Public Health and Pediatrics

The failure of sex ed in NYC

The mantra of the sex education crowd for years has been that if we only taught these sweet little cherubs the intricate details of sex and the downside of teenage pregnancy that they would catch the vision of proper precautions and the teen pregnancy rate would decrease.  Well, the enlightened ones got some sort of come-uppance the other day.  It seems that the New York City school system has been handing out “Plan B” emergency contraception for the past year, in an attempt to decrease the teen pregnancy numbers afflicting the system.  Plan B is a “backup” plan that consists of one tablet of levonorgestrel that helps prevent pregnancy after unprotected sex or birth control failure.  It seems that over 7,000 teenage girls became pregnant last year in New York alone, with the majority dropping out of school.  Sixty four percent of these pregnancies ended in abortion. 

The New York City school system had to do something.  What they did seems to me to be a tacit admission that sex education programs don’t or can’t deliver on their promises.  If they did, then there wouldn’t be a need for this Plan B. 

What’s next, RU-486 (the abortion pill) prior to gym? Or a walk-in abortion clinic after chemistry class?  And why even have sex education at all, if this is where it is going to lead?

 

Dr. K

Why Johnny and Suzy are so fat...because it's too easy!

If we were going to devise the quickest way to increase the fatness of our children, where would we go for inspiration?  I do believe that the science of seeing how quickly we can turn our children into tubs of lard just took a quantum leap forward with something that I saw some children toting around the other day.  It seems that a candy product called “Liquid Lollipop” has become the rage, at least in my little burg.  I did some research on this stuff and it appears that it has been around since the 80’s, but that it is enjoying a resurgence of sorts nowadays.  This glop is fruit-flavored corn syrup in a clear, plastic tube that has a rounded end with a small hole in it that your little ones will suck out as they squeeze on the tube like a roll of toothpaste.  Each tube contains over 300 calories, with the proviso that each tube consists of 3 servings. 

Right. 

Like a kid is going to share his Lollipop booty with two other sugar-addled bambinos…

Now I’m not one to denigrate the joys of a well-baked pastry or the nirvana of chocolate done well, but this seems to me to be the nutritional equivalent of mainlining heroin for the pure sake of a sugar rush.  What are we going to see next, little Johnny wandering around with a sack of sugar slamming down tablespoons of the stuff?  Where is the creativity here?  Shouldn’t our posterity’s gluttony at least have some sense of ingenuity?  If our children are going to die of a horrible obesity-related death, shouldn’t it be due to something that we can be proud of, like éclairs or crepes?  This smacks (smacks…get it?) of our society taking the easy way out.  I say, if we are going to go to hell in a hand basket (of sweetbreads, of course), then I say we outlaw this Liquid Lollipop and take our obesity seriously.  No cheap corn syrup drizzle to pacify our kids; we should demand quality such as Häagen-Daz or Godiva’s.  What do you say?  Are you with me?

Sweet…

 

Dr. K

“You’d better behave or the doctor is going to give you a shot!”

How many times have you heard this refrain?  This is likely number 1, or at least 1A on my list of irritating things a parent would say to their kids during a visit to our pediatrics office over the years.  The kiddos are often scared enough as it is; they don’t need their parents, the ones they likely trust the most, to conjure up a vision of an evil doctor filling a 3 gallon syringe with a 2 foot stainless steel needle filled with who knows what.  All the while ready to plunge it into any misbehaving miscreant of a child at the slightest provocation. 

 

 

Why would a parent say this?  For some reason I don’t think it started one day, many years ago, when some mom told her kid to behave and when the little tyke didn’t, the doctor piped up and said, “You know, I have just the thing to make that little turd shape up!” and proceeded to call in his large, beefy, nurse to whip out a needle and plunge it into the derrière of the reprobate child.  Thereupon, the mother, seeing this wonderful discipline technique, proceeded to spread this new gospel far and wide, where it has stuck in the consciousness of  America’s mothers ever since.

I suspect the more likely reason is because their parenting skills are so stunted or they are so lazy that they can only elicit good behavior by threatening their children with made-up images of bogeymen in every aspect of their children’s lives.  I wonder what else they say to their offspring throughout the day-

“You’d better behave or that taxi is going to come over here and run you over!”

Or…

“You’d better behave or that cook is going to come over here and scald you!”

Or even…

 “You’d better behave or that lifeguard will drown you!”

 

What I often found myself wanting to say was, "No, Johnny, I'm not going to give you a shot, but I might have to give one to your idiot parent."

At any rate, this is not the best way for parents to encourage the establishment of a nurturing, safe, and effective medical home.  It is more likely the way to encourage the same behavior in the next generation.

 

Dr. K    

The on-call blues, or why one might opt for another line of work...

The 2 am call jolted me out of a deep, peaceful slumber. There might have even been a snore going on there. “Hello?” I mumbled. “Is this Dr. K?” the disembodied voice queried.

“Yes, how may I help you?”

“You said to call if he got a rash.”

“Um, who is this?”

“Johnny’s mom.”

“Johnny who?” (There were probably 6 Johnnys in the practice)

“Johnny Smith.” “What does his rash look like?”

“Faint red, on his arms and face”

“How is he acting now?”

“He’s playing in my arms. But now I can’t get him back to sleep. He’s wide awake.” (That makes two of us, I thought)

“I really don’t think it was necessary to call me for this at this time of night. It would be better to call the office in the morning”

“Well, EXCUSE me for bothering you!” came the frosty reply as the sound of a phone slamming down assaulted my ears.

I tried to drift back to sleep with a thousand thoughts running through my head. My lovely wife rolled over and murmured “You really weren’t very nice with that one.” Since she hardly ever commented on my phone etiquette, I knew I had been abrupt. I made a mental note to call the mom in the morning with an apology. And so I did.

Even after more than a decade of being on call, I still wasn’t used to the grind that it places on one; the tether that ties a doctor both physically and psychologically. I have always had a difficult time describing this to a lay person. Even those closest to me have not been able to fully grasp how the toll that being at the beck and call of patients and their parents wears a body and mind down. Many times I would opt out of going to a family or social function knowing full well that I would be called out at any moment, or that the potential just existed. Knowing that specter was out there in the ether somewhere was enough to squeeze the potential fun out of many an outing. Nighttime on the weekend was even more onerous. Saturday and Sunday nights seemed to be filled with panicked moms for whom the thought of waiting until Monday morning filled them with dread that the sniffles would blossom into full-blown pneumonia (or even worse-DOUBLE pneumonia).

“Hello, who is this?”

“Sue Jones’ mom. She was seen by Dr. X today in clinic. She still has that fever. The medicine he gave doesn’t seem to help.”

“What medicine was that? What was it prescribed for?”

“It should be right there in front of you. It’s in her chart.”

“Um, ma’am, I’m at home. I’m not in the office.”

“Really!? I thought you answered these calls from the office.”

“No, I don’t. I have to go home at some point in my life.” (I really didn’t say this, only felt it)

This was one of the reasons for exiting the field of pediatrics altogether. The demands placed on the practitioners of this art were quite enough for me. I would let someone else field the calls that made such a difference in the lives of our little patients so often.

 “Hello, this is Dr. K.”

“Hi, my son just spit up and it looks like curdled milk…”

Sigh, here we go again.

 

Dr. K

A fairy tale about WIC and illegal immigration

Once upon a time in a country that shall remain unnamed (but it rhymes with Barizona), there was a federal program known as WIC that provided foodstuffs for women who were pregnant or had small children.  This program, with origins dating back to at least 1972, had been a resounding success in the state as numbers of clients steadily increased over the years.  However, a lady was elected queen in 2010 and knights of the legislative round table came to her and suggested that there be placed guards around the kingdom to prevent people from other lands coming and stealing from the citizens.  She indeed did agree and a decree was made that such guards be placed and thus they were.  In time this resulted in many of the people from other lands leaving and going back to their home kingdoms. 

When this happened the lords of the WIC realm realized that the numbers of citizens petitioning for WIC benefits dropped precipitously.  Faced with this calamity, there was much weeping, wailing, and gnashing of teeth amongst the WIC minions as this was interpreted as a failure of epic proportions.  Much of the WIC treasure was then spent urging all citizens of the land to sign up for WIC if they possibly could, since it made no sense that a benevolent government organization should LOSE clientele.  And the loss of clientele meant possible loss of employment for WIC workers. 

Lost in the swirling controversy was the point that the decree had unearthed the fact that many of the previous WIC clients had indeed been citizens of other kingdoms, and had been stealing treasure from the good country of Barizona and the Empire to which she belonged. 

After this episode, the good citizens of Barizona were left to ponder the following:

1. Is it wrong for people from other lands to rob from our treasure?
2. If there is less demand for a government service, is that necesarily a bad thing?

And they all lived happily ever after…

 Dr. K

The doctors and the terrorists

June 7, 2012 dawned in Florencia, Colombia as it usually does, hot and muggy as our team readied itself for the day’s teaching.  We were a bi-national team consisting of two pediatricians, an anesthesiologist, and a NICU nurse from the United States and a neonatologist and a pediatrician from Colombia.  We were volunteers in a program sponsored by the Church of Jesus Christ of Latter-day Saints that brings the American Academy of Pediatrics Neonatal Resuscitation Program to countries such as Colombia; we teach doctors and nurses in-country so they can perpetuate the same for their fellow professionals.  This area of Colombia has a relatively high rate of neonatal mortality compared to the rest of the country so it would make sense to provide this training at this place, at this time. 

 

 This part of Colombia is still partially under the influence of the FARC, the insurgency guerilla group that has fought the Colombian government for decades.  Considered a terrorist organization by many countries, including the United States, I became more acutely aware of the lengths they will go to exert their influence in the area.  

 When we arrived at the training site that morning, someone breathlessly told us what had happened late the night before.  A few miles from the city a woman had gone into labor late into the night and as she began to have complications, her lay midwife called for assistance.  An ambulance was dispatched with the requisite police escort in that part of the country.   The guerillas got wind of this mission of mercy and ambushed the party as they arrived at the woman’s house.  They killed the police, the ambulance crew, the midwife, the mother, and the newly born baby.

 When I heard the story, I was saddened and struck by the incredibly ironic juxtaposition of our mission to Colombia and the aftermath of the horrible slaughter that took place just ten miles away.  It is hard to fathom the disregard for human life that permeates this struggle on both sides of the equation.  The army and the police have participated in acts often as heinous.  

 What does one say to this?  I laud the heroism of Gloria Martínez and Julio César Ramírez, the Colombian docs who have been teaching the NRP course for years now, reaching over 1,300 of their fellow professionals as they selflessly give of their time and resources to help Colombian children reach their full potential.  In the end, I was left also to appreciate the strength of the Colombian common man, who has struggled to eke out a life in the middle of this maelstrom that has gone on for decades.  He continues to live, laugh, love, and especially dance in spite of the violence that often swirls around him. 

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

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  

 

Issue of the day: Obesity problem or Medicaid entitlement mindset?

The 44 ounce Super Big Gulp from 7-Eleven was almost invisible, lost in the folds of her massive upper extremity.  Its cool condensation left a trickle of cold water trailing along her considerable forearm.  The look of incredulity on her red, puffy, irritated face was designed to intimidate María, our intrepid front desk person, into waiving the $1.00 Medicaid co-pay for her child’s visit that morning. 

Yes, this mom was a well-known clinic regular.  And yes, she was asked for this co-pay every time she presented to the office.  For some reason she picked this day to dig in her heels and argue the finer points of Arizona’s Medicaid co-pay policy with our overworked staff.    Our María wasn’t having any of it.  She was a feisty bulldog when it came to these matters and she succinctly directed the mom to go out to her vehicle and scrounge up four quarters. 

In a huff the mom turned to stomp out the door, re-adjusting the bra strap that was peeking out of her sizeable tank top as she went.  Her sandals flapped loudly as she grabbed her child roughly by the arm and lifted her up.  The staff cringed as they contemplated the specter of a nursemaid’s elbow being generated right before their very eyes, but luckily for the daughter at least this did not ensue. 

After searching in the blue Dodge Caravan that the clinic staff had grown to know so well, she came back in with a dollar that must have been crammed in the front passenger seat since the first Bush administration.  She waddled back up to the counter and threw the bill towards María.  “There, I hope you’re satisfied!” she loudly proclaimed.  As a matter of fact, María was.

The mom went back to her seat in the waiting room.  The chubby daughter, who appeared have been cut from the same genetic cloth, whispered something to her mom, who at full volume told her: “Not now, we’ll go to McDonald’s after we see the doctor about why you are gaining so much weight!

Sigh.      

Dr. K