Friday, January 16, 2015

Selma - Not One for the Ages

We saw “Selma” last night. It is a powerful movie. Young as we are as a country, our mythical events are mounting steadily: Roanoke; the Pilgrims; the American Revolution; the Founding Fathers; Lewis and Clark; Lincoln and the Civil War; FDR and the Great Depression; the assassination of JFK; the Civil Rights Movement; a man on the moon. A short history compared to other countries, but with a sense of mythical mission and many enshrined moments.

I don't know if we have more myths than other countries – probably not, I probably just know them more because I'm an American. We are certainly a self-conscious nation, and it seems a nation given to drama. But in contrast to other nations, we have a command of media that no other nation has in the present day, and certainly far beyond any nation in the past.

Think about the ancient Greeks, just for contrast. They were a people filled with mythology, not just the gods, but the historical Trojan War, and the historical House of Atrius. In that time of low technology, how amazing it is that they preserved their myths for all time. For the Trojan War, they preserved it by oral tradition – oral tradition! They made it into a coherent story, and then they had to remember it, so they used repetitive phrases (“rosy colored dawn”) and most importantly, rhyme – rhyme is beautiful, but it is most importantly an aid to memory. That was their technology in the Mycenaean civilization. The oral tradition preserved the Trojan War epics until papyrus emerged in the classical ancient Greek world half a millennium later, and miraculously, the epics were thus preserved in written form.

At the same time, classical Greece had performance art to present and preserve their myths, not only of the Trojan War, but of the House of Atrius. Luckily for us, although the actual performances of their plays were themselves evanescent, the scripts of perhaps 1% of their plays were preserved on papyrus. It was a small sample, but it is enough for us to appreciate their dramatic sense of themselves.

Then, with the technology of writing on papyrus at hand, the classical Greek world invented history with Herodotus and Thucydides. Without the need for gods, drama, and rhyme, facts as the writer knew them could be approached directly, and causes postulated and probed. The search for facts wasn't then what it is now, but at least direct experience could be accurately transcribed.

Contrast the Mycenaeans and the Greeks to us. How easy it is to collect facts; how easy it is to write about what people have done with a fair degree of accuracy; and how incomparably powerful it is to convey visions with the most powerful instrument for conveying someone's vision that has ever been invented, the movies. A play is one thing, it allows one to imagine that the abstraction one sees on the stage is truth. But a movie is something far more powerful -- it shuts you in a room, dampens any other sensory distractions, focuses your attention on colors and giant images that are as clear as can be, and envelopes you in surrounding sound. There is nothing like a movie. Movies are the most persuasive, impactful, and indelible of any media ever invented. Movies are not only powerful, they are so easily accessible; more people see movies than read books or see plays by orders of magnitude.

So, where does that leave us with the movie Selma. It is, as I said, a very powerful movie. It is professionally done, with some excellent performances, and I think especially excellent camera work. It is impactful. It is in service of one of our most important myths, the Civil Rights movement, and one of our most important heroes, Martin Luther King. The problem with Selma, however, is that it contains a horrible lie. It is factual with the African-American protagonists, but it is terribly wrong in the way it treats Lyndon Johnson. It casts LBJ as an adversary to MLK, when in fact he was an ally. The story of the Voting Rights Act in fact has two heroes, and the film proffers only one.

Now, if you are trying to remember the Trojan War and you have only an oral tradition to use, you might well have to simplify, you might have to create a drama that centers on a central truth, and to invent and distort other truths so that the epic can be remembered and retold. It's something you might have to do. Your mission might not be history, but eternal truths, and to get there you might distort facts, but everyone knows who listens that this is the case.

If you are a historian of the Peloponnesian War, many facts might not be available to you, and you might have to tell only the part that you know to be factual. You might seek to highlight some eternal truths, but you do it within the facts as you know them.

Here in modern day America, we have different conditions from the Greeks. Both traditions continue, drama and history. We have new technologies that make drama more compelling (at least technologically), and we can ascertain historical facts as never before. We also have some of the same limitations – a movie like Selma has to make its money back, and so it needs to be dramatic. It also wants to make its essential points of bravery, glory, personal foibles, internal differences of opinion, etc.

But how far do you have to go in this mission? Do you have to lie? Does drama inevitably have to distort reality? Does drama have to disserve history? And if so, how much? What does “artistic license” entitle you to? (And, how much does artistic license act as camouflage for poor artistic ability?)

I can see the need sometimes to collapse two characters into one memorable character, if they are not the main roles. Maybe it's even OK to say Connecticut was against the Emancipation Proclamation when it wasn't (I actually don't think it's OK, but maybe I'm wrong). I definitely don't think it should be permissible to say that torture evokes information to locate Osama bin Laden when it didn't, that's really a lie that's too important to justify.

The issue is this: in the modern world, drama morphs into history. So many more people see a movie than read the books, and a movie is by nature so powerful, that the movie's “facts” are what people remember as truth. So you can say you have a drama, but you really need to act with the constraint of being reasonably close to history. What is “reasonable” is the point of contention.

To my mind, the lies of Selma are so profound as to be infuriating. They shouldn't have done this. What they have done is to sully the reputation of a great if terribly flawed man, Lyndon Johnson, when what he deserves is the exact opposite.

Selma doesn't shade the truth – Selma lies. Selma depicts Johnson telling Martin Luther King, “Not now. Wait.” This is simply untruthful. We have documentary evidence, we have recordings(!) of their conversations where LBJ tells MLK to find the best examples he can of the injustices laid on the African-Americans and publicize them, and the people will see, “That's not fair!” And then Johnson can deliver. That's what LBJ says.

We have the truth from Robert Caro's LBJ books – the truth is more than available. LBJ rose from poverty and the disgrace and financial decline of his father, from his own deficient education, to become adopted by the Southern masters of the Congress, and to lead and command the Congress as no one ever had. He worked as hard and as skillfully as anyone has ever worked in politics, and when he got to the top, he double-crossed his mentors. While they supported continuing the status quo and segregation, the LBJ of his boyhood turned on them, skillfully and with some compassion, but he turned on them for what he knew was right. Having risen by dint of their patronage, he now led the nation not toward their way, but toward the way of Martin Luther King. He threatened and cajoled and got the most significant civil rights legislation passed in over 100 years – and anti-poverty legislation as well.

But what do we see in Selma? We see a limited, self-interested man in cahoots with J. Edgar Hoover, of all people, which is just not true. In fact, Hoover was an insubordinate opponent to be outwitted and ultimately overpowered, with great skill and even bravery from LBJ.  We don't see the conjunction of two stars, the preternatural leadership genius of the young MLK who has known only one way, and the older genius LBJ who has led the more tortured and circuitous way to greatness. I'm sure it's harder to make a drama with two stars coming together, rather than one star with an adversary. Maybe the writers of Selma weren't up to it. But the way it is, it's a distortion, it's a desecration of LBJ, and it's a desecration of the truth. Even if our view of LBJ doesn't have the policy implications of Zero Dark Thirty's utility of torture distortions, it's still important.

It's true that the Civil Rights movement deserves to live in the mythology of the nation. The Black heroes of Selma deserve to live in history and myth. But because of taking the easy way out and gratuitously desecrating a white man who was a true hero of civil rights, this film is truly, truly misbegotten.

The Greeks would have done it better.

Budd Shenkin

Saturday, January 10, 2015

A Prominent Academic Specialist Denigrates the Periodic Physical

Is the advice of a skilled medical professional who knows you, cares about you, and sees you regularly, worth anything? According to one of the NYT's anointed medical columnists, Ezekiel Emanuel, the answer is no.

It will be hard for me to obscure my disdain for Zeke Emanuel. His arrogance is apparently familial. He doesn't seem to question his blinkered viewpoint of an academic administrator, an academic specialist as an oncologist, and his reflections on his role in shaping Obamacare seem always to be defensive – what we did was unalloyed good, and the best that could be had. He must be a politician of the “admit no mistakes” school. Although everyone does admit that he is smart, I have to say.

Zeke argues in this article that the yearly physical is an invalid procedure, something to be avoided. He says that “research shows” that little significant disease is discovered – “the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.” He casts doubt on the value of early detection of disease. He implies that too many tests and studies are ordered by the doctors at a yearly physical. He says that these visits drive up health care costs. He compares the visit to an automobile service, but with fewer positive results. He denigrates the value of the doctor-patient relationship.

What a turkey he is.

First, let's look at research. If you want to prove something is worthless, the best tactic is to posit an end result that is either impossible, impossible to measure, or just not the reason that the thing is done in the first place. And if you are to practice sophism, make sure you simply assume that the goal of the procedure is what you want, not what the practitioners want it to be.

So, Zeke – remember, he is an oncologist who treats severe disease – assumes that the primary goal of the annual physical is to detect cancer (or, possibly, heart disease or something else) early. Then he says there is no evidence that the annual PE does this, and that screening asymptomatic populations is not a good procedure. Yes, Zeke, it's not good for cancer detection – except for mammograms and Pap smears, and I would say PSA in the hands of good doctors. Not that early detection doesn't happen – it does, it does, and it can save lives. Maybe not “cost effective,” but that's another argument. But Zeke – that's not the purpose of the periodic PE.

The purposes of the periodic PE are several. Health promotion and prevention are important objectives – maddeningly derided by Zeke as something he can do himself. Surveys show that the leading motivation for smoking cessation is recommendation by a doctor. Yes, we know “we should.” But when a doctor talks, we listen. Likewise for weight loss, exercise, and healthy eating. Zeke might say “I don't need no stinkin' primary care doctor,” but most of us really do.

Moreover, where exactly are we supposed to find out if our cholesterol and/or our blood pressure are too high? Careful questioning and screening can reveal depression, a condition with high prevalence, and eminently treatable. Alcohol addiction can be detected and discussed and treatment begun. Even as a general pediatrician I routinely inquire about the state of the parents' marriage, knowing that this is the most consequential condition for child health, and that once again, intervention can make a difference.

Measuring the results of health promotion and prevention is terribly difficult. In cancer it's pretty easy to distinguish useful from worthless therapies. But healthier lives are hard to identify in themselves, and the effects of prevention can be felt so far in the future that research can fail to find it. No one has done in depth studies of the results of close relationships with a primary care doctor, and I don't know how it could actually be done. For Zeke to place the onus of proof of effectiveness of primary care on those who practice it, according to his own rules of science, is outrageous. Prove that a caring parent is necessary for a child, why don't you, and banish them all to orphanages if you don't find that it is cost-effective. His “science” is suited to him, and he wants to use it on everything, which just coincidentally puts him in the driver's seat.

Actually, probably the worst sin of Zeke's jeremiad against PE's is his denigration of the doctor-patient relationship. Particularly in our world today, what is the value of being cared for? What is the value of having a serious professional who knows you well and who cares, who is on your side, paying attention to you, and helping you with your health in sickness and in health? The cyber-billionaires contend that 80% of what a doctor does will be supplanted by computers – you think? You think that what a doctor does is to reason all day? This is personal, gentlemen. We have a need to be cared for, and this is not irrational. There are choices to be made, there are feelings to be accounted for, and one size does not fit all, at all.

Finally, how specious is the cost of care argument! One of the first things I learned in the Public Health Service was, if someone says they can't do something “because of the budget,” it means they don't want to it. The budget is generally an excuse. In health care, we know that high costs reside in specialist care and hospitals – and remember, “costs” are related to “price,” which is highest by far in the US compared to Europe, probably especially in cancer care for all I know – not in primary care. Cut costs in primary care and you have accomplished very little except degrading quality, Zeke. Look to your own institutions if you want to cut costs. Gore your own calf, why don't you.

Let's once again revisit where Zeke sits – he is an influential voice in establishment medicine. All too many establishment policy makers truly believe his self-interested point of view. Prevention and health promotion are not sexy and not remunerative, and not what the academic centers interest themselves in. Training for prevention and health promotion in internal medicine and even family medicine are usually deficient. Even in these potentially primary care producing training programs, more and more subspecialists continue to be churned out, with fewer and fewer primary care docs. As a result, fewer and fewer practicing primary care docs have less and less time, training, and attention to spend on periodic PE's.

The biggest structural problem in the health care system of the United States is too much specialty and not enough primary care. Zeke Emanuel would do well to support primary care docs in their tasks rather than to attack their rationale.

Budd Shenkin

Saturday, December 20, 2014

Businesslike Healthcare

Paul Levy has another interesting post:

In it he recounts the the practices of Heartland Regional Medical Center, of St. Joseph, Missouri. Basically, Heartland is the Scrooge of healthcare. They pursue debts with a fervor and an unfairness that is hard to fathom. Someone gets sick and comes to the hospital, fails to sign up for the hardship program that would reduce charges, and thus becomes ineligible to sign up when the program is eventually discovered, because they didn't start out as members of that program. Because there is a cap on how much they can recover from one paycheck, Heartland sues both wife and husband to get a part of each paycheck. Etc.

It's bad enough when corporations in other fields pull this. But in healthcare? Yes, healthcare needs better business methods. But when you think about it, "businesslike" seems to have two separate lines of thought, even two different meanings. On the one hand, good business is knowing your costs and recovering them, producing a better product, increasing efficiencies, etc. On the other hand, business practices can be rapacious, grab the money, go for the gold, do whatever it takes, etc. When people say that healthcare should be “run like a business,” mostly they mean #1, not #2. But if you confronted Heartland, odds are they would say “we need to run it like a business,” and mean #2, not #1.

Reading this reminded me of the dinner I had last Wednesday with two healthcare consultants and my long time close friend, Steven Wright, who is at once idealistic and ethical, and a practical and effective healthcare manager. Steven has run many programs in the mental health and alcohol and drug areas, and inevitably takes a failing program to effectiveness and profitability. He most recently did this with Thunder Road, an Oakland program for troubled youth. He brought this program to effectiveness and profitability, although a program in this field will never be a big winner – just breaking even is an achievement. Unfortunately, bringing the program to profitability was soon met with the declaration from Sutter Health, the owners who inherited the program, that Thunder Road had to be sold, because it didn't fit in with what they were trying to do, maybe didn't fit with their “core competencies.” The health consultants we were dining with nodded with sad and knowing assent. They know healthcare corporations like that.

(It reminded me also of the new owner of The New Republic, a magazine that had never run a profit and was never intended to. Let's go vertical, let's go digital, let's go Silicon Valley, said the billionaire owner who had been the roommate of Mark Zuckerberg at Harvard. Let's make money. Ambitious, arrogant, steeped in the modern digital culture that produces greedy young jerks. But I digress. Let him be a jerk, and I never liked The New Republic that much anyway. Maybe he'll learn something.)

But you just have to think, is profit an objective, or a constraint? If your objective is to help people one way or another, then profit can be a constraint – you can serve people, but only with the constraint that you can't lose too much money doing it, or you will go out of business and help nobody. If, however, it's the reverse, you then want to make as much money as possible, with the constraint that you do have to help some people along the way. Or at least not hurt them too much. Or at least not get caught hurting them too much, which would then start hurting profits.

So, if I look at a healthcare program, I have to think: OK, run it in a businesslike fashion, but is it businesslike #1, or businesslike #2? Are they doing well by doing good, or just doing well? The difference is pretty important.

Budd Shenkin

Sunday, November 9, 2014

How Sibelius Lost the Election

Election results are influenced by so many factors that interpretation is always necessary, often contentious, and mostly unprovable. While truth might be elusive, opinions most certainly are not. This is a fortunate circumstance for those who opine for a living, and for those conversationalists and bloggers who opine for a hobby, both of whom can be disbelieved, but neither of whom can be disproved. Or, to put it another way, competing for cleverness in interpreting elections can yield profits for some and lots of fun for others.

Thus it is with some humility but little fear of disproval that I offer my simplification as explanation for the November 2014 election. I believe that the Democrats lost the election more than a year prior to the actual voting, specifically on October 1, 2013 and the ensuing week, when the Obamacare .gov website failed. We can't even say “crashed,” because it didn't get that far. Instead, it just pathetically sputtered in anguish for weeks, and thus confirmed the public's worst fears about government and about Democrats – which is, that for all the reliance that Democrats put onto government, it just doesn't work.

It was the Republican mantra – largely and shamefully unopposed by the Obama Administration and Democrats in general – that Obamacare wouldn't work, that it was poorly designed, but also that government itself just can't be relied on. So here was the test – rollout! Places, Action, Camera! If it worked the way it should have, the Democrats would have been able to trot around the track in splendid victory, and their abdication of verbal defense would have been excused by the actual demonstration of competence. There would still have been the publicized failures in individual cases (many false), but they would have fallen by the wayside as cascading numbers of signups rolled in. Glory and Triumph!

Instead, the failure was ignominious. Instead, the Democrats were covered with the excrement excreted by website. There were were promises, there were mutterings, there were statements, there were reports that Obama was “really pissed off.” But mostly we awaited the advent of the A-team and the 60 day fix, wondering why the A-team hadn't been there from the start. It was pathetic.

But actually, even then, with the lurid failure that was the rollout, Obama still could have saved the day. If he was as reported “livid” in private, he could have shown it in public and acted on it. Maybe he didn't want drama because it cuts across the grain of his personality; maybe through the years he has learned not to be an Angry Black Man. But whatever it was that inhibited his rising up to the occasion, it's a shame. If he had declared his lividity publicly; if he had fired Kathleen Sibelius by the end of the week; if he had taken the occasion to declare (as I urged at the time in these pages) that governmental cyber-incompetence was intolerable, and that the site would be up and functioning in 60 days no matter what!, and that he was launching a multiyear effort to make the government cyber-competent beyond all suspicion, and that he was asking Silicon Valley to help him in this the way that industry geared up for the World War II, albeit on a more limited scale – if he had raised the stakes that way, he could have triumphed in the end, and maybe even gotten his approval rating up over 50% by election time. I think it would have worked.

And actually, if he had done that, Sibelius could have come out OK. She could have announced her resignation, saying that it happened on her watch and “mistakes were made,” implying “not by me,” and that she was falling on her sword the way a good commander should. She would have been defended and showered with praise for taking the consequences the way a leader should, and she would not have been the dead meat she is now. She would have “taken responsibility.” Obama would have been “tough.” The government would be seen not to have failed, but to have learned and moved forward, and Obama would have made lemonade out of a lemon.

That's what they should have done. But they couldn't do it. Obama is a cool personality, self-protective and cautious, and truthfully, he lacks the necessary decades of experience to be able to pull it off. And Sibelius is just that good little Catholic schoolgirl who also can't rise up and connect and draw us in. So even though the website actually got fixed, and even though Sibelius actually left in a few months, the damage was done. They were fried, and the Democrats up in 2014 were fried along with them.

Damage happened because suspicions were confirmed. Doubts were sown by the super-aggressive Republicans, and government, truthfully, has failed all too often in recent years. Democrats depend on defending governmental action, and Republicans depend on attacking it as incompetent, and thus call for downsizing rather than strengthening. This background made the dramatic narrative of incompetence believable.

There are other features of the election to note. It seems ironic to me that many of the Republicans who won on Tuesday were businessmen, who, like Mitt Romney, trade on their reputations for being able to “do things.” On the one hand, they say that government can't work, but on the other hand they say that they can make it work. But to the extent that the election shows anything beyond turnout of the elderly white and non-turnout of youth and minorities, it is a rejection of the Democrats, who aside from the key failure of, ran such poor campaigns, just as they had not spoken up for several years now, even fatuously not stating that they had voted for Obama, or featuring how they could and would oppose Obama policies. Sorry, folks, you can't do that if you're in his party. You all have to hang together and sell the policies and push back at the banalities of the opposition. You were politically quite stupid. Stand up, be smart, be counted, and ooze empathy, and you will win your fair share. Retreat, and you will be enjoying private life. Lesson perhaps learned, let's hope.

So, that's my thesis. My hope is for a Democratic regrouping and rethinking not so much of policies, but of public stances. You just have to be forthright and sometimes dramatic. You have to show emotion and determination, and you have to be 'splainer-in-chief yourselves. Nobody is going to give it to you. Chickens do come home to roost.

Budd Shenkin

Thursday, October 2, 2014

Everyone Makes Money Off Of Medicine

Last night at the Goldman School of Public Policy at UC Berkeley – my school! – I heard California Insurance Commissioner David Jones, a very engaging and impressive speaker and person, talk about Proposition 45, which will be on the ballot this year. Prop 45 would empower the Insurance Commissioner to review health insurance premiums for reasonableness, and rescind excessive increases for cause. Far from revolutionary, this power already resides in the state insurance commissioners in 37 other states, and a similar power resides in the California Insurance Commissioner for many other policies, such as auto and home owners insurance. Naturally, the health insurance behemoths have raised $37 million to fight against 45.

It surprised me at first that the California Medical Association has lined up with the insurance companies, as has CAPG, the California Association of Physician Groups, since doctors and health insurance companies are such enemies. Jones opined that the docs probably feared that putting pressure on insurance prices would cascade down to their own fees. Makes sense. It's surprising that the nurses are for 45 – good for them, for a change.

Dean Henry Brady puckishly asked why there needed to be regulation at all, since there are four predominant players in California – Kaiser, Anthem Blue Cross, Blue Shield, and Health Net. Isn't that enough to compete? Answer: no, it isn't. With an impressive show of wonkish economic argot, Jones swatted that challenge away with ease, saying that in lots of fields four isn't enough, that the barriers to entry in health insurance are enormous – just the financial requirements are staggering – so regulation is necessary here. He also gave some pungent examples of unwarranted rate increases that included the ill-advised California Blue Cross increases in 2009 that pushed the ACA over the finish line, a true “what were they thinking?” moment.

But that set me to thinking yet again, who exactly is it that is against health costs rising? Consumers, yes, and consumer groups have raised some money to support Prop 45, although not in the ballpark of the corporations with vested interests. But who else? Everyone in the industry wants a piece of the pie. Even some economists observe the support to employment provided by the health care industry, which is kind of stupid if you think about it, since it is disguised unemployment, really, employing people wastefully where they are not needed.

When Detroit was like this, and everyone in the industry was happy to have prices high (and quality low, but that's another matter), the Japanese realized that ships could carry cars and made a bundle as Detroit hollowed out. I have always thought that health care was impregnable to foreign assault. But I'm now wondering, is it really? There is already medical tourism to Asia for surgery – you get the operation, airfare, luxury hotel, and for all I know, a girl to help you through it (speaking as a guy), and save a bundle in the process. Maybe that's just for starters. Telemedicine is coming, and virtual visits. Radiology is being offshored to India, especially during our night and their day. Telemedicine can be pretty bad as it now stands – a testimonial from an enthusiastic woman in a recent SF Chronicle article raved about how her migraine was gone in hours after antibiotics prescribed via telemedicine. Antibiotics for migraine? But that can no doubt be improved. You never know what people will come up with.

High prices leave an industry vulnerable. Price regulation can be their best friend, fight it as they might. But there is no boundary to the shortsightedness of the health insurance industry, let alone private-spiritedness. It is good to hear that at this point Yes on Prop 45 polls 10 points ahead of No. I think I'll distribute some leaflets up and down my block. That's the least I can do for the American economy.

budd shenkin

Friday, September 26, 2014

Pediatrics and the NFL

So much starts at the beginning. As a pediatrician I'm used to looking at the long curve of life, and trying to help people adjust that curve for their kids at the beginning. We promote physical health – exercise! – and we prevent physical disease – immunize! But beyond the body, we try to promote and prevent with behaviors as well as physical health.

So as a pediatrician, I looked at the recent NFL problems of personnel misbehavior off the field with a weary familiarity. Yes, athletes tend to be spoiled by adulation and indulgence by organizations that hope to benefit from their skills. Yes, their sport is violent. But no, these are not just “dumb athletes.” They are people of good intelligence and character who just didn't get the early training – and pediatric guidance – that they should have.

I looked at the Ray Rice video and cringed along with everyone else. It was clear that Janay was coming at him – she had a lot to say, and it didn't look complimentary. She appeared pretty verbal even in a silent video. I saw Ray's bottled up fury. What could he do? I wanted to yell out to him: “Ray, use your words!”

I know that sounds all touchy-feely and nerdy, and to some ears it sounds unmasculine. Women talk and talk and we men drink beer with each other and grunt and laugh, right? Well, no, not right. Women might be naturally more verbal on average, at least in our society, but men can and should learn to use language instead of physical strength. This can be learned! It needs to be learned.

Parents teach kids to use words instead of fists. Even if the parents themselves lack the verbal and personal skills needed, they can send the kids to preschools to learn to use their words. My own children got a full dose of using words at a preschool that was decidely unacademic, but instead stressed social skills and talking with one another, and conflict avoiding strategies. If Ray Rice had been my kids' classmate, he would have had his teacher's voice in his mind. He would have heard her saying, “Ray, use your words!” And he would have had those words to use right there in his mind.

Then we got the grim news about Adrian Peterson, that wonderful running back whom I had always thought a fine man. My God, hitting his four year old with a tree branch? And then Charles Barkley saying that that's just the way of the South? Did your families never go to a pediatrician? Did you never hear about not hitting children, and in fact not hitting anyone? Hitting with a switch? My pediatrician (OK, also Northern and Jewish) mind just boggles.

Gentlemen, hitting begets hitting. Hit a kid and he will kick a dog, and when he gets older, he will in turn hit a kid and who knows whom else. Do you think fear of bodily harm is what keeps people in line? I'm not advocating guilt and shame, understand, but there are other things that work. Most people turn out like their parents, so setting an excellent example is the most important job of parenting. Discipline can be exacted by direction and attention and by setting proper incentives. The most important of all is positive reinforcement. Catch your kid doing something good, and praise him! Show him. Set expectations, set up consequences of bad behavior that withdraws privileges, give him a time out if you want. There are lots of things to do. But Adrian, and Charles, please, hitting is not the right way.

As pediatricians we try to get things right at the start, to set the curve of life in a positive direction. We try to direct our parents and their kids to positive interactions, to positive child rearing, to verbal self defense and explanation. Maybe it seems wimpy, maybe it does. But maybe some wimpiness is just what the doctor ordered. It sure beats cold cocking the girl you're going to marry.

Budd Shenkin

Tuesday, September 23, 2014

A Well Child Physical for Two Sisters

I had two little girls for check ups, ages 3 and 6, and their efficient-appearing mother. When sibs appear like this I generally do “double physicals” – that is, sisters together. That's always a nice thing to do, do it together. You can cover the things that apply to both, you can take a topic and make one comment for age 3 and another for age 6.  This is the way a mother thinks, anyway: column A for one and column B for the sister.  You can compare and contrast.  You can watch how the family interacts. It's a nice family thing.

So I didn't hurry; I felt like doing a really good job. They were nice little girls.  The 6 year old maybe wants to be a doctor, so I showed her how to wash her hands before you see your patients. I talked to them quietly and with some humor, as is my wont. I had them jump together. I asked the 6 year old to show the 3 year old how to hop, which she did quite well. I did some developmental queries, which were normal. I asked them both if they pooped every day, and if they had belly aches – they did, and they didn't. We looked at the growth charts, which were normal.

I imparted wisdom. I told the mother how we can say all we want to, but most of our children's behavior will mirror our own. If we are nice to people, they will be, too; if we are mean, so will they be. In the end, our knowledge of our impact on our children is a prime motive force for us to clean up our own act.

I asked them if they could swim – a prime safety concern. They can't yet. The mother can, however, which is good. I sympathized how it is hard to mobilize to get to a pool, lessons, etc., but opined that it was worth doing, and why. I asked about physical activity, which they get a lot of. I asked about screen time, which is limited in their house.

The mother objected when I tactfully examined the 6 year old's pubis while she lay down, saying she didn't want males to look there with her kids, and she didn't know why she had been assigned a male doctor. I told her that I get a little edgy examining the older girls myself, and usually urge them to switch to a female sometime after 11 years old. But while it's important to be careful – Uncle Phil might not be a safe babysitter – here we were with a doctor and being chaperoned by her, the mother. I thought it would be important for the girls to be able to feel safe with a trusted male, for their own future benefit. I hoped the point got across.

I took my time with the visit, not rushing, although you can never cover everything. I felt that I was really doing a good job with them. And then I said, “Is there anything else you would like to talk about?”

To my surprise, the mother responded, “Actually, I didn't know it would all take so much time. I thought I would just get the form signed and get out of here. Are you done?”

“Yes,” I said, “sure. I do think it's important for you to feel that you have a trusted source of care to come to here at Bayside.” In other words, there is something at stake in making a personal connection here.

And she said, “I do.”

“And I hope that the girls feel secure with their source of health care also.”

“Yes, they do,” she said.

So that was it. Kinda funny. There are forms people need filled out, and we take advantage of that obligatory visit to foist good health care upon them. Who knows, maybe I did some good. Who knows?

Budd Shenkin