunity offender.  It does seem to be a case of political correctness run amok; many of the issues on the list would seem to be some of the prime issues to discuss in a social studies test, for example.  It appears that a main motivation for the list (and there are many such lists around the U.S., just not as lengthy as the New York one) is to spare the test-takers any undue stress whilst taking the exam.  I’m not clear as to why a question about dancing (though ballet is okay) would be stressful, but that’s just me.  I’m not an educator. 

Bottom line here- when do our kids become exposed to what don’t even appear to be very controversial subjects?  Do we wait until college?  They’ll need to learn in time that life can be a wee bit stressful at times.  And at some point they will need to learn that there is another world out there with often a different take on things.  I vote for that exposure occurring at least in high school, or even before.

Besides, if we shelter these kids from the list's forbidden topics such as dinosaurs, creatures from outer space, celebrities, rap music, or parapsychology, then the tactic of having the National Enquirer at every checkout stand as a study aid for tomorrow’s test will have been totally in vain…

Dr. K

Ye are the salt of the earth...or were.

Dr. Rich Fogoros has been blogging here and here about the looming restrictions on sodium by the federal government (urged on by public health experts) that will spell the doom for those of us who like to sprinkle that extra bit of salt on our baked potato.  When he came out with the posts about a year ago I considered this to be more likely bombast and Chicken Little-ing by the usually astute DrRich.  To maintain the bird metaphor, I would like to eat some crow. (Salt-free of course)  Salt restrictions have already reached middle-town America. 

 

It seems that the USDA has released new guidelines for school lunches that dictate a gradual decrease in the amount of allowable sodium until there is only half the amount of sodium slated to be in school lunches by the year 2023, compared to current guidelines.  This little kernel of info is found buried on page 10 of the guidelines.  Don’t worry though, the guidelines do state that “Extending the timeline…gives the food industry more time to reformulate products, and gives school children more time to grow accustomed to foods with less salty flavor.”

How magnanimous!  The USDA is allowing our kids more time to get used to the bland food that will pass as edible fare…to paraphrase a line from Meridith Willson's "Music Man", the food will be "plainer than a Quaker on his day off"!

Why, just last week my wife was discussing the vagaries of school lunches with some colleagues when someone in the group brought up a vignette that was too funny and perhaps too sad to ignore.  It would appear that the meals served in the high school cafeteria already are meeting some of the standards for sodium restriction anticipated in the future.  Will our kids “grow accustomed to foods with less salty flavor”?  Unlikely.  Some of the kids who eat at the cafeteria have already figured out how to have their salt and eat it too.  They have taken to going to the friendly neighborhood McDonald’s and carting out the tiny salt packets to sprinkle on their government provided sodium-free lunches.  I’m almost afraid to post this; who knows if the kids will be frisked for contraband salt in the future if this scheme takes hold.

The issue here is wholesale population restrictions on sodium consumption without knowing the effects this may have on the health of said population.  Not to mention the reach of the federal government into our lives and those of our children.  I understand the reasons for salt restrictions for those with pre-existing hypertension, but I’m not sure the same principle applies to all of us, across the board. 

Besides, as the sneaky little high school lunch eaters have shown, if you want my salt shaker, you’re gonna have to pry it out of my cold, dead, salty hands…

Dr. K

  

Spanish in the medical setting...Accommodating or enabling?

As I walked into the exam room, the beautiful staccato rhythm of the Spanish language reached my ears.  I knew that this visit was going to be like the majority of my visits this morning, conducted in the family’s native tongue.  I would usually tease them as I entered, asking them, “¿Inglés o Español?  “¡Español!”, they would invariably cry.  The next question would follow (in Spanish, of course)-How long have you lived in the United States?  Something in the realm of 10 to 20 years would be the customary reply.  Just out of curiosity, I would inquire as to why they hadn’t learned English yet.  Too hard or not enough time was the usual sheepish reply.  I then would tell them that that couldn’t be an excuse; that I lived in Chile for only two years, well over 30 years ago, and I was speaking a fluent Spanish.  Then I would tell them that English couldn’t be that hard to master; I learned it when I was just a kid…

This vignette was played out many times in my career as a pediatrician.  As a resident in San Diego and in my practice years in New Mexico and Arizona, I had ample opportunity to hone the Spanish I had learned as a missionary in Chile from 1979-81.  There would be times in clinic when I would spend virtually the entire day communicating in Spanish.  This wasn’t and would never be a problem for me.  I was glad for the opportunity to be a resource for these families that needed the rapport necessary to communicate their medical needs to someone.  I never felt that the medical office was the place to worry about the immigration debate and I went along my way collecting cherished memories from some of my favorite patients and families.

I was reminded of these episodes in my career the other day when I was discussing the Puerto Rico Republican primary with a close friend.  Rick Santorum stepped in the euphemistic “it” politically there when he averred that Puerto Ricans should learn English in order to be admitted into the Union.  My friend was of a similar mindset, believing that the ability to communicate in English is an important aspect of living in the United States.  I can't disagree. Now, I'm not convinced that the United States as we know it will cease to exist if folks don’t learn English.  Besides, the latest census shows that fully 97% of us speak English already.  I will admit that not being able to speak English will make it difficult for this bunch to assimilate into society and it does indeed make navigation of the health care system more precarious if one doesn’t speak the lingo.  I also think that this demographic should be responsible for providing a translator for their personal needs.  It shouldn't be an imposition upon each doctor or clinic provider to be required to pay for this expense.  If they wish to do so for better customer service, so be it.  On the other hand, do we need to mandate that everyone speak English or punish those that don't? 

Creo que no.

Dr. K