Wednesday, December 17, 2008

new analogy

for those of you who know me, you know i think in metaphor. analogies are a way of life for me. so this morning i thought of another one.
i refresh my podcasts daily, it's a ritual. then i sync my phone and my ipod to update them. if any new software is available i find out. if there is a problem, i find that out, too.
if i 'sync' with God on a daily,  allow Him to refresh my spirit, hopefully even minute to minute, but at least regularly at least daily, i stay in touch with Him and what He wants me to do and He reminds me through His word how He wants me to act and what His nature is, so He pretty much 'updates' me and notifies me of problems, etc. 
by studying the bible, reading devotionals, meditating (or is that snoozing?), praying, all these are ways to 'sync' with God. somehow it takes on a different tone than the sanctimonious 'i have my quiet time' or 'i read my bible every morning' that i hear in christian circles so often and brings it down to reality and really more what it is - a relationship. i cannot 'sync' my ipod and iphone with my computer if they are not connected, nor can i sync with God if i'm not connected, or in a relationship, with Him.
just a thought, one of the random ones that roll around in my head!

it's all about me

it really is all about me. no matter how i act or seem, how good or bad, how selfish or selfless, it's still all about me. maybe this is the 'sinful nature' we are born with that is so much a subject of the bible and its writings, the 'old man', the 'flesh'. it makes sense, since that is a broad enough definition to include all the things the new testament writers include as manifestations of this 'old self', all the way from seemingly (now) trivial things like gossip and not respecting parents to murder and really bad stuff everybody knows are wrong to do.
in les miserables, jean valjean, aka monsieur madeleine at this point, faces this issue after javert discovers who he really is. victor hugo's description of valjean's thoughts and torment at this juncture are an excellent description of what happens when one is 'good', at least outwardly and perhaps inwardly as well, but that the 'good' he is and does is really just trying to make up for the bad he was before, to hide who he really is in his heart. when faced with the dilemma, valjean at first considers doing the 'right thing', the selfless thing. that is his first instinct, which i think tells of who he really is, not who he thinks he is, but who he has become. but self preservation takes over and he doesn't do exactly what he first thought to do. he looks for a way to get what we would call a 'win-win' outcome. why? because it really wasn't all about him anymore, not in his heart. his good actions were not just window dressing. sometimes we tell ourselves or other people to 'fake it til you make it', and that's what jean valjean had been doing. and at least for a moment, he had 'made it'. 
it may be like learning a new language. i could speak a little spanish, but i could never 'think' in spanish. apparently, immersion in the language and culture helps this process, and i'm sure the longer you soak the better. so he was soaking in goodness and selflessness long enough for at least his first short slight inclination was to do the unselfish thing. so all those years of soaking produced what? a momentary glimpse of what he 'should' do or be? then conflict between the angel on one shoulder and devil on the other? well, pretty much. 
we tend to idolize heroes who do the right thing the right way the first time, reflexly it seems, so that there is no time between action and reaction, and their reaction is always right. the 'tortured soul' who is left with a choice between doing what is best for him and what is best for his family or his town or his country or his world or whatever is the stuff of many movies, though, and these appeal at a different level. the heroes who are so decisive and always right are usually icons, cutouts in cardboard and characters in comic books, like superman. funny how right now superman has taken a back seat to the more contemplative batman and spiderman whose angst is so palpable and they struggle with the real questions of life in their superhero ways. this is just real life blown up really big so we can look at it closely, dressed up enough to make it fantasy.
i was reminded that it's all about me once again when i had managed to make a decision that i wanted to make despite the objections of others. by gosh, i wanted to do it, it was of no real consequence (it wasn't, at least the act wasn't) and i could do it if i wanted! how very much like a two year old that sounds! maybe we're all just big two year olds with a thin veneer of humanity covering a selfish core? is that it? ouch!
so what's the answer? the current worldview would tell you that this is just the way you are and you should just do what you want and it's ok unless someone else is hurt, and you can't help it and if you want to change you should go to a counselor and maybe get some medicine that will help you live with the two, the angel and the devil, so that you're always so conflicted that you can't carry on a normal life, and if you do enough good stuff a la jean valjean, that the good will outweigh the bad so if there really is a God and a heaven and hell then you're covered and your account will have a positive balance, because the positive balance is what counts and we all know that with enough drugs and the right diet we could be good for long enough to overcome any of the bad stuff we did before and balance out any current bad stuff we're doing and what we're thinking doesn't count because we didn't do it so we can go about doing nice things with selfish motive and look good and people will be impressed and blessed when in reality, deep down, we know we're doing it all because we know it's all about us but we're too proud to realize that our balance is and will be positive only if we let go and let Jesus' balance replace ours but that would mean it's not all about us but it's about Him and then where would we be but in a better place to treat others the way we want to be treated and to be more likely to be forgiving and merciful when people mess up and to look on people as Jesus did, with God's perspective and to realize that just like us, everybody's living life the same way except it's about them and not us in their worlds so it looks different to me but when i look at it that way it really helps get a perspective on things. deep breath.
this idea started with someone very close to me telling me 'you always have to be right' or 'you always have to do what you want' or something to that effect. that person was really teasing, but as my father always said, 'many a truth is said in jest'. there was a backhanded compliment at the end of the 'you're selfish and you think the world revolves around you' slam, when the person said 'but you hide it better than some people'. at least i took it as a compliment! 
how's this for reverse psychology? the only way to be in control is to give up control of yourself to God, so as you 'soak' in Him you become more like Him, as kids become more like their parents over time, and to increase true self esteem you realize how really selfish and sinful you are and that there is nothing you, by yourself, can do to fix that, so you trust Christ to give you His goodness so you can relax, and that's the bottom line for me - to relax in Christ, letting Him fly the plane, knowing that He lived a perfect life and so i don't have to be perfect (i couldn't even if i wanted) and when i get to that point i can much more easily look at other people, acting as selfishly as we all do, and understand with empathy that they are living the same life i am except that unless they have relinquished control and perfection to Christ, their world has a very different look from mine because now mine at least some of the time has Christ as the Center and me sort of revolving around Him instead of me as the center or them at the center and God sort of a cosmic slot machine or magic 8 ball to pull out and see what we can get when we feel like it and i can understand better their anxiety and stress and anger and impatience (and my own, this ain't a 'done deal', this sanctification thing, it's a process, not a magic wand and poof you're now holy and can leave behind selfishness and forget about it and now you're speaking spanish and thinking spanish and your old ways/language never come back under duress or any other situation) because i can remember when i felt the same way (earlier today?!) and how it felt so like in hebrews the writer (don't you like that, we don't know who wrote one of the books of the bible? what's up with that?) says we have a high priest who lived a life like ours with all the temptation yet was perfect - He saw things through our eyes and He knows what we're going through which makes it so cool, well we can be like that (except the perfect part) and see things through His eyes and the eyes of the person freaking out in front of us or on the phone with us because their kid is sick and it's christmas and how could this happen and we're flying tomorrow or there's a wedding/play/test/initiation/class/family reunion/tryout and instead of saying 'relax, you're way too anxious and you need to calm down' we can take the hit, empathize, help in whatever way we can while looking through God's eyes and not necessarily our own and not necessarily enable or be amateur providence or rescue them (one of my favorite sayings is 'a lack of planning on your part does not constitute an emergency on my part' - until i realize i'm the other end of that phrase sometimes when it's about me so i try to be kind!) but listen and let them talk it through and not be another problem in their world at that moment, doing our best to get along with all persons to the extent that it's up to us (heb 12:14, 2tim 2:23+, titus 2:8, 1peter 2:11) and live and act as if we're on the other end of the line or our mom or kid is on the other end of the line and how would we want to be treated in that situation and to know that we act right not just because we're told to but because it's becoming part of our nature to act right and be kind and that with time and prayer and 'soaking' in God we find it an unconscious 'reflex' in us and that at least sometimes, when the veneer is not getting too thin, we resemble our Father. there's no better compliment for me than to be told that i'm at all like my earthly father except if it's that i'm at all like my heavenly Father. and as my kids grow and leave and live their own lives, my hope is that someday they will be proud to hear that they are like their father, because he is like his Father. see, i told you, it's all about me!

Friday, November 28, 2008


ok, i'm going lower case for this one, maybe to blunt its powerful commentary on our current worldview and the state of affairs in just about everything in america, but definitely in the area where i 'live', pediatric medicine. and for a deeper spiritual assessment of anxiety, look for my wife's blog on this subject to be added today at
lots of anxiety exists when it comes to taking care of children.
i was sharing in this anxiety until recently, or at least sharing more in it, i can't just drop it completely any easier than you can. but i sure got a different perspective on it after listening to my favorite radio pastor, alistair begg, on november 7, 2008. much of what i'm writing he says in his podcast. no, i'm not putting myself in the place of God, trust me. i'm not qualified and i definitely don't want that job. i'm more in the ballpark with the airline pilot alistair mentions. it is this part that resounded with me so much.
if you are anxious on an airline flight, worried about crashing or the landing gear engaging or the weather or anything, to some extent you are thinking that you could do a better job than the pilot. despite no pilot training, you are at least, and probably/hopefully unconsciously, acting as if you could handle this situation better than the pilot. do you understand this concept? you have 'submitted' to the expertise of that pilot at least implicitly and once again possibly unconsciously. you know that, given the stick or the wheel or whatever they have to fly a plane, you couldn't handle it. sure, there are safeguards, like in the movies where someone comes from seat 23B and saves the day by landing the plane. but that's a movie.
i know the analogy breaks down when i translate it into patients as passengers and doctors as pilots. but hopefully you see the analogy to the degree that it applies.
the patients (i.e., the parents of the patients) often (very respectfully in general) question everything that i'm doing and recommending and have specific guidelines that they want to follow for their child/ren. these are often scenarios where i can easily say 'good luck' with an 'i'm sorry' ready for later when my advice should have been followed. i envy dr. phil his 'how's that working for you?'
i want to let you know that i really and truly share your concerns about your child/ren. and i really and truly do not want to harm your child or have anything i do or recommend turn out badly for you or your child.  there can be times when i'm wrong. i admit it, i've been wrong in the past, i'll be wrong in the future. i don't mind having my judgment questioned at times, and i understand the anxiety created by our current worldview that we are in control of everything and we have to get it all right every time or awful things will happen.
this is the most important piece of information i want you to grasp. you're not in control of things. i'm not in control of things. God is in control of things. regardless of how it looks at times, in the big picture, He's got it covered. we are supposed to rest in that. yes, you have to get up and feed and dress your kids and take care of them and yourself. i have to get up and go to the hospital and the office and give my advice and my prescriptions and you still have to go to the pharmacy and get and give the medicine, but God is in control. sometimes He concerns Himself with the tiny details of things - have you looked at your child lately and wondered how he/she started as a sperm and egg and ended up with ten fingers and ten toes and an attitude? He 'formed that child in your womb' it says in psalms. but as a society, as a world pretty much to one degree or another, we've stopped believing in a God who does all this and takes care of both little and big things, and guess who that leaves to handle everything? us! and that's scary! so i understand from whence the anxiety comes. listen to the world. read the world's opinions on things. but think of yourself as looking from sort of a google earth perspective, looking from a distance, and realize that you aren't in control and then be very grateful that you aren't supposed to be in control. and be very thankful that i'm not in control. i'm constantly looking to God, believe it or not, because i am very aware of my lack of control over things. regardless of what the world's wisdom tries to tell you, man's greatest wisdom is foolishness to God. if you can reset your worldview, and i have to do it daily, and recognize that we're all here because He wants us to be, and we're all doing what He would have us be doing, you will sleep easier tonight. you won't worry so much about sleep position and introducing solid food and bisphenol a and melamine and autism, you'll be more content with the stuff you've got to do, like the mundane 'get up, feed the baby, change the diaper, clean up the spitup, take a shower...repeat'.
in over 20 years of practice i've seen the number of concerns rise exponentially. it's amazing what people can be concerned about. some are given to this mentality from the start, and that's almost understandable, but sad, but many otherwise confident people become overconcerned lunatics where their children are concerned.
to summarize: i see myself as the pilot. i have the training, the expertise, and the skills to do the job for which i've been called, and for which i've been hired by my patients' parents. most have picked me from a very good lineup of possibilities, so that says hopefully that my expertise is appreciated somewhere. i know Who is in the real pilot's seat. He's not my copilot, by the way, i always thought that was a very prideful statement.
i don't begin to think i know everything. as my daughter, who is a first year med student, was told as her year started, 'half of what we teach you will be wrong in the future, we just don't know which half'. i understand that sentiment completely and could state it categorically at each visit. anyone who says or even thinks he/she knows it all at any given moment is seriously deluded and should be avoided. i have opinions, i have experiences that have taught me certain things i hold as truths, sort of like the pilot keeping the plane in the air and landing it safely. i also have areas where i question myself, my thoughts and practices, my feelings about how to accomplish certain goals and whether or not those goals are even important. much like the pilot who could choose more than one route from new york to los angeles, he has flown many of them many times and has picked the one he thinks is best based on his experience and guidelines he must follow. the takeoff and landing he knows will not differ much from airport to airport but the air in between could be clear or choppy or downright turbulent. in my case i 'take off' with many of you each time a new baby comes. 'landing' is way in the future, so we're stuck with all the air in between, and for the most part, as long as we don't crash, it's going to be fine. the time from takeoff to landing will differ, the route taken will differ, the pilot (with trust in a God who is in ultimate control) knows that he's going to get them where they're going in the best shape and in the best time possible. but the passengers must trust the pilot when he says 'sit back, relax, and enjoy the flight'.

Thursday, November 27, 2008


OK, what should we worry about? Is my kid (or am I) making little plastic pellet kidney stones as we speak? Why didn't someone keep this from happening? Why didn't they tell us sooner? 
First, it's likely that some amount of melamine or similar contaminant(s) has been in our food supply for quite a while and we are just now finding out about it. Last year it was cats and dogs, now babies who may suffer. One big lesson - look really hard at things 'made in china'. Sure, there are lots of good things made in china, and we probably couldn't get along in our current society without many of them. Another last year thing that had a 'china connection' (isn't it funny how 'last year' is so 'last year'?) was lead in the paint on toys. That passed, not too many people are asking about that lately. But still, consider whether you want to put something in your mouth if it's made in china. Just a warning. 
Second, related to the previous sentence, this will be 'last year' next year, so don't freak. I'm not envisioning kids peeing plastic pellets out at their parents during diaper changes.
Third, what else is there in our food and environment that's not good for us? Back to a paraphrase of a friend's quote about whether we should be concerned about the plastic in water bottles, etc., "when people aren't eating junk and getting obese and having diabetes and high blood pressure from doing stuff they know isn't good for them, then we can start worrying about the stuff we aren't so sure about...". Good, no great, point.
A story that I've used with my kids from time to time comes to mind as regards things that are present in things we are consuming (eating, watching, listening to, you name it): When her kids were watching movies that had 'just a little bit' of bad language and some sexual innuendo in them, a mom decided to teach them a little lesson. She baked them some brownies, and before they had eaten any she told them that she had put a little extra ingredient in the brownies. When they asked what she had put in, she replied "canine fecal matter" (which I will henceforth refer to as d.s. for those of you with sensitive eyes and I'll let the rest of you figure it out). She said she had put in 'just a little bit of d.s.' and that they wouldn't even notice that it was in there. Then she asked them if they wanted to eat the brownies.  They wouldn't eat any. They said that 'just a little bit' of d.s. spoiled the whole batch. After an appropriate period of time, during which they ranted and raved that she was nuts and they couldn't believe she had put d.s. in the brownies, she asked why 'just a little bit' of d.s. bothered them so much. They continued their protest until she asked if they knew where she had gotten the phrase 'just a little  bit'. When reminded of their use of the phrase regarding their choice of movies, they were forced to admit that 'just a little  bit' of bad can definitely spoil some things, and maybe it would spoil anything, especially once they were made aware of its presence.
OK, sorry, long story, but even 'just a little bit' of dog poop in anything is generally unacceptable. Well, I'll take that back, we've been told there are 'acceptable amounts' of insect parts in some of our meat products for years and we still eat hot dogs, so I'll give you that one. But in today's culture in America, we're all about full disclosure and responsibility so we agonize over shots with mercury in them and bisphenol A in plastic cups and bottles and now we have melamine in baby formula. Thank you, FDA. Or is ignorance bliss? Once informed, we're determined to get rid of whatever we've just discovered is present, and we're also quite inclined to blame everything from autism to global warming on whatever is this year's dog poop.
I guess one response would be to pull all baby formula off the shelves immediately. Hopefully you can see the problem inherent in this solution. We could vilify the makers of the 'tainted' formulas, except it seems that not all of their formula lines had melamine, just some. 
We could switch to 'safe' formulas, and I guess for now this is the best solution. When the next d.s. discovery is made, another group will be taken off (or put on) the list. Interestingly, one formula from each of the 'big 3' makers of formula contained some melamine or its byproducts, so no one was innocent, except maybe the Target and Walmart generic brands made by Wyeth Labs. Man, I wish they'd found some in the Walmart brand! The evil empire. The antichrist. Well, I really don't wish that because I have lots of patients on that formula and recommend it to patients often, so my interests shouldn't be put above the health of those babies.
My overall point is: remember lead paint in toys and bpa in bottles, they're pretty much 'old news'. 'Last year'. You can take it two ways. One, we are a 'what's in front of us is important regardless of its importance' society, so don't forget 'last year' stuff. Or, we are obsessed with our perceived control of everything and are disappointed when it gets proven that there are things beyond our knowledge and control, so don't worry too much and remember how many things have failed to live up to their gloom and doom predictions and have become 'last year's' concerns.
Stay tuned for my (maybe) next blog about how anxiety reveals the absence of humility and how we should 'sit back, relax, and enjoy the flight' rather than trying to fly the plane from 23B. For an audio on this from Alistair Begg on Truth for Life, where I stole these phrases and ideas, go to or .org, I can't remember which, and go to November 7 "a Biblical approach to anxiety". For the whole deal, go back to the 6th and listen to it all. I'm praying for a kind heart as I write this blog! 

Thursday, November 6, 2008

'new' old parenting book

i have always remembered - and taught patients - the parenting lessons taught me by barbara coloroso in 'kids are worth it', but when i was learning these, they were available only as tapes, and they were very good, and very funny, and obviously made a great impression on me and my parenting style and teaching of parenting. so i 'rediscovered' the book version of this book and i was scanning it this morning and wow! it's everything i remember and more. i highly recommend going to amazon or wherever you go and search 'barbara coloroso' and 'kids are worth it' and get it. it's old enough that the shipping is more than the book, but it's very worth it, and will reveal to those of you who are patients of mine where i've stolen a great deal of my material. i'm going to add it to the bibliography of recommended books on my handouts, but i thought i'd share it in this venue first, for those of you blog-savvy moms and dads who check out 'radical thoughts' every once in a while. 

Wednesday, November 5, 2008

fall colors

Regardless of whether your guy won or lost yesterday, you will be happy to know that the trees are still beautiful this fall, not seeming to really care who the president-elect is or what his stance is on health care and other social issues. So nice to see that at least part of my world doesn't fret about gas prices or wars or the economy or autism and vaccines and plastics and sleep positions and antibiotics and yeast overgrowth or to spank or not to spank - you see that I need something to look at that is not commenting on or asking me about or for something. This year, and I probably will be told that I say this every year, the trees are the most beautiful I can remember. 
Not being a real outdoor person, I still love the fall. It is my favorite season, and it has nothing to do with football. The colors that come from green leaves amaze me every year. Even though the wind pretty much blew away the gorgeous reds of the maples yesterday, I have discovered a new favorite tree for this season. In the windy line to vote yesterday, I was told that this tree is the Chinese pistachio, but I don't know for sure, the guy who told me looked like he spent as much time in his yard as I did this year. Whatever it is, it has replaced the Bradford pear as the "parking lot tree", and I guess I was blind to it until this year.  
Here in Edmond, the most beautiful tree, or at least it's in the top 5, is on an ugly corner by a gas station at 2nd and Coltrane. It is the type of tree I was describing previously, so if anyone knows what it is, let me know. But it is so many colors that I couldn't even describe it adequately. It goes from orange and yellow to red and some leftover green, and pretty much every color in between. 
Just driving on the turnpike is a feast for the eyes right now. I'm impressed that someone was thinking enough to plan the trees along the Kilpatrick, especially at the intersections, especially at I-35 coming from the north.
The wind didn't spoil all the beauty at all, and maybe it even helped get rid of some old stuff that was in the way of new beauty. Even the cloudy/rainy skies this afternoon provided a backlight for some of the most orange/yellow trees that they seemed as if they were on fire but not being consumed a la Moses on the mountain.
So, to end this rambling, I am reminded that whatever happens, happens because the Creator made it happen, whether it be trees or presidents-elect. He's got our best interests in mind, regardless of how it may look at times. I've heard it said that He lets us see the back of the tapestry He is weaving, and I'm pretty pleased with the fall colors He's put in this year's addition to that tapestry.

Tuesday, October 28, 2008

8 important words for parents

Once again, I stole this material, this time I think it's from Parenting with Love and Logic, by Foster Cline and Jim Fay. An excellent book, worth reading several times. An aside: these guys are Christians and their parenting philosophy is Christian, but they forgot to mention that in their book and just set forth the principles and guess what? Their material is used in the public schools and teachers are trained in this philosophy! In our Godless public schools which by the way both my kids attended and maintained their faith and got an education, but that's another blog.
1) "Good luck"
By the time your child is 3 or 4 years of age, if you've been using this phrase and philosophy from the first birthday, he/she will know that they are getting ready to mess up, or maybe mess up, or take a harder way than necessary, or be uncomfortable. It is a method of 'detachment' as a parent that as an observer of your child you are commenting on something he or she is getting ready to do. As long as the consequence or cost of the poor choice they are making is not illegal, immoral, or life threatening, 'good luck' is a very effective couple of words. You can start anytime, but the earlier the better.
2) "I'm sorry"
You (or at least I) have to watch the tendency toward sarcasm when using this powerful phrase. When your child is hungry, cold, hot, when he has failed a test or been allowed to forget to turn in a project and gets a '0', these words come in very handy. The mental mother in your head is standing there shaking her finger saying "if you had just done what I said, this wouldn't have happened". But don't succumb to her influence. It is far more effective to empathize sincerely and allow the child to come up with the "if I had listened to...". By the time the choices have illegal, immoral, or life threatening consequences, your 'good luck' should bring to mind many 'I'm sorry's' and perhaps a better decision.
3) "Nice try"
Instead of crushing your child's spirit when he throws a fit or makes an argument you can give him credit for the effort and keep the part of him that was passionate about and willing to sacrifice time and effort to get what he wanted. Jesus has a couple of parables with a 'nice try' in them: the parable of the wicked (or shrewd) servant where the guy is getting fired and he knows it and he makes deals with businessmen who owe his boss money so maybe he can get a job when he gets his pink slip. the other is the persistent widow who just pretty much bugs a judge who finally makes a ruling in her favor to get her to quit pestering him. In these cases, the effort is rewarded, and in the case of the widow, the  'nice try' even works. This can be accomplished with your kids in several ways. I've always thought that parents should have a set of flash cards with numbers on them, like 7.5, 9.0, 9,5, etc., to give kids a visual 'score' for their 'effort', whether it's a tantrum or just an argument. Just the acknowledgment that you noticed and appreciated their effort will go far toward changing behavior while maintaining 'spirit' and 'spunk'. I'm not recommending tolerating bad behavior, but I see and hear parents squelch their child's 'fire' when a 'nice try' would have been appropriate. Such a tactic can be hard in the day to day activity of dealing with kids, but it is worth the effort.
4) "Regardless"
This, along with #5, is a "stopper". Use this when you've exhausted all the other tricks, when a 'good luck' won't work. When you have to say 'no'. After you've said 'no', and the argument/tantrum is going, you could give them a 'nice try' but still you have to stay 'no'. That's when 'regardless' comes in handy. "Regardless of the fact that all your friends' parents have bought them cell phones, we are not buying you one."
5) "Nevertheless"
Another "stopper", this word takes into account all the arguments, acknowledges the effort put into changing your mind, and comes close to agreeing that your position is hard to explain or defend. It is maybe a longer and wittier version of "because I said so"."Nevertheless, you are in the 2nd grade and you may not get a tattoo." 

Most parenting scenarios can be handled using these words or variations on this theme. Practice them when your kids are young, and when they are a little older, they will give up and beg you not to say 'nevertheless'!

Monday, October 27, 2008

rolling billboards

I truly cannot stand seeing those bumper stickers that say "my child is an honor student at...". Who cares but you? And the grandparents? What if the kid now is pressured to stay in honor society because you've put their achievement on a rolling billboard. But those aren't the worst things I see that really irk me. It's the baseball or soccer ball or batter or football player or gymnast or name your sport and its image. Now picture the kid's name under or beside that image. Besides the fact that I'm philosophically opposed to kids in team sports before middle school, these window dressings are a gross form of pride. As if the parent has no identity other than the chauffeur of their little Jack and Jill to and from practice and games all the time. "Look at me, my kids are on the *&^%^&'s and I get to drive them back and forth and probably yell at the coach and the ref or ump and make a general nuisance of myself while wondering why I have no life". Are these window stickers fundraising materials? I hope so. I truly hope they don't decorate/desecrate their $50,000 Escalade just to be able to find theirs in the parking lot along with all the other high dollar SUV's, even, God forbid, Porsche SUV's! Maybe the kid should have a sticker on his bat or bat bag or maybe his soccer ball that has a picture of the Escalade, or maybe the Cadillac symbol, and his dad's name under it! How about on their book bag or school desk "my parents apparently love me more because I'm in the honor society". 
I really don't think most parents' love is conditional, I really don't, but man, it sure seems that way. "Son, you need to join a team with a cool logo because I've still got a little space in the back window of the Hummer". "I have no life, I didn't achieve much, but I'm going to make sure you do, and to help you along, I'm going to give as much attention to your achievements in first grade as I will to you graduating from high school or college or making it into law school or med school or whatever. I've set the bar so high right up front that there is no way to distinguish the big achievements from the little ones." It's like I've blogged about birthday parties - don't make their first few birthdays such big affairs that you're going to have to go to Disneyworld to celebrate #5 because you blew it so big early on. Save yourself. Chill. 
Acknowledge privately your happiness that Susie is on the honor roll or that Bobby plays on a baseball team that is successful. The bumper sticker just adds a cheesy note to the whole accomplishment or activity and is embarrassing. Maybe grandmothers should be exempt from my recommended ban on child-praising bumper stickers and window decals. Kids are way too self-focused today as it is without their parents confirming their lofty opinions of themselves so blatantly and without tact. Put the sticker on the refrigerator with the finger painting and other 'gifted' artwork and accomplishments. Then don't drive your refrigerator around town. You will like your kids a lot more if you don't put them on pedestals at all, but definitely not at young ages and for achievements of dubious merit or significance. I think I'll take a poll of kids and ask them how they feel about all these 'isn't my kid great'  displays. My bet: they agree with me!

i'm in a hurry

I get this reality reinforced regularly, but I think it bears mentioning. maybe it will be a gas saver or even a life saver, certainly a stress saver. There is an Alabama song called "I'm in a hurry (and don't know why)" and it came out a number of years ago. True then, it remains true today. 
I was on my way to the hospital this morning and an elderly man pulled out in front of me on a stretch of road where the speed limit is 55 and the usual speed at this area is 10 or miles per hour higher than that. He was going maybe 35 and showing no sign of increasing that turtle pace, despite the fact that the light was at least 1/2 mile away. I passed him, on the right, because he also was a left lane loser, and continued on to the light. Guess who pulled up right behind me at the red light? You guessed it. Tortoise and the hare, and despite my jackrabbity move he plodded right up to where I was waiting and we made the turns together and entered the hospital parking almost simultaneously. 
This is not even close to the first time such a thing has happened. It happens on I-35 when I pass somebody doing less than the speed limit, zip merrily on my way only to find them exiting and/or getting to the destination at the same time I do. It is not worth it to stress over who's slow and who's fast. We all get to our destinations at nearly the same time, more safely, less stressed, and maybe the 'slow' guy even gets a little lift when he sees me stuck at the light with him after I had blown his doors off with my Volvo precision racing machine (well, it is a Volvo). 
I find the same thing happening with patients in the office. The more hurried I get the more 'by the way' questions I get, and against all ethical and patient satisfaction advice, my hand is gripping the door handle throughout most of these encounters. That's a big no-no. And it always backfires. If I can go in each room with the idea that I'm there for that patient at that time and take care of their needs and answer their questions readily and ask at the end of the visit "did we cover everything you wanted to have checked?", I'm happier, they're happier, and it took no longer, and arguably less time, than it would have had I been rushed.
So, take a deep breath, go the speed limit, pay attention to the people passing you and seeming to be in a hurry, then look for them at the next stop light and smile, maybe give a thumbs up sign. Especially if you have a fish on the back of your car. God's not a fan of bad advertising. 

Saturday, October 18, 2008

an answer to reverend mom

there is a place in heaven for people like reverend mom. her comment on 'my real healthcare plan' brings up an excellent question. children or adults with multiple medical problems pose the biggest problems for and biggest burdens on the current system. obviously not everyone is healthy. disclaimer: i am not a politician or an expert in healthcare policy or funding.
to be candid, i have mixed feelings about this particular case, but it brings to light issues that need to be addressed. i admire all the reverend moms out there, people who are willing to adopt children who have multiple medical problems are truly being 'religious' as defined in the book of james in the bible - caring for widows and orphans. under the plan i laid out, her daughter would cost her quite a bit of money in flexible spending account funds and it is possible her major medical policy would have a higher cost as well. certainly there needs to be some way to make such adoptions more financially feasible for those families willing to take on the responsibility. i don't know who should provide the funds to help. it seems to me that it is not the state or federal government. perhaps the christian community could facilitate such sacrifices of time and love. i may be wrong, but it seems that it's usually christians who do such things. i hope i'm right. maybe some of that money that goes to 'art' or all the money used to advertise tobacco while telling people they need to quit smoking, that would be a start. some of the private funding for the campaigns of politicians could be redirected and more than pay for it, given there is a commercial starting or ending with 'i am ............ and i approve this message' competing with the 'mattress brothers'. 
people with multiple medical problems need health care. if such a person is a child with no family, it takes a special person to even become involved in their life, much less adopt them. it shouldn't bear a penalty, but it will come at a cost. but here are my 'mixed feelings'. the person who is willing to adopt this child needs to know what they have to look forward to in the way of health care costs. yes, it may be a deterrent to said adoption. a family needs to know up front the financial costs involved and make the decision to adopt with eyes wide open. 
so, having a system where the costs of care are known as i have mentioned would allow there to be a forecast of future expectations of the financial aspects of such an adoption.
as for those families whose children or parents or brothers or sisters have these problems, but who are not up for adoption, or even for those people who have these problems themselves, there should be a way that they can live without their health consuming all of their assets. i'm talking about things that people have no control over - to provide aid for those with all the 21st century ills representative of our lifestyle would break any bank.
i still don't think the government is responsible for these problems. the government shouldn't penalize people for doing the right thing, but subsidizing them? i don't think so. there should be ways to not tax the money used for healthcare that's legit. much like where insurance pays for your gallbladder surgery but not your boob job, pre-tax dollars could be used for the former but not the latter.
so...rambling, i don't have an answer for people who, by doing the right thing, have added burdens to themselves that are not 'fair'. i really think many would do the same thing regardless of who pays for it. they would find a way. it may be the government involvement in health care that has caused the problems we have currently. without their 'help', the 'church' as a whole would have been responsible and it would have had to step up and show that the 'true religion' is their true goal. regardless of how these things turn out, He knows what He's doing, we don't have to worry. we have to work, we have to be active and we have to pray, but we don't have to worry. i suspect that many of our health problems would be gone, and others more easily managed, if we stopped worrying. but that's another blog.

Sunday, October 12, 2008

mirrors 2

ok. this may be a little deep and maybe i'm going down a rabbit trail or rabbit hole or whatever, but i thought of another angle on mirrors. here goes.
as parents, our children are mirrors. they do reflect what we do more than what we say, that is true. and it has been said that most of our beliefs are in place by the time we are 8 years old. 8 years old.  our 'programs', if you will, are up and running, including our world view, the way we treat other people, and many things of which i'm not certain, but i'm pretty sure there's more. that should make us pretty nervous if our kids are under 8 and very observant if they're older. we should take care of what our children see and hear. we should teach them the values we want them to have. they are like clay that hasn't hardened, cement we can put our handprints in, a blank slate we get to write on. we too often delegate this to others. i'm not talking about schools, because most of the time before 8 is gone before kindergarten starts, so even though some can make homeschooling work, not everyone can, and public school won't ruin your children any more than homeschooling or christian school will fix them. you are the most important teacher your child has, even if he spends a good portion of his day at school. your influence will reach through that of the teacher and the principal and the friends. your attitude toward others, how you treat them, what you say about them when they are there and when they are not, how your actions look when people are watching line up with those when you're alone, all these things will show up in 'the mirror'. your mirror. 
do you know those microphones that seem to have a delay between what is said and when you hear it? or those keyboards that have you typing for several characters before you can view what you've written? multiply that delay by a lot. what you do today with your kids may not show up for a long time. a very long time. the bible says 'train up a child in the way he should go and when he grows old he will not depart from it.' i had trouble with that verse in proverbs for a long time. i know plenty of people who are good people whose kids have turned out not so good. and i know the opposite occurs as well. but someone clarified it for me - it doesn't necessarily mean that they won't depart from it but it also means it won't depart from them. hence the discussion about programs that are running.  and mirrors. mirrors with delay. so thinking about our kids as mirrors should sober us and make us consider our actions. but there is a danger in this mirror philosophy. some people, many i would say, see these mirrors as something different. 
when we treat our kids like mirrors that are reflecting back on us, we make a mistake. we can't let this occur. by doing this we don't let our kids fail because we don't want to be seen as failures as parents. mistakes, poor choices, are good teachers if we allow them to occur and go to their logical end. when they are toddlers, we should let them be hungry when they don't want to eat what we've prepared for them. but she's so thin! if i take away her bottle she won't eat anything! the lady at walmart says she thinks my child has malnutrition! maybe even a vitamin deficiency! 
it gets worse when they go to school. teachers and school counselors are either witting or unwitting (is witting a word?) participants in this phenomenon. 'he's gifted, you need to get him into a special program after school' ' she's not performing up to her potential' ' he's our best player' 'she's not turning in her homework' ' he doesn't seem to care about his grades'. you name it, you may have heard one or more of these. the undertone of such comments is 'you're not a good parent' or 'you can succeed  through your child'. both are bad. moms seem to be more susceptible to the former, dads the latter. so you do their homework, put them in the special program, let them join the traveling soccer team, whatever. but so you look good in the mirror, you will do it. it often shows up as mom saying things like 'we have a lot of trouble in school' or 'we're not eating very well' or 'we're so busy going from practice to practice'. when moms say 'we', i cringe. in this setting, this means she is taking over for the child, and the child will be damaged by it. what is that mirror (the delayed one) going to look like when she grows up? when he goes to college? gets a job? never having been allowed to fail or quit the gifted/ap class or take time off or not perform at full steam all the time, he will have unreasonable expectations of himself, not knowing that he never did it alone when he was younger. she may be distressed, depressed, stressed. he may keep it up and pass it on to his kids, like the mirror that he is. his programs are telling him that to rescue his children is the right thing to do and that he would be a bad father if he lets them fail so he goes against what his education/religion/faith/psychology class/pediatrician tells him to do, and goes ahead and does what his mother/father did, almost without thinking. so the cycle continues ad infinitum. i see it daily on both sides, the 'bad mom' side at least as often as the 'dad living through his child's success' side. of course the 'bad mom' victims come to me for help for their 'poor eaters' and 'underachievers', while the stress fractures and misuse/overuse injuries of the latter group are their ticket into my office. it's amazing what one can see when one looks for it.  you just have to look in the mirror. 

Saturday, October 4, 2008


the only thing worse than having televisions (and loud music bothers me, too, but that may be my age) in restaurants is having mirrors. big mirrors, along the walls, where one can't help but look. it may be tempting to some to watch a sporting event while eating if the tv is within easy view. it truly is a temptation, no doubt, and for me, at least, it doesn't matter what's on, just that something is on. and i don't even watch that much in the way of tv sports at home on my own tv!
ok, though, mirrors are worse. it's nearly impossible not to look at oneself in a mirror that's within view. am i looking good? bad? do i have something in my teeth? is my fly unzipped? is somebody watching me watch myself in the mirror? it's a big problem. humans are drawn to mirrors like flies to ...
my favorite preacher on the radio, alistair begg, recently said "the value of the mirror is not narcissism so that we can congratulate ourselves, the value of the mirror is in order for us to see our predicament and do what we can to fix it." well, in a restaurant, beyond fixing a hair that's out of place or an unzipped zipper, we're faced with either narcissism or seeing our predicament. it always looks to others like narcissism, trust me. but to me, unless i happen to be in some place where i can compare myself favorably to the others in the mirror, i'm faced with a predicament, and that predicament isn't going to be helped by eating in that restaurant. i'm overweight, slouching toward obese. i'd like to be thinner. maybe they should put skinny mirrors in restaurants as they allegedly do in clothing store dressing rooms. then narcissism could at least have a turn. as it is, the mirror that i can't help but look at is showing me this guy looking back who's not the guy i picture in my mind's eye. and i hate the mirror for that. for showing the truth. 
my wife recently gave a great statement - "our bodies are older than our minds are willing to admit". ouch. what happened to "you're as young as you feel?" 
in the bible in 2 corinthians 10:12, paul says "we do not dare to classify or compare ourselves with some who commend themselves. When they measure themselves by themselves and compare themselves with themselves, they are not wise." so really a mirror is just a way to compare ourselves with ourselves of the past or some other "themselves" who are svelte and fit and look great. we are not to do that. sure, we are to see our predicament and look for a way out of it, whether it be physical or spiritual.
but the real fault is not with the mirror or the restaurant, they are just players. the fault is that i, like many of us, spend too much time, whether in front of a mirror or not, looking at myself. not in aristotle's "an unexamined life is not worth living" way, but in a "what about me?" "why me?" "what am i going to do?" "what do they think of me?" "what can i do to make them like me/love me/keep coming to me/keep working for me/keep paying me/keep being my friend?" way. those things are not for me to consider regularly. sure, a brief check in the mirror is fine, but to get lost in it considering the person in it is wrong. we are called to consider others more than ourselves. humility is not thinking less of oneself, it is not thinking of oneself. what a goal! in 2kings there's a king named hezekiah and he shows off his "stuff" - all the treasures of judah and the temple - to some people, in a "look at me and what i've got" way. God wasn't happy with that and so isaiah (i think it was him) told him that he would be punished and that the punishment was that his children and his children's children, yada yada, would never be kings and would suffer all kinds of stuff and the country was going down after he was gone. his response? "but nothing's going to happen to ME?" we are hezekiah, or at least i am. more concerned about us and now and what i've got or don't have than about my ancestors and neighbors and those around me every day at work or school or wherever and what my actions and words do to them or for them beyond what they get me and to heck with the budget deficit and the environment and social security and medicare and world hunger and the war in wherever and my church and my pastor and the lady who's ministering to inner city kids and my friends who are in pain from divorce or their kids and the effects on them and ... i can't go on. i feel like the teenage girl in boulder, colorado, from early in my practice when "mall bangs" were all the rage and cans of hair spray were used daily and 'green' boulder began to broadcast the depleted ozone message and the effects of aerosol cans and global warming and all that when it was new and news and her response was "to heck with the ozone, i've got to have my bangs!" ouch. 

Monday, September 1, 2008

my real healthcare plan

Everyone should take out a high deductible major medical policy to cover catastrophic stuff, big stuff, then have enough money available either liquid or line of credit, to cover that deductible should it be needed. Then we should pay out of pocket for our "incidental" stuff like sinus infections, bronchitis, sprained ankles, prescriptions, shots, checkups, etc. We could use a health savings account, use pretax dollars, and be able to "roll over" unused balances from each year if available. Then we would become better consumers of healthcare and not the entitled brats we've become. We would think more carefully about the MRI that's ordered, the prescription that's given, whether we should get generic, etc., and be responsible for our own healthcare costs. For families having kids, they might save up a few years' worth of savings from their good health to cover the costs of a new baby, and then the catastrophic plan would cover a premie with big needs or a high risk pregnancy. We would be more likely to have mom come move in with us, maybe we would even build on an addition for her and hire a nurse/aide to care for her at her home or ours, if we compared the costs of a nursing home and the heartaches of such an arrangement with this "radical" though time-tested method of caring for the aged.
Sure, you could go with the car insurance idea to decide how much insurance you could get for the money, but the idea of using the difference between the premium on your major medical policy and your "cover it all including prescriptions" plan to put into a health savings account with the ability to roll it over and even get interest on the money would help the elderly pay for their long term care since they've been paying into this for years and haven't been counting on the government to manage it, they've been managing it, and if they want to go to the Bahamas to retire to a seaside village "nursing home" and they can afford it, so be it.
I'm not political enough to know who's for this, if either of the candidates is, but I'm pretty sure it's not Barack Obama. 
As a physician, I should become more like our colleagues, the veterinarians, and know how much things cost and be able to give people a reasonable idea of how much things will cost and let them help in the choice. If there's a cost difference for the same procedure at one place vs. another, they should know. We would have a big element of change on our hands, both physicians and patients. For this generation, which has grown up saying "sure, go ahead, I've got insurance" to find out how much something is going to cost and decide if they should get it or do it, is going to be uncomfortable at first. It's going to affect malpractice because if I recommend something and the patient doesn't want to do it (like vaccines now!) then has a bad outcome as a result of choosing not to do it, I'm liable under the current system, even if I was adamant about them needing to do it or get it or whatever, and documented my advice. Maybe videotaping of consent will help this. You get taped turning down my advice. Now of course if my advice results in a bad outcome...I'm still liable and should be. And many things aren't black and white, and the definition of a bad outcome will have to be ironed out. Oh, so many things, but our consumer economy can get through it, we just have to quit being ostriches as far as how much things cost (physicians and patients) and be willing to present and accept options.
Unlike our friends the veterinarians, though, one of our options (at least currently) isn't going to be "or for this amount, we can put X to sleep". I'm a little afraid that time may not be far in the future, especially if humanist atheists are running the system. But I digress...

Sunday, July 20, 2008

But I need to know!

Very often, in the course of a day, a mom will bring a baby who is fussy. Or who has a fever, or isn't sleeping. It's amazing how happy they are when I find something wrong! Or rather, how disappointed they are when I don't. It's better for the child to have an ear infection to explain the problems than it is to have some viral thing without a specific name causing all the trouble. Regardless of the fact that the virus will pass without treatment and the ear infection will likely require antibiotics (for more on this, see future blogs about antibiotic use). Oswald Chambers, in My Utmost for His Highest, my favorite daily devotional, said on July 18 "We command what we are able to explain, consequently it is natural to seek to explain". In this instance, I think his words ring true. An ear infection is a known entity. Viruses are not. Some people will say "it's just a virus" and be happy or disgusted that their child was lucky enough not to get some infection that had a name or a treatment. The truly paranoid, of which there are a growing number, think of all the viruses that strike fear into the hearts of parents, like West Nile virus, or measles or mumps, or HIV, to name a few. A balance between disgust and fear is a reasonable position. It just is interesting that parents, especially closer to the weekend, are happy that their child has a "known" problem, rather than a nebulous one that is not as predictable or treatable, even though their child will live through it and be fine after.

Sunday, July 13, 2008

a behavior management metaphor

OK. I talk to parents daily and discuss behavior management. I try to teach to ignore certain things that aren't good if they aren't trends in that child's behavior but are more just episodes. But I couldn't/hadn't come up with an analogy until just the other day. And it really applies in several areas.
Our new employee lives in an apartment complex. They have assigned parking spots. They have the right to call a number and have a car towed that is in their spot. They pay for that right in their rent. So, someone parked in her spot. Once. It was a big truck. She debated calling the number for the tow, but decided against it for a couple of reasons. One, it may have been a mistake or ignorance on the part of the big truck owner. Maybe he wasn't informed of the policy, maybe he had an emergency and the seriousness of that superceded the importance of the policy at that point. Maybe, if she talked to that person, she would find out. Her choice was to call or just deal with it and park somewhere else. But, even though she considered the possibilities above and chose not to call, another reason for not calling was that she was afraid of the response of the person driving the truck. He would know who called because the spots are assigned, and he might cause her some trouble if she exercised her rights. So, she didn't report it and let it go. And it's only happened once. Did she make the right choice? Yes. Were her motives good? Yes and no. Or maybe just yes. However, if the truck continued parking in her spot because of her lack of response, if it became a trend rather than an episode, she needs to report it and take it to the next level. Regardless of the possible ramifications? Maybe. She should definitely consider these and make plans to control them to the best of her ability, and she should find out who this big truck's owner is and why he's parking in her spot. Then, if he is just doing it because he can, and he refuses to cease and desist, she must exercise her right to the spot and take the necessary actions.
Can you see the analogy between this and a child's behavior? Maybe he forgot to take out the trash like you told him to. Maybe she didn't remember to make her bed, or to call when she got to her friend's house. But if these things continue, and the rules are spelled out and communication has occurred and the behavior begins to be a trend rather than an episode, the parent must take action. Action taken when it truly is an oversight or accident is counterproductive and often results in the attitude of "heck, I get in trouble no matter what I do, so I'll just do what I want because my parents are controlling jerks and yell at me when I make a little mistake". Whereas, if the episode is overlooked and the child later realizes it, and is remorseful ( I know I'm asking a lot of the imagination), then great strides in trust and relationship have been made.'s ok to find another place to park every once in a while, even though it is your spot and you have every right to claim it for yourself. You may end up with a new friend or a relationship that you didn't expect, because the owner of the truck really didn't mean to park in your place and he's really surprised and grateful that you treated him with respect despite his behavior, or his perceived behavior. Motive is the key. Many are looking for reasons to get mad, to exercise their rights, because they see the affront as being toward them vs. an honest mistake or an episode of behavior. Parents have to be grown up enough to distinguish between episodes and trends, to be willing to park elsewhere if needed, or to call for a tow truck if needed, and to not be afraid of the child's response to this and the damage that child could do if called to account for the behavior. But boy it's easier to call for that tow truck if you'd made every effort to communicate with the child and only have them towed if they are unwilling to fix their problem. Maybe on another blog we'll discuss what to do when the tow truck is called. 

Sunday, June 22, 2008

"be like a child..."

Being like a child seems to be getting harder these days. It's always been hard for adults to be like children, but now it's hard for kids, too.
I saw a first grader last month with a "to do" list. Anxiety related problems are more common than ever in children in my practice. GERD, breathing problems, stomach aches, headaches, they are all at least potentially and in part anxiety related disorders.
Kids have been told to have good self esteem, and the trouble is that with self esteem comes self awareness, and with self awareness comes the awareness that they're not as good/perfect as they've been brought up to believe, and that stresses kids out. What's the answer to this problem? Should parents stop praising their children? Should we stop preaching self esteem and be more honest in our appraisal of our kids while emphasizing unconditional love? What would that look like?
"I love you no matter what, so you don't have to worry about that. No matter what you do, I can't NOT love you, so chill and rest in that assurance. Now, about that...grade, performance, attitude, behavior, etc..." Kids know they're not perfect, but as my wife quotes often, "a lie told often enough becomes a truth, even if it is a lie". So, a realistic view of our children is now considered demeaning and limiting and "not allowing them to realize their potential or explore their boundaries".  Pretty much you're bucking the trend if you try to raise your children with a true self awareness that includes their moles and warts and accepts those as a part of a loved person but that some people are better at some things than others and not all kids are really as "special" as they've been taught in school - just by breathing they automatically get credit for being the next rocket scientist or Tiger Woods and people push them to expect things from themselves that are unreasonable, then they're stressed and depressed and they go into therapy where they're told that no matter how broken they are it's not their fault and there's medicine to help their alleged chemical imbalance and when that doesn't fix the problem they again go to therapy where another diagnosis is made to justify another unnecessary and dangerous drug and the cycle continues until they either grow up and become realistic or grow up and become more unrealistic and expect others to adjust to their weirdnesses since it's obviously the other people that have the problems, not them, because they're "special", their parents and teachers told them so a long time ago and dadgummit, they believe it. Whew! My high school English teacher would dissect that sentence and use a whole red pencil just to mark the errors, but it felt good to vent.
OK, childhood does still exist, but I just found out about it. A 13 year old friend of mine described staying out til 10:30 the other night playing dodge ball and hide and seek with other kids in the neighborhood. Thank goodness that still happens. Amazing how I don't have those kids in my office for stress-related disorders like the kids who just got back from their soccer tournament at 10:30 and fell into bed to get up and travel to another tournament tomorrow where they're likely to get yelled at for not playing as hard as they can or not played at all because they aren't scoring like another kid on the team. Oh, don't get me wrong, to play everyone on the team for the exact same amount of time without regard to performance is to play into the above self esteem game, but I'm talking about the kid who comes and practices and tries and has a good attitude, but needs a chance to prove himself but can't get it because every game is too important to risk losing to give a kid a break. Enough on that, most of you know my opinions of youth soccer, or any team sport in young kids for that matter. But childhood is still out there to be had, and I'm glad, because the lightning bugs are still there and the woods are there and the imaginations are there to build the fort and make the club and we, as adults, must let kids do these things more, even if it's a little scary, because if every minute of every day of your kids' summer is planned with camps and lessons and tournaments and trips to Disneyworld where they better have fun because it cost you a bundle and they better not mess it up and it's more about you than it is about them because you're trying to be a super parent so you can talk to other super parents about how super you all are, while leaving your kids in planned activities because God forbid they should have any free time or they might not realize their potentials, then you're going to have Harry Chapin's "Cat's in the Cradle" playing at your funeral and your kids are going to send flowers but they're too busy maximizing every opportunity to come to pay respects and say goodbye. Ouch, that hurt. Sorry. No, I'm really not. I'm making a point. Sometimes one has to go over the edge to make the point, but the point needs to be made that kids need to have time to be kids, lest we begin needing to put prozac and adderall and nexium in the water supply because we're all depressed, distracted, and have indigestion.

Sunday, April 27, 2008

healthcare plan 2

OK, I know it won't work to make health insurance just like car insurance. You can drive safer and have lower rates, or have wrecks and tickets and get kicked off your insurance, and even if you're "innocent" in a wreck or problem, your rates still seem to go up. That doesn't seem feasible for health insurance. Too many things are "innocent", especially with kids, who are at the mercy of their parents, and to be too restrictive in the care that some parents seek for their children would be to invite disaster. So we probably shouldn't punish people for health problems but...and in this I'm the one I'm talking about...the health problems we bring upon ourselves by doing things we shouldn't do and know better, those might need to be grounds for raising our premiums. These are the tickets, speeding, reckless driving, DUI, etc. Some are forgivable if only in their commonality, but some are downright bad not only for the person doing them but also for those around him.
I obviously wax philosophical at times, quit laughing, and I need to be grounded by wisdom vs. overthinking. A friend did this for me yesterday. We were discussing (I was spouting off, he was apparently listening) whether the chemicals in plastic were a concern since we're all drinking from plastic of some sort all the time, it seems. He said "until people aren't obese and they are exercising at least a little and they take care of their type 2 diabetes and high blood pressure and high cholesterol, I think it's stupid to worry if the chemicals in plastic are harming us. We're harming us!" I took liberty with the quote, his was more pithy than mine and I don't recall the exact words but the message was loud and clear. We strain at a gnat and swallow a camel as Jesus said. The chemical issue is the gnat, the obesity "epidemic" is the camel. Sorry, but some need the explanation of the metaphor. 
So...perhaps the equivalent of "points" in the car insurance industry - where our records reflect our wrongdoings like speeding tickets and the like and our premiums are up and down commensurate with the number of points - should be our weight, waist size, BMI, you pick the measurement, and make it broad (no pun intended) to account for those of us who are "big boned" but not really obese (yeah, right). Truly there are persons whose weights or BMI's look to be out of whack but they are in shape, etc., and need not be punished. Perhaps to justify one's size, one must come up with laboratory results that reflect the state of one's health - so if your BMI is over 30, but your cholesterol and triglycerides and hemoglobin A1c are in acceptable range, you're exempt from the premium increase. Life insurance companies sure don't mind raising premiums if you're high risk. So, if your weight or BMI is OK, you're good to go on the "no points" premium, but you're rated higher for obesity, etc., if you are, in fact, obese and can't provide good evidence that your obesity hasn't apparently endangered your health yet. I guess you'd have less money to spend on food if your premiums were high, then you'd lose weight, right? Wrong. Because good, healthy food, unless you grow it yourself, is at least allegedly more expensive and doesn't keep as long as the frozen tv dinner with 40g of trans fat per serving. 
This little aside is to let people know that I realize you can't just penalize people for having bad health by charging them more for health insurance. Too many illnesses are not directly the cause of anything we know anything about. Babies born with birth defects through no fault of the mother or father. Premature babies who just happened to be born a few weeks early and had to spend expensive time in the intensive care unit. Someone gets run over or into by a drunk driver. 
Realize that anytime we begin to discuss such things the issue of euthanasia or "letting someone die" or attaching quality of life potentials as parameters for who lives and who dies begin to surface, since an entity, likely the government but just as easily Blue Cross and Blue Shield, will be determining who pays what for health care and how much should any one person get, etc. Tough questions. Not for us to decide. For God to decide, but God, though He hasn't been consulted on these issues in our science for quite some time, often has different ideas than our human wisdom. We've taken Him out of the equation, and what's funny, even sometimes I, as a Christian who should know better, forget that He is sovereign over all. I have a parenting technique I tell parents about called the "good luck" theory, I think I stole it from Foster Cline and Jim Fay of Parenting with Love and Logic, but oh well. I think God knows about the "good luck" theory. He's saying "good luck", go ahead and try to decide who lives and who dies and who has what cancer or disease and try to cure it and screen for it and delve down into the human DNA code and see what you think you can do with it - I created the whole thing! Try to make things perfect here on earth by eliminating disease and suffering and starvation and toxins and try to have your cake and eat it too by flying and driving everywhere and using food for fuel and...good luck. The next line after "good luck" is "I'm sorry" when things turn out the way the parent knew they would. God has infinite patience, and I think He's saying "I'm sorry" to lots of things right now. There was a good Dilbert recently where the boss presented an idea that we could turn fresh water into oil - and thankfully Dilbert saw through the solution to the problem and asked "wouldn't that turn the world into an uninhabitable wasteland in the long run?" Someone needs to follow several lines of medical and other scientific "logic" out to the long run. 
My point there was that we really have no ultimate control over things, we just think we do. We play around with genes and chromosomes and talk about stem cells and cures for diseases, but in reality, we're kids playing in the sandbox while the One who made the whole beach is just watching and waiting and letting us think we can do it our way, and what's worse, that our way is better. At least that's what many think. That the way God's had it going for several millenia is a bad deal and that we, as humans, are here to save the day! We've got a better plan.

Back to health insurance, sorry. We need to quit requiring every test for every thing there is before we act on anything. I'm all for making sure a diagnosis is correct, but did you know that there was disease before the MRI was invented? And people somehow managed? Doctors made diagnoses by taking histories and doing physical examinations and thinking and studying, whereas now even if we do the H and P and actually think and study, we have to have our decisions backed up by test after test, so after a while, it's easier just to do the test and forget the first part. That's where much of medicine is, and the public is partly responsible. It's like depending on a calculator vs. learning simple math. Sure, the calculator's nice, but if the basics behind it aren't known, a vital piece is lost. Or even more pertinent and current, keeping phone numbers in our brains vs. our phones - once we start using the phone to store numbers under peoples' names, etc., we lose the memory of that number and rely on the machine vs. the mind. In medicine, the public currently is bowing to the prowess of the equivalent of a synthesized computerized piece of music over the art of a gifted performer. We want the test, not the doctor's opinion. But what's funny is, the patient wants the doctor, too. They want to know what I would do if it was my kid. Or my dad or mom. They can search out the diagnosis on webmd and they still want the doctor to confirm it or refute it.
So, as far as I'm concerned, we still need doctors. We still need hospitals and medicines and tests. Don't get me wrong. I like storing numbers in my phone. I just don't want to lose the ability to remember them myself. The art of medicine is to decide when to go with the obvious diagnosis instead of covering one's ass with a zillion dollars' worth of tests. And this is where both doctors and patients will benefit in a good healthcare system. The doctor who is able to practice good medicine, I mean good medicine, with a minimum of testing and treating, would be rewarded, and the patient who goes to the doctor for a real problem vs. a problem they think they might have and demands a bunch of tests is penalized with the doctor who orders a CT scan for every headache and a CBC for every fever. Just because one can order and do a test doesn't mean the test is needed. We've lost the doctor/patient relationship over the past 2 decades due to insurance rules and tests. 
So...we need to remember Who created us and that He has a plan. We are apparently being forced into at least discussing a "new" health care plan, and depending on the winner of the November election, the discussion will differ, but the outcome likely will not be that different. We are talking about doctors and patients here, and neither handles change well, especially change that feels like it's forced upon us. It's amazing that no insurance or government entity forced the concept of the "urgent care center" upon us, but I would venture that these "docs in the box" are the fastest growing healthcare providers around. Obviously, the drug companies and the doctors who write for their products are paying no attention to the fact that people are having to spend more and more at the pharmacy for their medicine. And as newer tests become available, patients demand and doctors order (or is it the other way around) ultrasounds so expectant parents can have daily cell counts on their new embryo! Or MRI's on joints that are sprained, and then instead of a "sprain", which sounds mundane and survivable, they have a "torn ligament" or a "stress fracture", which sounds (and is) more expensive. And guess what? The insurance company will pay for more physical therapy for "stress fractures" than shin splints. So, we're shooting ourselves in the foot, and we probably should stop. It's going to be hard, it's hard for us to give us something then tell us we can't have it anymore. There will be so many loopholes in any new healthcare plan that it may need to be administered by the IRS! 
OK, that's enough. Just rambling. Maybe I can take off on one of these thoughts and go for another hour or two, but I'm done for now.

Tuesday, April 8, 2008

my healthcare plan

OK, I'm not running for office here, I'm just ranting and putting some thoughts together formed from 20+ years in healthcare.
Why can't health insurance be like car insurance? Or homeowner's? You have to get it, by law, at the car insurance. To get a tag for your car you have to show proof of insurance. Sure, some fake it or lie about it, but most (I think) really have it.
So make it a law that people have to have some level of health insurance. If they qualify by income level like for DHS support, they can get it for free. But they still have to have it. I have told people for years that they should buy a major medical health insurance policy with a high deductible, to cover catastrophic stuff, and then use the money they save vs. a full coverage policy with prescription drug coverage, etc., to pay for their occasional doctor visits and medicines. 
You may say, "but people won't be able to get the drugs they need or the tests they need or the medical care they need...". Here is where "need" needs to be defined as true need and not "want" or "expect".
The proliferation of prescription drugs to "fix" all our social and personal ills is a good sign that there's money to be made in this business. It's like all the restaurants going up all around, people want to eat out, and they do it a lot. And people want pills, a lot of them. Driving through town today I saw evidence of so many things that are "wants" and not "needs" and they are unashamedly marketed out there on the street for people to see and "want" some more. Before I go on, I should tell you that I'm like the guy in the AA meeting standing up and saying, "hi, I'm Kelly, and I'm a 'wantaholic'". I see these things because I'm looking for them and they tempt me. Maybe if I was closer to the "need" stage, if I had little kids, especially, I'd be less likely to be going off on these things, but I don't so I am. Exotic play grounds for the backyard, all redwood and bright plastic with slides and faux rockclimbing attachments, the kind you used to only see in neighborhood playgrounds or God forbid, school playgrounds. I'm talking big monstrosities that look like they'd take a crane to get them in the backyard or several weeks of putting tab A in slot B and then screwing it all together, a nightmare in my opinion. Well, I digress. Well, except for pets. Like kids, there are things available for pets that someone visiting our country from even 20 years ago would have laughed at in amazement. Play groups for pets, dog parks, and supermarkets with only pet stuff, most of which no pet would even care about, much like much of the junk available for kids who'd rather just have a stick and some dirt and maybe a tree to climb and a bike to ride, but we "need" this stuff - because it's available and for sale.
Back to the health insurance issue, after my rabbit trail and segue back in - most of the medicines and tests like MRI and 4D ultrasound and designer blood pressure/cholesterol reducing drugs, reflux medicines, antidepressants, stimulants for ADD, etc., are really "wants" disguised as "needs". They are available, we know someone who has had one or takes one and so we think we must need one, too. And besides, they're for sale and all you have to have is a doctor's order, or at least that's what the commercials say. Commercials for medical stuff - another thing that a visitor from the not so distant past would find amusing, until he saw how well it works. Sure, the drug companies used to buy doctors by buying lunch or golf trips or whatever, and they still do, only mostly with food now, and "consulting fees" or "speaker fees" by having one of us review an article about their drug and then talk to our colleagues about them at a fancy restaurant. And this is paying off, I have no doubt. But nothing has paid off as well as "just ask your doctor about...". The 4 hour erection on the ED drug commercials is the best way I've ever seen a drug's potential side effects sold as a subliminal tease. I remember a show on "commercials you'll probably never see" and there were these 2 boys about 8 years old who are talking about what they're saving their money for and are overheard by their mother when one says "I'm saving up to buy OB tampons" and the other one says, "OB tampons, why?" and the first one says, "I saw on TV that if you buy OB tampons you can go swimming and skiing and biking and hiking..." and of course the mother cracks up quietly laughing. Commercials affect different people differently. And instead of eating right and exercising, I'd like a pill to make me get in shape and lose weight or lower my cholesterol and make me smarter without studying and a procedure to erase the wrinkles of aging and suck the cellulite out of my thighs and...
So we're now selling medical care as a "need" when most of it is really just a "want". That a CT or MRI is "standard" care for a painful shoulder or knee or for a headache is a recent phenomenon. To some degree driven by malpractice fears, doctors are able to justify an "overevaluation" of fairly common problems. The thought process of diagnosis is often short circuited by all the tests. That's a different topic, sorry. But the idea that our insurance should pay for whatever whenever is a fallacy that has gotten us to this point, and we're going to have a hard time getting off this high center of expectations from the public. I'm not going to argue that healthcare is a 'right' in our society. It is, because we say it is. But how much is 'right' when it comes to healthcare? Is there such a thing as too much? I think we all would like to think that at least some healthcare is a good thing, so there is such a thing as too little, but too much? The way I see it, we're well into a 'too much' phase right now. Too much medicine, too many opportunities for elective procedures, too much screening (in the name of health, but in reality a ploy, many times, to generate business for a particular segment of the healthcare industry), too many required tests, too many lawsuits for too much money. But we've come to expect this level of 'care' and it's going to be hard to cut back. I tell parents all the time to start small and work up with praise and rewards, etc., or they may get to the point where there is no reward large enough to make a child want to do something to get it, because the child already has it all. We are those children, and in fact, we have watched this thing grow right in front of our eyes since most of us were children. I can't tell you how many times a parent says something like "my mom never took us to the doctor unless we were dying". So why didn't she? Was there not a doctor around? I don't think so, because then they'd say, "we never got to go to the doctor when I was a kid because the nearest doctor was too far away". Was there not enough money? My dad was a doctor. I remember him charging $10 for an office visit and taking items for barter if the patient couldn't pay. Money for a doctor may have been somewhat of a luxury for some, but it wasn't the astronomical figure we see now, even with inflation. What is responsible for this rise in cost? You don't have to pay for it anymore. You pay for insurance and your insurance pays the doctor. It's like going out to dinner and not having to pay. Or, more realistically, you don't have to pay while you're there, you may get a bill for part of the meal later, but it's distant from the actual meal so it seems separate. Which gives rise to people forgetting how good the meal was and how they ordered dessert and an extra drink at the time because they wanted it and it didn't cost them anything anyway, so when the bill comes, they argue about paying it. I could run this analogy's legs off if I desired, like how you could go to certain restaurants and have dinner and have it paid for, but for others you had to pay, or at least pay more of the bill. And you could only order certain things unless you had prior approval. But I won't.
Automobile insurance is different. The expectations are different from the outset. If you want, you can only pay for liability insurance that covers any damage to others but doesn't fix your car. You don't expect insurance to pay for filling up with gas or getting an oil change or a brake job or even a new transmission. You have insurance to pay for damage done in accidents. And you don't even want to turn in many claims for that unless you want your premiums to go up. So you pay for the repairs out of pocket. How would this look in health insurance? 
Maybe we could buy an insurance policy that would cover big stuff, like accidents or severe illnesses. Then we could pay for the incidental stuff out of our own pockets. I'm cutting my own throat here, so be nice. If you had to pay for your baby's checkups and shots, you'd be looking for the best deal you could get. Sure, you want the best for your child, but if Dr. X charges 25% less for his checkups than Dr. Y, you're at least going to go see for yourself. This is the WalMart mentality. The best for less, or something like that. So, Dr. Y either has to convince you that his fees are reasonable due to better service or something else he provides that Dr. X doesn't, or you're going to change doctors. The same thing goes for procedures, and medicine, and vaccinations, and on and on. Capitalism at its finest. Ouch! No longer would there be this built in fee schedule based on what the government will pay for things. This is a pretty easy thing to see, I think. Competition is good for a business. It makes the consumer the driver of cost more than the government or big business. There is a place for the profession to police itself and the consumer needs to know that he doesn't know as much as the professional in some instances. In the same way that I take my car in to be fixed and I don't know what's wrong or I don't know how to fix it or have the equipment to diagnose and repair it, I have to rely on the expertise of the expert in this area. To some degree, I am at his mercy. But one develops relationships which are built on the assumption that the mechanic can do the job I'm paying him to do.  If he does it well and charges a reasonable price, I'm usually happy to pay it. Sure, I could go to a different mechanic for every problem, but having one who knows my car, and knows me and the way I drive and what I use a car for, that's important. In healthcare, as I'm sure in car care, there are many opinions out there that the 'experts' are ripping you off, making you sick, not doing you right. This lack of trust is natural when one is spending money on something that isn't always tangible. Like the story of the electrician who comes to a house to fix some appliance and all he has to do is push some button or tighten a screw, and when he gives the homeowner the bill, the homeowner gripes that "all you had to do was..." and the electrician responds by saying that the homeowner is paying him for the knowledge of which button to push or which screw to tighten, not the actual work. 
So, as a pediatrician, I would need to be competitive in my fees or provide something special that others didn't, in order to have higher fees than the guy down the street. It's the steak dinner at Denny's vs. the steak dinner at Outback vs. the steak dinner at Boulevard Steakhouse. There's a difference. Yes, it's all steak, it's all cooked and served to you, but some prefer to move up a notch or two in quality or service and are willing to pay for that difference. So there will be doctors who do the basics and ones who provide a level of care above the basics. One would hope that each would be reasonably similar in their ability to diagnose and treat common problems, and the difference might come in the amount of time one spent with the doctor or the waiting time was less or the office was nicer and cleaner and friendlier. There will be, and already are in some places, doctors who provide a 'concierge' level of service. They don't accept insurance payments and are pretty much on retainer for a certain number of patients who have access to this physician when they want it and don't have to put up with the 'regular' stuff the 'regular' patients deal with. This will become more common. 
So, we are not cars. We don't just decide not to fix someone and sell them or scrap them. That's illegal, immoral, and generally distasteful. We don't get a 'lemon protection plan' and we can't just get a new kid when the old one 'wears out'. And we're not pets. We can't just decide to put our kid to sleep if he's got some illness that's going to be difficult or painful or expensive or all of the above. But there are similarities. We can use 'premium' gas and extra long life motor oil and the best spark plugs and really pamper our kids just like our cars. We can buy the best dog or cat food and have them groomed regularly. But those are our choices and we pay for them. 
We get diseases that must be treated. We have accidents. We need doctors and nurses and hospitals for some things. We need MRI sometimes. We need medicines sometimes. But do we need them as much as we think we do? What if we paid for it? Out of pocket, prices listed on the 'menu' at the desk, optional extras like prescriptions called in or faxed vs. written, shots with clean needles (just kidding), phone calls returned the same day for one charge, within a week, different charge, sort of like shipping charges. 
This is all well and good for most of my population of patients. I think they'd find that they need me far less than they think when they had to pay out of pocket. They'd be less demanding in some ways, more in others. They probably wouldn't come in for a cold as often. They'd wait and see if a child actually got sick before they came in, and they'd have an opinion as to what drugs we used to treat the child (more than they do already). This shift of responsibility to the patient would cause many changes in my behavior and that of my patients. Do you want to see the doctor? That's this much. If you want to see the nurse practitioner, that's this much. If you want to see the NP but have her consult with the doctor, that's this much. Would you like an estimate to fix your problem or do you want us to fix it while you're here? This is already happening in consultations with some specialists. It would be a different world. I would have to earn your business because there's another doctor's office that you pass on your way to mine and she's pretty good. This already happens with urgent care centers, but when people figure out that they're paying double to have their kid checked by a doc in a box and then come see us the next day or two for followup when they could have/should have just waited until the next morning and visited us once. But this is America and I want to be seen now! Even if it's by someone I don't know and don't trust and now that I'm here I'm wondering if this is the right thing to do and I think I'll go see my doctor tomorrow anyway. Enough on that. That's not the future, that's the present.
For patients with jobs and some money, those not on welfare, it would be a requirement to have a major medical policy to cover catastrophic illnesses/accidents so you don't go bankrupt paying for this problem. This should be pretty cheap compared to what most insurers charge for 'full coverage' currently. Flexible spending accounts or health savings accounts could provide the cushion for the 'regular' stuff like checkups and ear infections and the occasional stitches, etc., and you'd still save money. I've told people this for a long time. I even said it several paragraphs ago. But to do this we would, doctors and patients alike, have to change. Quite a bit. But it's amazing how money is a catalyst for change. Many things we have now would decrease or go away. It might go back to where only the rich and famous could have cosmetic surgery. Where only professional athletes had their knees MRI'd 'just in case'. Psychotherapy would be the domain of the rich and famous (maybe the ones who didn't get their cosmetic surgeries, or maybe the ones that did). We would observe mild viral infections and see how our child fared, seeking care only if things were not progressing normally. We wouldn't screen our 2 year old boy for autism because he isn't talking yet even though the reason he won't talk is that he doesn't have to because you do everything for him and talking would just complicate life. We might go back to the 'old days' where an illness was allowed to 'run its course' and we'd all seen one do it and the kid survived even an ear infection without an antibiotic and an antihistamine/decongestant and alternating tylenol and motrin every 3 hours to make sure he doesn't have a fever even though the fever is what God gave us to help fight the stinking infection to start with...I digress. Again.
OK, enough about how wonderful life would be if people had to pay for their own oil changes and fillups. How only major crashes would involve insurance companies and capitalism would reshape the healthcare industry. What about the poor? Those zillions of uninsured or underinsured? 
Well, for starters, in today's world, if we adopted my 'car insurance' plan above, we'd all be considered underinsured. 
But for the truly poor, one of a couple of things would happen. What would likely happen is that the state would pay the premium for this 'major medical' policy and there would be state clinics and hospitals contracted to care for the incidentals like checkups and earaches and stitches and those contracted providers would be paid a lump sum by the state to care for those for whom they are responsible. This payment would likely not be very much. It isn't now. That's why it's hard to find doctors willing to care for patients on state insurance. There's no good answer here, and the idea of healthcare as a 'right' has to be defined. How much? How soon? How good? Depending on the income qualification for the state insurance, one could envision a plan where the only difference one would experience would be at the hospital level, where a state hospital would go back to the status of a teaching hospital maybe with either altruistic doctors who love to teach and care for people regardless of their ability to pay or doctors willing to work for less because they can't make it in the 'real world', or they're honing their skills to make it 'out'. At the outpatient level, this population could pick their healthcare provider like everyone else and use a health savings plan or plain old cash and shop for 'the best for less'. 
The other scenario would be that doctors would care for the people unable to pay along with those who are able to pay, and either charge them reduced fees on a sliding scale, or be really Christian and just see them for free. If everybody (docs, I mean) had a few of these patients, it wouldn't be so burdensome. 
But none of this is going to happen, because of American politics and expectations. We're all going to be forced to pay more for healthcare, whether we need it or not, and the government is going to dictate the prices and who gets what tests and really it's not going to be a whole lot different from the sorry state it's in now where people want prime beef steaks for Denny's prices and are upset when they get a bill for the difference. I don't see it going to a Canadian system or a British system where if they run out of money before they run out of year, all the surgeries and tests scheduled get put off until the new year begins, unless you die before that in which case, they're sorry but someone gets moved up on the list. We have too much invested in our healthcare economy to dismantle it completely to go to the Canadian system, where I've heard there's maybe one or two MRI machines in the country and there's not a 'heart hospital' where you just check in and get your stents placed because of your 'cardiac screening' results the day before. There will be a 'concierge' level of healthcare pretty much regardless of how the elections go and what he or she does to Medicare and Medicaid and what the FDA does to streamline drugs into the system and whether third party payors will continue being more and more restrictive on where they'll spend your money. They may try to put everyone on a 'diet' of less fancy stuff, but I bet, given the lobby power of the pharmaceutical companies and big business medicine, they will continue to treat healthcare as an inalienable right whether you need it or not, but they'll try to ratchet down the cost by just paying less for it, and the doctor is supposed to sit still and be happy he still has a job. That's when the quality will go down, even further than it has, and medicine will be a job and not a calling for most people, and docs will just leave at 4:30 because their shift is over and they don't feel any accountability to the patient because they're just a government employee in a white coat. And then, like some who choose to pay for private education for their children even though they still have to pay their 'fair' share of the tax for the public school, people will be willing to pay for a level of care that stands out from the government clinic or hospital and is not as accountable to the government but is instead accountable to the patient. It's a slippery slope, and it's been slipping since the concept of HMO was born. Can you imagine a CMO - car maintenance organization? Where you are told where to take your car for gas and oil changes and who can work on it and how often it can be worked on and you get in line for a transmission overhaul or a new set of spark plugs because there's a waiting list and the mechanics get paid by the number of cars under their contract and not by the number of cars they actually work on? And we ate it up when Hillary made it the topic of her first 'presidency'.
OK, I'm through, sorry for the rambling.