Sunday, March 4, 2012

white space

in reading malcolm gladwell's book, Blink, i came across a phrase, a concept, that i find interesting. in a part of the book dealing with decisions made in a hurry that turned out wrong, such as police officers shooting someone because they thought he had a gun when in fact it was his wallet, he mentions that the situation set them up to assume he had a gun and that the circumstances were not such that they had any 'white space' to consider their actions more rationally...they were acting on instinct, in this case, wrongly. the whole book is really a wonderful read and sort of reinforces my notion of balance, in this case between acting quickly and decisively on gut feelings vs. considering/thinking long and hard about a decision. gladwell explores the goods and bads of both. i recommend the book.
now to my point...i find myself providing 'white space' more and more. in my capacity as a pediatrician, i am faced with emails, texts, phone calls regularly that are from people facing a problem and they are wanting advice on what to do. usually it's at night or on the weekend when the 'white space' provision comes up. 'do i need to take him/her to the ER or urgent care for this fever/cough/earache/belly pain/acting weird/possible ingestion of poison/bonk on the head or can i wait and see how he/she does?
this wasn't an issue in the not so distant past when there wasn't an urgent care center on every corner. i'm waiting for starbuck's to add a clinic. even my employer has sided with the devil and has clinics in walmarts. and this wasn't an issue before the news started getting bored with just what was happening in the city/state/nation/world and started running stories on the weird stuff that very occasionally happens to people in otherwise seemingly normal situations. 'he was fine until his shots, hit his head, got a fever, started coughing' name it, 'and then he 'had a seizure, stopped breathing, started bleeding, went unconscious, has never been the same'. mind you, these things sometimes happen. but way more often, they don't. and often the talking heads have to go far and wide to find the story. and of course they wouldn't run a story on a kid who fell off the counter and landed on his head after having a fever of 105 and drinking a bottle of tylenol and eating honey and peanuts together in infancy and lived and was normal. that's boring. but that's normal. but it's not normal if you aren't afforded any 'white space'. if you've just watched the story of the kid who got brain damage and died from a seemingly innocent fall and you hear that sickening thud in the next room and realize it's your baby who just learned to roll over when you thought he was safe on the bed...his dad was watching him while he was folding laundry and just stepped away for a second to shut the lid of the washer so it would start...and you rush in all scared and panicked and set up for an adrenaline-charged reaction (with a heavy dose of guilt because you were watching the news or getting stupid updates on facebook and following rabbit trails on the computer looking for things to worry about so you could avoid all pitfalls in the life of your child when you should have been either the laundry or the baby-watching - send your comments, i'm ready) and you rush to the ER and the goose egg on the kid's head hasn't even gotten a chance to grow. there you run into a doctor who just read an article on 'the effects of traumatic brain injury on otherwise normal children falling from beds at home while supposedly supervised by their parent and who look completely normal and way better than their parents' who is similarly set up to see helicopters landing outside to take your child away if he doesn't act quickly (or he sees lawsuits being delivered on said helicopters because he missed the traumatic brain injury and your child was that rare exception he just read about and you just watched on TV). nobody looks at the child. they do a CT scan. why? because they can. because you want them to. because they think they are supposed to and are justified in doing one. because the hospital owns the CT scan machine and they didn't buy it to toast bagels, they've got to pay for the crazy thing so you'd better use it when you can or your job might be in jeopardy and besides, once you do it you're off the hook and now the radiologist who reads the scan has to interpret it and make the right diagnosis (at least the radiologist isn't supposed to have seen and examined the child first).
nobody considers that the radiation from the XRay or CT scan will add up over time with other 'necessary' tests involving radiation and when the 40 year old kid who somehow survived all those falls off the bed and those jumps out of the swing and stitches and casts now has a weird cancer and that maybe it had something to do with the cumulative radiation exposure from said tests. we're just concerned with the immediate problem.
back to 'white space'. in allowing patients to email me (or text/call if they have found my cell number) perhaps i (and cathy, too, don't forget the cutest little curly headed provider of 'white space' to good Catholics and friends of her daughters everywhere) provide the time needed to slow down and think a little,  the shoulder/s on which to unload at least some of the responsibility, so that all minds can get back to the common sense that says 'he's running around playing, he just ate a crayon and didn't throw up, he's opened my iPhone and is accessing his own apps...wait, he's downloading new apps, who gave him the iTunes password?' and i guess he's fine and i'll stay home and not go to starbucks where they have a caffeine addiction clinic that also sees children and they have a drive thru CT scanner that is begging me to pay for it.
ok. i'm happy to provide 'white space'.
most problems don't need an evaluation right away, if at all.
the reason that 'ER' and all those hospital shows get weird really quick is that the exciting stuff...well, it just isn't that common. it's mostly patients set up to worry about the miniscule chance of a fever and headache being meningitis or a stomachache being appendicitis or a head bonk being an epidural hematoma colliding with a room full of people who are primed for an emergency and whose assumption is that your child has all those things and more until we do enough tests to rule them out.
there's an old medical joke that goes 'an internist, a radiologist, a surgeon, and a pathologist go duck hunting. some birds fly over. the internist looks and looks and says they may be ducks but they might be geese and i'm going to need to run some tests before i decide. the birds fly away. next flock of birds flies over. the radiologist says these birds look to be consistent with the appearance of ducks but are not absolutely diagnostic of ducks unless coupled with clinical evidence to support the presence of ducks. the birds fly away. the next flock of birds come by. the surgeons stands up, starts shooting every bird he can see, then he turns to the pathologist and says - 'find me a duck'.'
we have a lot of information and a lot of ways to act on that information and unfortunately no guaranteed filter through which to sift that information. we're going to miss shooting a duck sometimes, and sometimes something other than a duck might get shot. but in the end, 'white space' allows people to look a little closer at the flock of information and act correctly most of the time instead of jumping to the worst case scenario conclusion quickly and acting on it.
so, maybe 'primary care provider' isn't the best name for us. it's not PCP now, it's WSP.


Candice said...

Nice. I would have to say when Cole fell into the corner of a window sill and had a little bit of an indent in his huge goose egg if his doctor was inaccessible and our good friend was not an ER doctor who would look at him real quick at her house we may have gone to the ER. She told me that the CT scan could give him enough radiation for future cancers...why is this not being told to us ignorant non-medically trained parents?

He has conked his head in the shower since then and since he did not lose consciousness, throw up, or show any signs of a traumatic head injury we just watched him and made sure he was ok and skipped on the freaking out.

But I do have to LONG are we supposed to wait for them to decide to potty train!??? :) It is killing me and he is over 3 and a half!!!! 4? 5? forever? :) I know you'd disapprove, but I have seriously considered trying to force him again! If we sent him to "school" at age 3 like all our friends they would have made him do it by now or be expelled! :-)

c said...

good luck with forcing him. and if he went to 'school' he would be trained (at least there) in 2 days, maybe only 1. peer pressure is powerful, and can be a good thing. but he will not go to kindergarten in a diaper!

Saltwater Daisy said...

It doesn't help that we live in a world where "answers" are immediately available at our fingertips. We want to know, and we want to know now.

Waiting isn't easy. I'm finding in my journey of faith that God rarely offers answers as quickly as I'd like to hear them. I'm also discovering that "strength will rise as we wait upon the Lord." There is something powerful in waiting process. Maybe our moments of white space help prepare us for the moments of split-second decision making?

Tor Hershman said...

Some folks consider this video to be a radical thought, however...if good vs. evil is so’s just a great tactic