Monday, September 23, 2013

Parenting Expert


I went to bed at 8:30 last night.  I know.  Foolish.  That is how I found myself awake at 2 am, reading the Twitter profiles of people I have never met.  Do you know how many parenting experts there are out there?  Many.  More than I would expect.  Go search “parenting expert” on Twitter and then come back and finish reading this.

It’s not that I don't think it’s possible to be a parenting expert.  I am just astounded that so many individuals have achieved the status.  And here I am, with my doctorate and my pediatric training and my two kids and my kindle full of parenting books and I am definitely not an expert. 

Example 1:
I have spent the past two months trying to get my three-year-old to stay in his bed at bedtime.  Instead he spends two hours needing one more hug and one more drink and one more potty run and one more stuffed animal to cuddle and one more standing in the doorway of the living room looking lost.  Our pediatrician recommended a sticker chart with prizes.  I will admit I am skeptical.  The only sticker chart I remember from childhood was the reading chart in fourth grade.  And I did not care about the stickers or prizes.  I just cared about reading more than Jenny, who lived two blocks away and routinely out-read me.  But I am desperate for a solution so I will try it.  I wonder if Jenny has read more parenting books than I have.

Example 2:
My nine-month-old has taken to shrieking as her preferred form of communication.  Especially when there is food involved.  The three-year-old thinks it is hilarious and copies her.  She thinks he is amazing and echoes back.  And now it is something like a shriek conversation.  They are screaming in unison with every bit of air that can fit in their lungs.  Meanwhile, I use my calm, stern Mom Voice and say “No shrieking,” “No shrieking,” “No shr-,” “Do you need to leave?” “Stop.” “No shrieking.”  Before you know it, I am screaming, “No screaming at the dinner table!” at the dinner table.  It works but I cannot imagine that I am modeling the right behavior.

If you read Malcolm Gladwell’s Outliers, you will recall that it takes 10,000 hours to become an expert at a given activity.  There are 8,765 hours in a year.  If one has a kid who is literally “up all night” for the first year of life, that person could become an expert in about a year and a half.  Although, I might wait and see how he or she does with kid #2’s sleep habits before I listen to any advice.  Alternatively, Gladwell says, it can take ten years to become an expert.  So maybe any parent of a ten-year-old is an expert?  In just the past month, I have had the mother of a nine-year-old and the grandmother of an 11-year-old request prescriptions for prn sedatives for their children.  My gut reaction is that there may be exceptions to that rule. 

There is a writer named Eric Barker, who blogs here, and points out that these 10,000 hours or ten years leading to expertise must involve actual dedicated practice.  In fact, some studies suggest that after ten years some experts may see their skills worsen.  Experts need “countless drills” to improve mastery.  I am not exactly sure what parenting drills would look like.  As a physician, I have practiced suturing on pig feet bought at the grocery store.  I have rehearsed physician-patient interaction with paid actors.  I have resuscitated plastic mannequins time and time again.  I wonder what a third-party would think of my Mom Voice.  A plastic mannequin would certainly prove even more steadfast than my three year old in response to my verbal commands, although the "picking up and placing in bed" strategy would probably be very effective.

I guess seven years from now I will be an expert, too.  I will either be very good or even worse than I am now.  Just in time to start parenting teenagers.  Either way, I will be sure to add Parenting Expert to my Twitter profile.

Sunday, September 15, 2013

Spotting measles

There is a sort of game I like to play at work.  Based only on what the triage nurse writes as the chief complaint, I try to guess the final diagnosis. The game is especially fun when the chief complaint is something like "Eats shirts,” but that is a story for another time.  A few weeks ago, a little girl came into the Emergency Department.  The triage note read, "Fever, drooling, mouth sores."  I narrowed my guess to two common viral illnesses.  A good history and exam and the diagnosis would be in the bag. 

My resident saw the patient first.  He came out of the room and described to me a previously healthy, unvaccinated girl with fever, drooling and mouth sores.  Suddenly everything changed. Sure, this child was still most likely to have a common virus, but now I had to consider a list of diseases that I almost never seriously entertain.  Diseases I have never seen because we live in the post vaccine era.

We live in the post vaccine era.  Isn't that amazing?  Vaccines have so changed the landscape of modern medicine that they have earned their own era.  We often talk about how vaccines mean that children are protected against death and morbidity from diseases like tetanus, polio and diphtheria.  While this is true, vaccines have also revolutionized the way that doctors manage infection.  Because of vaccines, I can view fever as nothing more than the normal response of a healthy immune system.  I can confidently tell more parents after a simple, painless examination that their child has an illness he can fight off on his own.  No irradiating him with x-rays or cat scans, no painful blood draws, no tubes shoved into orifices.  It is a great time to be a pediatrician.

As a physician who has only ever known medicine in the post vaccine era, there are some drawbacks.  The most valuable teaching in medical school and residency came from patients and the experienced physicians instructing me.  This is what pneumonia sounds like.  This is what a surgical abdomen feels like.  This is what leukemia looks like.  This.  Right here.  Don't forget this.  Even the best textbook pales in comparison to the real thing.  My knowledge of these vaccine-preventable infections is exclusively from textbooks.

So on the night that I see this little girl with fever and drooling and oral lesions, things go a little differently than usual.  I still think she has a common virus.  But could it be epiglottitis?  I don't know; I've never seen it.  It is probably best to get an x-ray to be on the safe side.  And maybe some labs.  And if we are drawing blood, we better try for an IV.  Could it be measles?  I don't know; I've never seen it.  My resident and I pore over pictures of Koplik's spots.  The textbook says they should have a blue or gray hue, and I don't think that hers do.  It is hard to be confident.  The ramifications of being wrong play out in the back of my mind.

I discharge her.  In my note, I document no cough, no coryza, no conjunctivitis, no rash... no evidence of measles.  Because, according to articles like this US Measles Cases in 2013 May Be Worst in 17 Years, that is a real concern and there may come a day when I no longer have the privilege of saying, "I've never seen that."