Child Anxiety

As a pediatrician I have known that child anxiety is important to detect and talk about. I have seen a lot of anxious parents, and a lot of anxious children, and not very surprisingly, the two seem to travel together. I'm prone to anxiety myself, which is a pain, and I also seem to provoke it in myself. Somewhere I seem to think that if I'm not anxious, I'm not doing my job, or I won't do my job, or I won't get ahead.

Actually, I think I get it most from my father, although I could be wrong. I think I got it as I got older, but didn't have it at the start. As I think of myself in fourth grade, for instance, I can't remember being worried, or concerned, or anything, really. I remember mostly thinking that this is the best grade there is – we were the top grade in our assembly and I was the Student Council representative, but when we got to fifth grade we would be the youngest in the new assembly. So I was taking it for what it was – King of the Hill for the year. No anxiety there, none at all. That came later, mostly at college, I think.

But I digress. A pen pal of mine on the SOAPM listserve, Dick Schwartz, a veteran pediatrician from Virginia, posted this the other day. I liked it so much I'm passing it on here. With a thought. Isn't this important? If you took your kid to Dr. Schwartz, and he detected that your kid was anxious, and he pointed you to this way of dealing with it, wouldn't you be grateful? Don't you think this could change part of the course of childhood? Don't you?

And yet, do you realize that this detection, this conversation, this treatment, all of it, would go completely undetected by the Quality Police? The pediatric QP look for all sorts of things in a practice – immunization rates (important), lead testing rates (unimportant), chlamydia testing in teens (not very important) – lots of things that are (1) routine and (2) measurable. Surely, there is a need to measure quality, and if there is a need, there must be a way to do it. But is there a way? Well, there is and there isn't. You can detect some things, but some of the most important and life-changing things, are those you can't detect and you can't measure. So you have to rely on the professional diligence of your doctor.

Dick's patients are very lucky to have someone as diligent as he is. I was diligent, too. I like to think I made a difference for my patients beyond giving them shots, and maybe I did. I dunno. I hope I did.

But I digress once again. Let's just look at what is suggested for the anxious child. Makes a lot of sense to me.

Dealing with Child Anxiety? 9 Things You Can Try

by Renee Jain on March 24, 2015

As all the kids line up to go to school, your son, Timmy, turns to you and says, “I don’t want to take the bus. My stomach hurts. Please don’t make me go.” You cringe and think, Here we go again. What should be a simple morning routine explodes into a daunting challenge.

You look at Timmy and see genuine terror. You want to comfort him. You want to ease the excessive worry that’s become part and parcel of his everyday life. First, you try logic. “Timmy, we walk an extra four blocks to catch this bus because this driver has an accident-free driving record!” He doesn’t budge.

You provide reassurance. “I promise you’ll be OK. Timmy, look at me… you trust me, right?” Timmy nods. A few seconds later he whispers, “Please don’t make me go.”

You resort to anger: “Timothy Christopher, you will get on this bus RIGHT NOW, or there will be serious consequences. No iPad for one week!” He looks at you as if you’re making him walk the plank. He climbs onto the bus, defeated. You feel terrible.

If any of this sounds familiar, know you are not alone. Most parents would move mountains to ease their child’s pain. Parents of kids with anxiety would move planets and stars as well. It hurts to watch your child worry over situations that, frankly, don’t seem that scary. Here’s the thing: To your child’s mind, these situations are genuinely threatening. And even perceived threats can create a real nervous system response. We call this response anxiety and I know it well.

I’d spent the better part of my childhood covering up a persistent, overwhelming feeling of worry until, finally, in my early twenties, I decided to seek out a solution. What I’ve learned over the last two decades is that many people suffer from debilitating worry. In fact, 40 million American adults, as well as 1 in 8 children, suffer from anxiety. Many kids miss school, social activities and a good night’s rest just from the worried thoughts in their head. Many parents suffer from frustration and a feeling of helplessness when they witness their child in this state day in, day out.

What I also learned is that while there is no one-size-fits-all solution for anxiety, there are a plethora of great research-based techniques that can help manage it — many of which are simple to learn. WAIT! Why didn’t my parents know about this? Why didn’t I know about it? Why don’t they teach these skills in school?

I wish I could go back in time and teach the younger version of myself how to cope, but of course, that’s not possible. What is possible is to try to reach as many kids and parents as possible with these coping skills. What is possible is to teach kids how to go beyond just surviving to really finding meaning, purpose and happiness in their lives. To this end, I created an anxiety relief program for kids called GoZen. Here are 9 ideas straight from GoZen that parents of anxious children can try right away:

1. Stop Reassuring Your Child
Your child worries. You know there is nothing to worry about, so you say, “Trust me. There’s nothing to worry about.” Done and done, right? We all wish it were that simple. Why does your reassurance fall on deaf ears? It’s actually not the ears causing the issue. Your anxious child desperately wants to listen to you, but the brain won’t let it happen. During periods of anxiety, there is a rapid dump of chemicals and mental transitions executed in your body for survival. One by-product is that the prefrontal cortex — or more logical part of the brain — gets put on hold while the more automated emotional brain takes over. In other words, it is really hard for your child to think clearly, use logic or even remember how to complete basic tasks. What should you do instead of trying to rationalize the worry away? Try something I call the FEEL method:

• Freeze — pause and take some deep breaths with your child. Deep breathing can help reverse the nervous system response.
• Empathize — anxiety is scary. Your child wants to know that you get it.
• Evaluate — once your child is calm, it’s time to figure out possible solutions.
• Let Go – Let go of your guilt; you are an amazing parent giving your child the tools to manage their worry.

2. Highlight Why Worrying is Good
Remember, anxiety is tough enough without a child believing that Something is wrong with me. Many kids even develop anxiety about having anxiety. Teach your kids that worrying does, in fact, have a purpose.

When our ancestors were hunting and gathering food there was danger in the environment, and being worried helped them avoid attacks from the saber-toothed cat lurking in the bush. In modern times, we don’t have a need to run from predators, but we are left with an evolutionary imprint that protects us: worry.

Worry is a protection mechanism. Worry rings an alarm in our system and helps us survive danger. Teach your kids that worry is perfectly normal, it can help protect us, and everyone experiences it from time to time. Sometimes our system sets off false alarms, but this type of worry (anxiety) can be put in check with some simple techniques.

3. Bring Your Child’s Worry to Life
As you probably know, ignoring anxiety doesn’t help. But bringing worry to life and talking about it like a real person can. Create a worry character for your child. In GoZen we created Widdle the Worrier. Widdle personifies anxiety. Widdle lives in the old brain that is responsible for protecting us when we’re in danger. Of course, sometimes Widdle gets a little out of control and when that happens, we have to talk some sense into Widdle. You can use this same idea with a stuffed animal or even role-playing at home.

Personifying worry or creating a character has multiple benefits. It can help demystify this scary physical response children experience when they worry. It can reactivate the logical brain, and it’s a tool your children can use on their own at any time.

4. Teach Your Child to Be a Thought Detective
Remember, worry is the brain’s way of protecting us from danger. To make sure we’re really paying attention, the mind often exaggerates the object of the worry (e.g., mistaking a stick for a snake). You may have heard that teaching your children to think more positively could calm their worries. But the best remedy for distorted thinking is not positive thinking; it’s accurate thinking. Try a method we call the 3Cs:

• Catch your thoughts: Imagine every thought you have floats above your head in a bubble (like what you see in comic strips). Now, catch one of the worried thoughts like “No one at school likes me.”

• Collect evidence: Next, collect evidence to support or negate this thought. Teach your child not to make judgments about what to worry about based only on feelings. Feelings are not facts. (Supporting evidence: “I had a hard time finding someone to sit with at lunch yesterday.” Negating evidence: “Sherry and I do homework together–she’s a friend of mine.”)

• Challenge your thoughts: The best (and most entertaining) way to do this is to teach your children to have a debate within themselves.

5. Allow Them to Worry
As you know, telling your children not to worry won’t prevent them from doing so. If your children could simply shove their feelings away, they would. But allowing your children to worry openly, in limited doses, can be helpful. Create a daily ritual called “Worry Time” that lasts 10 to 15 minutes. During this ritual encourage your children to release all their worries in writing. You can make the activity fun by decorating a worry box. During worry time there are no rules on what constitutes a valid worry — anything goes. When the time is up, close the box and say good-bye to the worries for the day.

6. Help Them Go from What If to What Is
You may not know this, but humans are capable of time travel. In fact, mentally we spend a lot of time in the future. For someone experiencing anxiety, this type of mental time travel can exacerbate the worry. A typical time traveler asks what-if questions: “What if I can’t open my locker and I miss class?” “What if Suzy doesn’t talk to me today?”

Research shows that coming back to the present can help alleviate this tendency. One effective method of doing this is to practice mindfulness exercises. Mindfulness brings a child from what if to what is. To do this, help your child simply focus on their breath for a few minutes.

7. Avoid Avoiding Everything that Causes Anxiety
Do your children want to avoid social events, dogs, school, planes or basically any situation that causes anxiety? As a parent, do you help them do so? Of course! This is natural. The flight part of the flight-fight-freeze response urges your children to escape the threatening situation. Unfortunately, in the long run, avoidance makes anxiety worse.

So what’s the alternative? Try a method we call laddering. Kids who are able to manage their worry break it down into manageable chunks. Laddering uses this chunking concept and gradual exposure to reach a goal.

Let’s say your child is afraid of sitting on the swings in the park. Instead of avoiding this activity, create mini-goals to get closer to the bigger goal (e.g., go to the edge of the park, then walk into the park, go to the swings, and, finally, get on a swing). You can use each step until the exposure becomes too easy; that’s when you know it’s time to move to the next rung on the ladder.

8. Help Them Work Through a Checklist
What do trained pilots do when they face an emergency? They don’t wing it (no pun intended!); they refer to their emergency checklists. Even with years of training, every pilot works through a checklist because, when in danger, sometimes it’s hard to think clearly.

When kids face anxiety they feel the same way. Why not create a checklist so they have a step-by-step method to calm down? What do you want them to do when they first feel anxiety coming on? If breathing helps them, then the first step is to pause and breathe. Next, they can evaluate the situation. In the end, you can create a hard copy checklist for your child to refer to when they feel anxious.

9. Practice Self-Compassion
Watching your child suffer from anxiety can be painful, frustrating, and confusing. There is not one parent that hasn’t wondered at one time or another if they are the cause of their child’s anxiety. Here’s the thing, research shows that anxiety is often the result of multiple factors (i.e., genes, brain physiology, temperament, environmental factors, past traumatic events, etc.). Please keep in mind, you did not cause your child’s anxiety, but you can help them overcome it.

Toward the goal of a healthier life for the whole family, practice self-compassion. Remember, you’re not alone, and you’re not to blame. It’s time to let go of debilitating self-criticism and forgive yourself. Love yourself. You are your child’s champion.

Simple tools can help alleviate your child’s anxiety. Start teaching your child coping skills with animated lessons here.

This was originally posted on PsychCentral as 9 Things Every Parent with an Anxious Child Should Try

 

Isn't this important? And where will you get help except from your primary care pediatrician? Yup, primary care. The same pursuit that some health policy people are trying to run out of business with High Deductible Health Plans. But I digress. Time for me to get back to preparing my upcoming presentation to the Goldman School of Public Policy Board of Advisors on High Deductible Health Plans. That's making me anxious.

budd shenkin

The Health Care World is Looking for a Hero

Everyone is familiar with the basic problems of health care in the United States. It costs a lot, it is inefficient, and quality is highly variable. With these problems, virtually everyone in the field, liberals and conservatives, agree on the so-called “Triple Aim” of health care reform: decrease the rate of change of the cost increase (bend the cost curve) if not actually decrease the cost; improve the consistent quality of care; and improve the health status of the population at large. In theory, this should be doable with better organization.

There are a few programs in place trying to achieve cost reduction, hopefully while also achieving the other two objectives. Accountable Care Organizations are one such program. Another is an attempt to change the fee for service mode of payment and replacing it with so-called Value Based Insurance Plans, which would generally pay a set amount for various conditions, and so put the onus on practitioner organizations to make their services cost-effective. But the most advanced and widespread program of cost reduction is health insurance called High Deductible Health Plan (HDHP). I have explained my opposition to HDHPs before on this blog with some passion. I was also lead author of the American Academy of Pediatrics policy paper criticizing HDHPs – http://pediatrics.aappublications.org/content/133/5/e1461.full.pdf+html. These plans accounted for over 20% of employer-sponsored health insurance policies in 2013, and that percentage has doubtless markedly increased under the ACA (Obamacare).

The key result of HDHPs is to decrease the volume of health services at the lower level of care – primary care especially, but lots of other basic services as well. In other words, its effect is to cut utilization and thereby to cut costs. The most prominent pro-HDHP article I'm aware of appeared a couple of years ago in the journal Health Affairs; written by Amelia Haviland et al., its title was “Growth Of Consumer-Directed Health Plans To One-Half Of All Employer-Sponsored Insurance Could Save $57 Billion Annually.” Pretty assertive. Now a followup article has appeared: “Do consumer-directed' Health Plans Bend the Cost Curve Over Time? “ The conclusion is yes, they do. Amazing. If you raise the price of a service people consume less of it. Bring on the Nobel Prize. And try to ignore the other two elements of the Triple Aim, quality and health of the community, because with HDHPs quality and equity have to decline.

But health care costs do need to decrease, and the HDHP advocates are doing the research necessary to show that, whatever the defects of HDHPs (and I think they are severe), at least costs are reduced, or so it seems at present.

The is this: yes, HDHPs are poor policy, but where is a better substitute? We don't have compelling alternatives, for many reasons. So, to try to fix the problems responsibly, we have to take preliminary steps to help these alternatives to appear.

So, here is my suggestion for the research someone should undertake. It would be easy research, it would be significant research, and it would be great for someone's career. Here's my suggestion:

We have good evidence that a major problem with the US health care system is not over-utilization, but over-pricing.  See tinyurl.com/pz7oumm.  Here is an example: in 2012, the average hospital day in the US cost over $4,287.  The next highest hospital day cost in international perspective -- not the average international hospital day cost, but the next highest -- was Australia, where the cost per day was $1,472.  That's not a small difference.

This shows just one item of comparison, the cost of a hospital day. This same report shows many, many items wit the same order of difference. The average price for an angiogram in the US was $2,430.  In Chile, the next highest country, it was $378. Given these differences, how can one think anything else besides, what would happen to US health costs if the prices of medical goods and services were in line with the rest of the world?

So, that's the research project. Do the same thing the first Haviland article did. Take about 20 of the common and overpriced services. Compare the cost of all these services together and see how much they cost now, and how much they would cost if they had international prices. Here's the matrix:

-->

		annual frequency	average US price	x times y = total cost
CURRENTLY
	Service 1	x	$y	$z
	Service 2	x’	$y’	$z’
	…
	Service 20	x’’	$y’’	$z’’
	TOTAL			TOTAL COST 1
			average intl. Price	x times i = total revised cost
REVISED	Service 1	x	$i	$m
	Service 2	x'	$i’	$m’
	…
	Service 20	x’'	$i’’	$m’’
	TOTAL			TOTAL COST 2
	AMOUNT SAVED = TOTAL COST 1 - TOTAL COST 2

Then publish the paper in the mode of the first Haviland article: “Curtailing the Price of 20 Common Medical Services to International Norms Would Save $100 Billion in the US.”

Say the Amount Saved turned out to be really significant, as I think it would be. Then, although we wouldn't have a program that would be competitive with HDHPs, we would have a target. Find a program that would reduce the prices of key overpriced services, and there it would be, a program that decreased costs without interfering with quality of care. Yes, it would be hard to find that program, but at least the target would be clear and present.

That's my proposal. The medical cost world is looking for a hero. Somewhere out there, that hero is waiting. Hey, read my blog!

Budd Shenkin

Anthony Doerr responds

On the advice of my friend Bob, who said that he thought the author would like to read my reflections on his book, I sent my last post on to Simon and Schuster to forward to Anthony Doerr.  And here is what he wrote back:

Dear Budd Shenkin,

Thanks much for spending some hours with one of my books and for your gracious and lovely blog post. I’m so grateful that you enjoyed the book. And your post spurred me to revisit the parable of the blind men and the elephant, too. 

Wishing you a lovely and bright springtime,

Yours,

Anthony Doerr

I was so pleased to get this!  Isn't that nice?  He seems to be a nice man, and actually, that's what you would expect from All The Light You Cannot See.  When we were discussing the book at our book club last night, I realized how much caring for one another there is in the book.  Everyone cares for Marie-Laure, and you the reader are grateful for each one.  Werner cares for his classmate Frederick.  Werner regrets it when he can't care for his sister Jutta, but he thinks about it.  It's the villains who don't care for anyone, and who don't have anyone to care for them.

I guess I'm still thinking about the book.  A good sign.

budd shenkin

All The Light You Cannot See

I have always been fearful of being blind. I thought, what would I do if I went blind? I might kill myself. It's so important that I haven't even wanted to think about being blind, for fear of bringing it on. Just as Natalie Wood, a Russian – that irrational people – drowned when that was her biggest fear. Just as I for years bought more expensive PPO rather than HMO insurance because I explained, using an example, what if I had a brain tumor, I would sure want to go to the best place for it, wouldn't I? So sure enough what was it I got, a pituitary tumor. Close enough. And I was going blind with it before the operation. So blindness, not that I'm superstitious, I'm not, but still, just don't think about it.

So I didn't want to read “All The Light We Cannot See,” by Anthony Doerr, even though Sara my stepdaughter gave it to me for Christmas and Sara's choice of books is always, always excellent; and even though my friend Larry pushed it as a read for our book club. I just didn't want to read it. I didn't want to read about some blind girl and what she goes through. But when the book club chose it, and I even found myself putting my hand in the air voting for it somewhat unaccountably, I had to.

I loved it. I cried at the end, even though it's not a tragic ending, it's just time going on and people living in it. OK, the guy's a great writer. He can write sentences, he can set a scene, he used a modern form with short chapters following two main stories simultaneously, and a third smaller story coming in a bit later, and the stories shifting from pre-WWII to 1944 and 1945, back and forth, in a way that really works to build affection for the characters and tension in the story and the three strands all intersect at the climax, as you know they will, so I'm not giving anything away. And as I say, I guess I cried at the end, tears came to my eyes and even though I'm allergic and it's flower season and all my bulbs are coming out in the front yard and the window was open and it was near dawn as I finished it, I think it was the story and not my allergies.

For me, this book was an eye opener, especially with my fear and dread. (Don't think about it.) Marie-Laure (love the name, especially since Laure is the name of the female principal in Spiral – see Netflix) loses her sight to congenital cataracts at the age of 5 or so in pre-war Paris. Her mother died in childbirth and her father is a saintly dad as he raises her and loves her. He cares for her, he is tender, he makes wooden scale models of the neighborhood so she can feel them and orient herself for moving around, and he is a genius in constructing the wooden models with secret ways to access the insides that sometimes contain presents for her. She feels her way by touching his pants, she feels and hears – I know we've heard this about blind people, how the brain expands in the areas that function to compensate for the loss of sight, but Doerr brings us to exactly how it feels. Later on, when she is at St. Malo – which by coincidence Ann and I visited just last year, so I know it, even Place Chateaubriand http://www.trekearth.com/gallery/Europe/France/West/Bretagne/Saint-Malo/photo1392483.htm – she can tell all the snails and other molluscs by feel; she is a natural biologist taught by her father and colleague at the museum where he works. People are so kind to her. Her world is not like seeing, but it's her world and it's a tender, exquisite world all by itself.

The parallel story is about a short German boy with white hair named Werner, a little older than Marie-Laure, who lives in an orphanage near Essen, who has a mechanical ability. He makes a radio and he and his precious little sister Jutta listen to it and hear a Frenchman broadcasting stories about science and physics in a warm and cuddly voice. Because of his emergent ability Werner is chosen to escape the mines and become brutally trained in a Hitler youth school, where he befriends a gentle soul, Frederick, who identifies birds by the songs he hears, not needing to see them. Werner helps invent the technology that triangulates radio signals to find hidden broadcasters. So, I realized, Werner is like Marie-Laure, because he uses radio with his ears and not the eyes. When his hearing is translated into sight, his friend the giant soldier strides into small, primitive cottages that are broadcasting and kills the partisans as they transmit.

As I was reading and realized this, it hit me – what I am doing is a blind activity, too! I'm reading and making up pictures in my mind. Reading is like a blind activity, so I'm part of it, in it with them, doing a similar thing.

And then I thought even more – “Keep thinking, Butch, that's what you're good at!” – we are all so often looking (note, “looking,” maybe it would be better to say “listening for the future”) but we really can't see it. We imagine what it might be, we seek indicators to project what it might be, but we are really essentially blind to the future. Sometimes if somebody thinks he has it, he'll say: “I can see it clear as day!” Maybe. It sure is great when you can.

And then, Doerr is constantly referring to what is happening in nature as events unfold. St. Malo is about to be besieged, the populace is being herded into areas, airplanes are dropping bomb loads, food and water are missing – and what is happening in nature? The birds are doing what they always do, chirping, finding food here and there whatever it is they eat, I think Doerr knows what that food is but I don't. The snails are doing what they always do, creeping and filtering the calcium from the water to build up their shells. They are blind to what is going on around them with the people and the larger landscape, just as the people are blind to what is happening with the birds and the snails.

Then there is the long term working of nature, the evolving crustaceans and molluscs that Marie-Laure orders in her bedroom, so she can feel them as they have evolved, see the long term trends and changes maybe you could say. No one planned it but it happened and afterwards we see the results, but never before. We can see the past, which we can't affect, but we only intuit the future, we only hear it coming but we don't know exactly what it is.

Marie-Laure's favorite book is Jules Verne's 20,000 Leagues Under The Sea. She learns to read it in Braille, and later she reads it on the radio. Captain Nemo explores, but he often can't see much. He is under icecaps and he is picked up by a giant squid, which he can't actually see. The sea is dark and inky, and he and the sub are tossed about, hoping for the safety of chance. Listening to Marie-Laure read it on the radio, Werner is just like her, because neither of them can actually see what it is, they are picturing in their minds.

I think it's just coincidence, but just in the last few months before reading All the Light, I have been thinking more and more about the parable of the blind men and the elephant. http://www.buddhisma2z.com/content.php?id=471. We really see so little of what there is in life, we understand so little. It is best to be humble and listen, but it is also important to try to understand, to try to put things together, and to try things even though you know that your vision is limited and many of the things you try to do will fail.

What a book!

Penicillin

On our SOAPM pediatrics listserve we have had a conversation about treating strep throat. The options are: (1) take oral antibiotics once or twice a day for seven or ten days, or (2) get one shot of penicillin at the time of the visit. Factors include the fact that a shot hurts (briefly); and that it is hard to fulfill the oral medicine instructions for a week or more even if it is yourself, let alone a kid, so that “lack of compliance” becomes an issue with oral medication.

Myself, I've always been a shot guy. Over and out, I figure.

But many of the doctors wrote that they hesitate to give the shot because they themselves remember the pain when they were kids. For instance, my friend Iris Snider from Tennessee writes: “Kim, like you I had my share of Bicillin shots as a child and am loathe to give them. I average about one every 10 years and apologize to the 'victim' every time I do.”

Here's my response:

Sissies!

When I was probably about 6 or so - I was born in 1941 - it was summer and we were at the New Jersey shore, in Beach Haven.  Somehow I got an infection in my foot.  It was bad enough that I had to go back to Philadelphia and was hospitalized, probably at Graduate Hospital.  Penicillin wasn't that old a drug and we were lucky to have it.  At that time there was probably only crystalline penicillin.  I don't know if it was every four or every six hours that the nurse came into the room with a big hypodermic needle and I cried at the prospect and my mother helped to hold me down.

Then after a while my mother reasoned with me.  She said, “Look, it's going to be done, so why don't you stop resisting and just accept it and make the best of it, and after all it is fixing you all up,” or who knows what words she used. 

The next time the nurse came into the room I smiled and turned over and offered my cute little butt to her ministrations.  She said, “Well, what got into him?”

And you guys are complaining about a one time shot, with pain-killer as one of the components, when the kid can walk out of the office and not think about it again?

You should have been in Philadelphia right after the war and seen a little kid with a foot infection in the hospital bed and offered him that choice!

Budd Shenkin

Vaccines, Anti-Vaxers, SOAPM, and Jimmy Kimmel

Pediatricians have been hot! Ever since measles spread out from Disneyland, what we have been dealing with internally in pediatricianland, how to deal with the anti-vaxers, has gone mainstream.

For me the heart of pediatricianland is SOAPM, the Section on Administration and Practice Management of the American Academy of Pediatrics. There are over 1,100 of us in this section, and on the SOAPM listserve 50 messages a day is a slow day. If you are lonely and have little to do, joining SOAPM can fill up your day real fast. And truthfully, SOAPM has become a real home for me, and my admiration for SOAPM denizens fills my heart. It makes me so pleased and proud to be a pediatrician. Practical people, assertive people, inventive people, imaginative people, people with great hearts and minds and values, people who are not ashamed to say, “No margin, no mission!” And then they go out and do the right thing.

So when measles got hot, SOAPM got hotter. Some of our energy has been going into how do we convince anti-vaxers to vaccinate? Some energy into, what does our American Academy of Pediatrics do with the rogue pediatricians who capitalize on the anti-vax movement to sell books and get publicity? Shouldn't they be drummed out of the AAP and lose their imprimatur as Fellows of the AAP? Some of our energy has gone into how the AAP should respond publicly, especially after they issued a somewhat tedious statement once again reaffirming the value of vaccination with zero pizzazz. Some of our energy has gone into trying to get the AAP to revise its statement that practices should not dismiss patients who delay or deny vaccination, but should work with them.

Truth to tell, my practice was always counted among those who accepted anti-vaxers and worked with them. But now, if I ran the zoo, I'd change that. For one thing, the public tide has turned and there is value in putting up a common front. For another, there is now evidence that shutting out antivaxers convinces more patients to vaccinate than “working with them.” But of course I know longer run the Bayside zoo – thank goodness!

But then, while all the sturm und drang of SOAPM dialogue was proceeding, up came a message on the Listserve from James Weidman of Los Angeles – “Watch the Jimmy Kimmel show,” he said. And then came this clip:

http://abc.go.com/shows/jimmy-kimmel-live/video/VDKA0_pbn5p6mh

This clip made me so, so proud to be a pediatrician and a SOAPMite.

OK, the AAP was too reserved and stodgy. But, is this a great country, or what? In liberal democracies there is a multiplicity of channels and freedom of expression. Enter popular media! Enter emotion, enter sarcasm, enter dirty words! Enter great intelligence and communication and presentation skills, and enter great directorial skills that enabled these real life pediatricians to be such great performers! To me, these pediatricians perfectly bridged the profession's rectitude with being able to relate as lovable human beings, which to my mind is the essence of being a pediatrician.

I am just so proud!

Sometimes, the best politics is great entertainment.

Budd Shenkin

Israel, Arabs, and Postulates for Living

Postulate one: you learn in life that generally you can only control what you yourself do. Others will generally do what is in their own interest, except your parents, if you are lucky, and except your spouse, if you are lucky, and sometimes other members of your family, or sometimes someone else, but you can't count on it. It's a blessing when someone understands you and helps you, something to be relished.

Postulate two: it doesn't help much to blame others and to hold a grudge. I'm talking about utility, not justice, and not even truth. If things go bad, you do best to look at your own actions and make them better next time. You can acknowledge what somebody else did wrong, and how somebody else is a jerk, but aside from choosing who you associate with next time, blaming somebody else doesn't have that much utility, except maybe legally.

Postulate three: it's a good thing generally to do “the right thing” without expecting either appreciation or reciprocity. Don't go crazy about it, but just do the right thing, even if the other one is a jerk (most people are not jerks all the time, although I've heard that some are, mostly concentrated in the financial industry.) You may get appreciation, you may get reciprocity, or you might get resentment. Still, I think it does you the most good to do the right thing. Just don't go overboard.

Do these postulates apply in political affairs? Especially, do they apply in international affairs, where I believe there really is a clash of civilizations? Clearly, turning the other cheek to Mr. Putin is not the right thing to do. Bullies must be stood up to, not collapsed to.

But let's not talk about Russia, let's talk about Israel. The Israelis are much afflicted in their neighborhood, where school children in neighboring Muslim countries are taught to hate Israelis and Jews. Being sweet to Hamas or Hezbollah isn't likely to help much. Even being nice to the Palestinian Authority brings a mixed bag; the PA has to answer to its people, and there enough hard-liners to make it very difficult to make progress.

But thinking a little more short term actions and long term results, 20% of Israel's population is non-Jewish, mostly Muslim, but also Christians and the Druze. This population is generally discriminated against in many ways. But in fact, they offer a major opportunity for Israel to do the right thing.

So, here's the proposal: If Israel took this population as a gift, as an opportunity to do the right thing, it is possible that they could really make some headway. What if they preferentially delivered excellent educational opportunities to them? What if they practiced affirmative action for employment? What if they went out of their way to make this population successful?

OK, it would be hard to do. But imagine what might happen. First of all, would they be appreciative or resentful in the short run? Or suspicious? Probably appreciative and suspicious, but who knows – I've never even been to Israel. But I can't imagine that this population wouldn't take advantage of a smoother road to become educated.

Then what might happen? They might become a very economically successful part of Israel. They might develop their own institutions, but they would probably just integrate. I can't imagine the Jewish businesses not incorporating such talent. In time, these non-Jews might become some of the most appreciative and patriotic citizens of Israel of all.

Then, what happens in the rest of the Arab world? Well, they might declare jihad against these turncoats, some of them. But mostly there would be envy and maybe admiration, and maybe even competition. If there were resentment and denial, it would be rebutted by families and relatives who would know the truth.

The truth would out. The eighth century Caliphate ideal would be replaced by the twenty-first century modern ideal. The misled Middle Eastern Muslim masses would be slow to come around, but thought leaders with some sophistication would privately and then publicly point to Israel as a beacon for Arab advancement elsewhere. There would actually be a way out of the tunnel.

Call me a fabulist. Call me naïve. Call me uninstructed. But, as they say in the movie review part of Robert Townsend's Hollywood Shuffle, “It could happen.”

Or maybe nothing would happen. The Israeli right wing would waylay it; the Arab world would become even more antagonized by the attempted seduction; the most respected law of social affairs would rear its head, the Law of Unintended Consequences. But so what. At least the good people of Israel would have done the right thing, and that is reward enough on this earth.

Budd Shenkin