Dr. Maller’s Blog

You probably missed it but our president gave a pep talk last week to the recalcitrant public on why his health care takeover must happen ASAP. Viewership was notably poor despite the usual tailwind provided by his friends in the government-controlled media.

An example he chose to underscore what he sees as the problem with our current system was a slap in the face to every practicing physician. To paraphrase it, if your child is brought to his pediatrician with a succession or sore throats, the doctor might decide to take out the child’s tonsils because he’d make more money that way.

Here we have the spectacle of a man who can’t wait to take control of one-sixth of the US economy and he is as ignorant of medicine as he is of building cars or running a bank. As Homer Simpson would say, “Doh.” Tonsils are not removed by pediatricians. Moreover, the going rate for the procedure goes down every year and no one will ever get rich that way. The really infuriating thing, though, is to have one’s entire profession insulted by a politician, someone who has never held a job in the private sector, never done anything to create wealth, who won’t release any school or personal papers, who consorts with radicals and terrorists.

Does he really believe that doctors are in it for the money? Maybe there are such people but I’d be hard-pressed to name any. On the other hand, have you ever known of a politician who didn’t get rich in office (or richer)? OK, not counting the ones in prison.

“What is the use of discussing a man’s abstract right to food or to medicine? The question is on the method of procuring and administering them. In that deliberation I shall always advise to call in the mind of the farmer and the physician, rather than the professor of metaphysics.”

So said Edmund Burke in 1790. It is not a new debate. As the most influential philosopher of our American Revolution, his counsel should be heeded.

Our Declaration of Independence assures each of us the rights of “life, liberty, and the pursuit of happiness.” It may seem indisputable that health care is a “right” in that it may affect life or its loss. But there is a problem assigning a right to the public which entails servitude on the part of those entrusted to dispense it. The question was academic until the last 75 or so years, before which time medicine had little to offer the afflicted or dying. Now practitioners of the healing arts fix ill and broken patients every day, because they can and should. But that is done by contract, and whenever possible the practitioner deserves payment. Our social systems have evolved in the direction of a safety net for all, and few would argue otherwise. But to our political class a “right” to medical care means total takeover by the tax collectors of both the means of care and its payment. The contract is no longer between patient and caregiver. Already much care is mediated by insurance companies and there is continual conflict of interest among patients, employers, government and them.

Education may also be considered a “right” rather than a privilege, and generations ago we turned most of it over to the public sector but the product turned out by our schools has become a national scandal. Politicians rarely send their kids to public schools, just as they have no intention of forgoing their excellent health plan if they accomplish their intended takeover of our present health care system.

Please remember when you need a highly trained physician with rare skills, a trauma surgeon, oncologist, neurosurgeon or ICU doctor that he or she went into practice after a dozen or more years of training, probably in a great deal of debt, possibly with a family, and that you do not have a right to demand the services he or she offers, but in our great country you will get the care you need and more than likely the doctor will be paid, usually far less than deserved.

Do you think $1000 is too much for an MRI or CT scan? Is $5000 too much for an eye operation or cancer surgery? I’ve had them all and knowing the best and brightest were on the other side of the curtain was priceless. I hope our future generations have the same.

When I started blogging a year and a half ago I promised myself I’d steer clear of politics. But politics is coming after me, and you, and everyone who dispenses or consumes that 15% of our economy known as health care. I have enough faith in the common sense of Americans to trust that we can fix what’s dislocated without breaking every bone in our structure as a society.
But the heat is on again from Washington, and the lies and distortions are drowning out more temperate and rational debate. In no particular order, here are ten of the most common lies with some historical references.

1. There is a crisis that must be solved before Labor Day or Halloween or whenever. Really? Since Hillarycare was defeated 16 years ago, what has changed? The figure of “47 million uninsured” is repeated so often but what does it mean? Polls show that 70-80% of Americans are satisfied with their current plan and do not want their taxes raised to make coverage universal. Twenty percent of the uninsured are illegals. Another 20% make over $75,000 a year and choose to do without health insurance. Another fifth are eligible for existing programs but haven’t signed up, and millions of others are young people between jobs or in school. The real “crisis” may be too much care; every emergency department is overloaded with routine cases who can’t or won’t go to a doctor’s office. If the swine flu has its way with us this fall we’ll have a true mess on our hands, but don’t expect the honchos in Washington to help. They’ve got the best insurance plan on the planet, but it’s not for us common folk.

2. Electronic medical records will save tons of money and may save your life.
As they say in the computer world, GIGO. There is no proof that EMR saves money or lives. The VA system uses bar codes to identify IV solutions. Sounds brilliant, except that it took four months for a human to note that the bottles were mislabeled. Nobody died so you didn’t hear about it. Reluctantly I’m beginning to enter that paperless world in my practice. Since I type like I dance, it’ll be slow going. Every minute at the keyboard is a minute not engaging the patient and family. Is that really progress? On the other hand I will recoup my investment in this system by about 2030, Of course the system will be obsolete long before then. I’m not a Luddite; I realize that computerizing a patient’s medical record may reap benefits down the line. But growing pains have been so bad in this area that some hospitals have already scrapped their systems. If you show up in an ER in bad shape don’t expect the doctor to wade through hundreds of pages of mostly unimportant stuff AND save your life. Can’t have both!

3. A public plan will bring down costs. Has that ever happened? We have public plans that account for half of our current “system”of care – Medicare, MedicAid, VA and so on. They are breaking banks in every state capitol as well as Washington, so just what lesson can we take from that? Do you believe that the US Postal Service would perform better if we made FedEx and UPS go away?

4. American business can’t compete with other countries because they have socialized medicine and we don’t. We are suffering to some degree in the world economic arena because of our high taxes, burdensome regulation, and government incompetence. Health care accounts for more of our GDP because we choose to buy it and because it’s usually good.

5. Infant mortality is lower in many other countries with socialized medicine. This lie is perhaps the oldest of the top ten. Other countries don’t count a “birth” until 28-30 days (e.g. Scandinavia) and others exclude the smallest babies. We also have a hard-core mostly inner city underclass of drug-addicted parents, illegal aliens with no prenatal care and other problems that no government scheme has yet unraveled. In fact because Congress is mostly lawyers, no real tort reform is likely and there are increasing areas of the nation with no qualified MD’s to deliver babies. (See Edwards, John).

6. Government experts can decide on the basis of “comparative effectiveness research” that only their approved treatments will be paid for. In England they have such a committee known as NICE (George Orwell must have made that one up!). Like the secret Hillary task force of 1993, it includes not one practicing physician. It is, first and last, a rationing board. Over 65? Kidneys on the way out? Uremic poisoning isn’t so bad – you go into a coma and die quietly, and you’ll be saving the taxpayers oodles of money. Need a bypass? Take a number. MRI? How’s nine months from yesterday work for you?

7. Life expectancy is better in some countries with socialized medicine. Yes, and worse in others. Japan’s is better than ours. They eat more fish, they’re less obese (maybe because they smoke!?), they’re less diverse. Russia’s life expectancy keeps going down; why not blame socialism? Or is it the vodka, the assassinations, the weather, or the sheer misery of living in a nation with so little hope. Point is, life expectancy in the USA is getting better all the time; since 1900 it has jumped an entire generation. All that with no government-controlled “system.” Take away the incentive to develop new cures, vaccines, biotech wonders which only America can do, and the world will pay a huge price.

8. Mandatory health insurance will provide universal access and lower costs. Hawaii tried it – for seven months. Massachusetts continues to try it but the state and hospitals are going broke, and there remains a stubborn minority of folks in John Adams country who just won’t board that train. We’ve had mandatory auto insurance for years now. Ever been in an accident with an INSURED driver? And just what “access” are we talking about. Every squeeze on the provider community costs the public more doctors and hospitals. “Boutique” and “concierge” offices are multiplying all over our once-free country. For old-fashioned cash, usually reasonable without all the third-party interference, care is offered as simply as getting a haircut. But the D.C. crowd won’t let that go unchallenged. It would have been illegal under Hillarycare to give or receive care privately, and I suppose the current incarnation will be no different. It is ironic that countries with socialized care are looking to increased privatization to lessen the strains on their antiquated systems, as in Canada, England and elsewhere.

9. Emphasizing prevention will lower costs. It pains me greatly to deny this because as a pediatrician I spend more time and resources on prevention than any other type of doctor, but there is no evidence that such care really saves money. We do it because it’s right and we will continue to do so. Remember when the cigarette honchos actually reminded Congress that they were saving the country millions in social security benefits by selling their wares? It’s true! Besides, government has always said prevention was great but the reimbursement paradigm is upside-down. As a primary care physician I have no incentive but my personal honor to talk to patients about changes in lifestyle, emotional stresses and a host of other non-diseases. English and Canadian doctors are given ever-increasing rosters of patients to see. Each encounter is so short as to be meaningless; no one gets undressed or properly examined. English dentists (yes they do exist) have a quota of patients to see. If they finish, they go on vacation because they will not be paid another quid (whatever that is) for working longer.

10. A public option is needed to spur greater competition. We already have 1300 companies selling health insurance. As the American Association of Physicians and Surgeons (of which I am a member) has said, adding #1301 doesn’t figure to change the playing field. But of course if it’s “I’m from the government and I’m here to help” those other companies are toast. Now neither I nor any doctor I know will defend the insurance companies. In fact they are so unpopular that most doctors want the government to take over and get rid of them. But be careful what you wish for. Because the government already skews the market so badly in controlling half the market, the private sector cost-shifts by overcharging everyone else. But remember, the government cares not a fig about your health. It is your vote they covet. As a believer in free market principles, I recognize that health care can’t be as unfettered as car or furniture sales (perhaps cars are a poor example right now). But I’d rather see a truly competitive private system that answers to a more enlightened public than one that’s run by the crooks in Washington who are on the power trip to end all power trips.

Just today I read that buried in the thousand pages of the health care bill that no one has likely read is a program to enforce vaccination requirements, including going into private homes with the legal authority to overcome parental objection. If you’ve been following my blog or coming to my office you know how dedicated I am to the goals of vaccination. But have Americans allowed their freedoms to erode to this degree?

On the cover of my favorite political magazine this week is a caricature of our president, grinning menacingly as he slips on a green latex glove, saying “Just relax.”

Please do NOT bend over.

The topic du jour this week has been the emergence of a new influenza strain in Mexico. Initially it was reported to be “part pig, part bird, part human” and as it seemed to coincide with the visit of our Boy President and his 500-person entourage to Mexico City, my paranoia meter went bonkers. Such a chimera virus sounded like the product of an evil lab somewhere, perhaps a trial terrorist run.

Now the hysteria has abated and we have a more rational basis for assessing the threat. This is a new H1N1 strain, an Influenza A virus primarily associated with swine contact (not eating pork). The outbreak in Mexico has caused some deaths, and cases have been identified in several states here as well as countries around the world. Overall though, the severity of this strain seems ordinary. It seemed odd that the source was Mexico as flu strains usually come out of Asia, but there is evidence that this outbreak began with a visit to Mexico of a citizen of Bangladesh who was quite ill on arrival.

This is not a harbinger of a 1918-like scourge that killed tens of millions of people in the wake of World War I. It seems more like the 1976 strain that struck Fort Dix NJ and led to the emergency production of a new vaccine which forty million Americans received. It was apparent by the fall that the “epidemic” had not materialized but the program went ahead as government programs usually do. The fallout was about a thousand cases of the paralytic condition Guillain-Barré syndrome, and a widespread antagonism toward vaccine mandates that carries over to this day.

Influenza is a true menace; it kills 36,000 of us in an average year, and the present choice of vaccines will not protect against the new strain. So far we can be hopeful that by fall an effective vaccine will be available and that the Virus Formerly Known as Swine Flu will prove to be manageable. Antiviral drugs are of some help (TamiFlu or Relenza) but their use in kids is problematic because of side effects, and the best they do is shorten the illness, not cure it.

Since influenza is seasonal, we won’t hear much for a few months about this. Schools and public venues should stay open and I hope folks won’t flock to emergency rooms with minor symptoms. But there is some precedent for new flu strains to appear mild at first, then return after summer with a vengeance. (One of the great mysteries of influenza is where it hides for six months, only to reappear, often in the same communities.)

Stay tuned, but enjoy the nice weather.

An old favorite smidgen of poetry went lost during one of my office moves, but most parents know it:
Children’s faces looking up
Holding wonder like a cup…”
Last week I had a cute little patient show up in an Alice Blue gown. I asked what the occasion was and her Mom said she always dresses like that (she’s 3 and a half). I grabbed my Polaroid (yes they still make them) and took two quick shots, one for her and one for me. The wonder in her eyes was priceless as she saw her Princess image slowly appear.

Why bring that up? Because I’m afraid for my profession, afraid for tomorrow’s children and the health care they’ll receive. That may be a stretch but these are worrisome times for all of us at both ends of medicine. Will the doctor who starts her practice in 2016 have the time and opportunity to catch those moments as I have since 1966? It seems unlikely.

This last election seemed so foreordained that I wonder how many folks listened to the choices regarding health care as well as so many other issues. In 1993 we were clearly threatened by Hillarycare and responded effectively. This time all of us are sick of insurance companies, $500 prescriptions, and the drumbeat of “47 million uninsured” that we’re permitting a select group of technocrats (mainly unelected) to take over and redesign our most personal health care decisions. The solo practitioner is targeted for extinction – you can look it up in Mr. Daschle’s little book on the government’s plans for your family’s care. If you have elderly folks in your family, they’d better stay healthy!

One of the key strategies in this conversion to socialized medicine is electronic medical records, which will allegedly eliminate mistakes and inefficiencies. Now many doctors and hospitals are going in that direction and for those who can afford it, there may be some benefits. But don’t buy that “efficiency” BS. It’s all about control of the patients and doctors, endangering both our and your privacy so the wise people in Washington and Sacramento can decide who gets what care and whether it’s worth paying for (after the fact of course). Fact is many hospitals and medical groups report a whole new set of problems in this brave new world. Even the Joint Commission, the body that accredits hospitals, has warned that reliance on computers is leading to less focus on patients and more opportunities for errors that keep repeating themselves. The VA system (which is pretty much what medicine will look like if the government takes it over) recently found out after months of errors that their computerized bar-code reading medication system was set up wrong and that thousands of patients got incorrect doses!

Do you really want a computerized robot taking your history and examining you? (I know they can do surgery but humans still have to tell them what to do.)

Yep, our health care “system” isn’t a system so much as a conglomeration of arrangements so typical of America. Foreign visitors are always amazed at all the choices we have, from cars to cereals. Our medical care is a mess but it’s the best in the world, statistics be damned. Winston Churchill famously said that democracy is the worst of all possible political arrangements except
for all the others that have been tried. So it is with our health care.

Chatting with a young pediatrician recently I remarked on seeing about 350 cases of spinal meningitis in my one year as an infectious disease fellow at LA County/USC. She was amazed; she had never seen ONE!

Such is the march of progress over one’s career in medicine. Most cases of bacterial meningitis are caused by Hemophilus influenzae Type b, commonly called “H flu” or “Hib.” One of my attending physicians at Columbia-Presbyterian in New York during my residency was Dr. Hattie Alexander, who pretty much owned “H flu”, having done much of the early work on it. Since its name is a misnomer, she deserves to have it renamed after her (Hemophilus hattiae has a nice ring to it).
In the aftermath of the pandemic of influenza that swept the globe after World War I and killed many millions, a newly recognized species of bacterium was isolated from many cases and was thought to be the causative agent; ergo, H. influenzae. But it was a virus, something long imagined (“little man”) but never seen. H. flu has made its mark despite that inauspicious beginning. It was responsible for about 25,000 deaths in American children every year until the mid-80′s when a vaccine came out. Before sulfa drugs and antibiotics it was always fatal, and it remained deadly even in the modern era. Not only did it kill through nervous system infection but it caused a respiratory disease called epiglottitis, often fatal without an emergency tracheotomy. Pediatricians in my training days were taught the art of low-tech tracheotomy using a key. Did it work? I never found out.

In this era of vaccine controversies it is all too easy to forget what life was like for children growing up. I remember the terror every summer when polio lurked behind each headache. In the two years I spent at Columbia, 30,000 cases of congenital rubella occurred in New York City alone. My oldest child had measles at two during a vacation trip through redwood country, probably 300 miles from the nearest children’s hospital. In my early practice years, before my community hospital had a pediatric unit or even a proper emergency department, I treated about ten cases of H. flu meningitis myself. All recovered but one was permanently left deaf, a common result.

Now H. flu deaths are so rare that each calls for a conference when it occurs. The vaccine is safe and very effective, often combined with others and given in 3 or 4 doses by 18 months. Since 1985 over half a million of our babies have not died of this classic killer. Rubella no longer threatens pregnant women. Polio is gone from our part of the world. Measles should be but imported cases and resistance to vaccination continue to cause localized outbreaks.

The accomplishments of vaccine research are so staggering as to defy comparison to any other field of medicine. New vaccines will strike cancer (we already use one now) and other chronic diseases. A flu vaccine that doesn’t need to be reinvented every year is on the way.

Why have we so soon forgotten where we’ve been?

Tomorrow is the 200th birthday of two of the most famous men who ever lived – Abraham Lincoln and Charles Darwin. And no one can be that famous for so long without being controversial.

President Lincoln is revered for saving the Union, at least outside Dixie. But he suspended habeas corpus, swept away states’ rights, and went through a bunch of mediocre generals before finding a winner. Slavery, that abomination which still goes on today in many parts of the world, would eventually have disappeared as it had in England, but eradicating it was a noble cause.

I believe Darwin is much more of a provocative figure, especially in our country. His theory is just that, and in this 150th year of its presence, it is perhaps less accepted than ever as truth. In an earlier blog I spoke of “science vs. truth”. Science is a path to the truth, a set of tools, but in our secularized world it has too often been used as a cudgel to threaten and punish those who have faith, who believe in divine revelation and intelligent design. No one can question that evolution occurs within a species or that millions of species have disappeared because they could not compete. If Darwin’s insight is correct, where are the missing links? How do we explain “irreducible complexity”, the staggering number of proteins and structures needed to make just one cell, much less an eye or a brain? If the Darwin ideas (many lifted from his friend Alfred Wallace) are so unassailable in the eyes of most science and education authorities, why are they so hysterical about their suppositions being challenged? If evolution explains all the wonders around us, why can’t scientists make it happen in a lab? If it matters that chimpanzees have 98% of human DNA, where are the books they’ve written, their art and music, their bridges and hospitals, their agriculture, their cemeteries – well, you get my drift.

In 1859 “The Origin of the Species” was a ground-breaking sensation. In 2009 it stands as a landmark in mankind’s search for the truth, but the ground beneath it is more sand than rock.

A favorite motto of mine is “Illegitimi Non Carborundum”. It appears on my cell phone when I activate it. It also adorns an archway at New York University, probably put there in the 19th century. I was an ace in Latin in high school, and that translates to “Don’t Let the Bastards Wear You Down” despite some folks denying it really means that.

The climate in the country is decidedly worrisome in general, and downright apocalyptic in the world of medicine. Congress is passing a near-trillion-dollar “stimulus” bill that will put our nation further in debt as far as the imagination can stretch. (A spider bite is also a “stimulus”.) Tucked into the 837 pages which few have actually read is the beginning of the end of our health care system as we know it. A government agency is to be set up to determine whether the care you need is allowable. If you’re over 65 in most developed countries, you can’t get dialysis, you’ll probably die waiting for your angiogram, and so on. Need an expensive drug? You’re so not worth it! (Unless you’re a congressperson or a large donor to one). Since the bill will effectively put a damper on biomedical research, we and the rest of the world will have to learn to do without the latest medicines. All this control is to be obtained by digitizing your medical records. Lots of luck with privacy issues. Good people, I take it as a serious responsibility to protect those records from snoops. Insurance companies have already gained far too much access in my opinion. Of course the cost of going fully electronic is beyond the reach of most small practices, but that is OK with our pals in Washington – in fact the playbook for this takeover, written by former Sen. Daschle in anticipation of his becoming the health “czar” (before he pulled out in disgrace for his $140,000 income tax slip-up) specifically calls for eliminating solo practices as too inefficient.

Two days ago I saw a case of mumps, my first in several years. It was an “augenblicht” (the blink of a light), a diagnosis I could make from five feet away. This seven-year-old boy had a swelling over the angle of his jaw. His Mom suspected it despite his having been vaccinated twice. Mumps vaccine is only about 90% effective. No treatment, no worries. Yesterday I got a call from the county health department, to which I had already initiated a report as required by law. After many questions, the young lady asked me what lab work I had done. I held my temper and asked what tests she expected. “Well, we can’t confirm this as a case without a viral culture and two blood tests.” I resisted the urge to impress her with my resumé and said, “That’s your problem – goodbye!” Besides the hundreds of dollars wasted, those tests would be of NO value to the patient, which is my criterion. A small example of where medicine is going.

Some days the only salvation is humor. As Art Linkletter, my college roommate’s father-in-law famously wrote half a century ago, “Children Say the Darndest Things.” (He’s still going strong at 96). Two new patients came in recently for physicals. I asked the 3-year-old, as I always do, to copy a circle. Then I asked her to draw Mommy, which she declined. Dad spoke up and said to draw him; she wrinkled up her face and said “You’re too ugly!”

Some years ago my oldest grandkids were in the office because the younger, age 6, had a fever. I first checked his throat, ears and chest, then looked up his nose, whereupon his 9-year-old brother said, “What a way to make a living!” Indeed it is.

So your baby’s a year old or so and doesn’t need formula any more. What are your options?

First of all, let’s talk delivery systems. Since my patients often breast-feed for a long time, they may be unfamiliar with the bottle or even with formula. Taking Baby off the bottle may be a challenge, but the sooner you do it the better, for several reasons. Using a bottle after a 12-15 months is unnecessary, and may cause major problems such as tooth decay and ear infections. “Nursing bottle mouth” is more than a cosmetic issue; it can ruin the permanent teeth and even lead to life-threatening infection. There’s another reason I push for no bottles, despite resistance from grandmothers, babysitters and parents; it’s an opportunity to establish who’s boss. Learning to parent effectively involves a series of confrontations. It’s my job to help you anticipate and deal with them.

A new device just came on the market called a “Tilty Cup” which enables the baby to drink from a training cup without getting into the “chug-a-lug” position. I make a point of introducing a cup early in infancy so as to make the baby’s transition easier.

The nutrition aspect deserves detailed attention. Despite uniform insistence on whole milk for babies one to two by the government and its assorted experts, I have always recommended 2% milk, and here’s why. True, fat is important for a toddler’s brain growth. However, a baby fed whole milk is more likely to reject other foods and to become iron-deficient. It’s time to focus on the “4 basic food groups”, only one of which is dairy. Moreover, there are healthier sources of fat such as olives, nuts, avocado and even eggs. Parents rarely object to this reasoning if it’s explained. We have obesity rampant all over our country, government wringing its hands, lawyers preparing to sue fast-food companies, and yet we know that prevention is the only useful approach. Fat babies may be “cute” (I was one) but I prefer “lean machines”.

Now you may be thinking, “Does this doctor really think he’s smarter than the U.S. government?” I have a 1940 book published by the Childrens Bureau (I’m not making up that name) instructing parents on nutrition, toilet training and other issues. Almost everything in it is wrong! Committees of experts (and they are smart folks) get together regularly to tell doctors what to tell their patients and parents about vaccinations, nutrition, sex, guns, drugs and so on. Trouble is these decisions seem to be made (like most government stuff) in a vacuum devoid of common sense. I’ve worked in such bureaucracies. There is a dangerous combination of arrogance and elitism afoot. Ordinary people are assumed to be irresponsible, ignorant, and worst of all, independent and therefore needing to be told what to do.

I’ve stayed in solo practice almost all my career largely because I love being my own boss. Would I get away with recommending 2% milk if I were in government service or at a clinic? Would I defer certain vaccinations as long as possible so they’d be more effective (as I learned at CDC) and get away with it? No, and thereby hangs a tale. When the chickenpox vaccine came out in 1995, I chose to give it at age two because the research had been done on that age group, and the 12-month recommendation was based on those factors described above and not on sound medical science (let’s nail those babies as early as possible because they won’t show up later). After a dozen years it was found that kids vaccinated at age 12 months had significantly poorer immunity than those immunized when older. Meanwhile I’ve had to lower my age for varicella shots to 18 months because I was getting dinged by the insurance companies and government health plans because my patients were “out of compliance”.

Yep, those brilliant government types who’ve been so successful with Fannie Mae and Freddie Mac, the Dept. of Education, the Post Office and the DMV are slowly but surely taking over the practice of medicine. Don’t you feel better already?

Perhaps it’s unfair to blame Gucci for my seven-month absence from my blog, but you see every time I’d try to write she’d sit on my lap or the keyboard and I just couldn’t do a thing. Pretty lame, eh?

Truthfully it’s been a rough year, probably for many of you as well. But it took a reprimand from one of my moms and a few quiet hours on an airplane a few weeks ago to get my writing itch going again.

My 42d anniversary in my Van Nuys practice just passed. A cynic might say I’ve not had 42 years’ experience, but one year’s worth 42 times. Not so. Practice is so much more than runny noses and tummy aches. Lately I’ve had a remarkable run of interesting challenges.

Yesterday started with a 2-year-old girl who celebrated Christmas by putting blueberries up her nose (mom had removed one and the other mercifully found its own way out). Before the day was over, I’d welcomed a new baby girl, seen a 3-week-old baby boy who’d already survived open-heart surgery for a severe congenital defect called transposition of the great vessels (a diagnosis made by ultrasound a month before birth!), done a checkup on a teenaged boy suspected of Marfan’s syndrome (Abe Lincoln had it – he does not).

The last patient of the day deserves his own paragraph. He’s 7, raised by a single mom. From infancy he had been markedly obese with behavioral problems that progressed to the extent that I expected him to have to be institutionalized. At school entry he weight 107 and was too unmanageable to attend regular school, but he had started seeing a child psychiatrist and the tide started to turn. Ordinary ADHD drugs did not work, but an old drug (Klonopin) and a new drug (Abilify) have been quite effective. Yesterday he had grown 5 inches in two years while remaining 107 pounds, still too much but a 17% drop in his BMI (body-mass index). More important, he could read at third-grade level and was delightful to talk with. His mom is married and expecting. She never gave up on him, which would have been easy to do. He may have Asperger’s Syndrome as the psychiatrist says, but his physical and social awkwardness keep improving. Whoda thunk?

Yesterday also featured a little boy with a serious elbow fracture, a little girl hospitalized with another urinary tract infection, probably her sixth, and a history of convulsions with high fever who probably has a defective bladder because of a hidden spinal anomaly, a delightful 3-year-old boy being checked for bronchitis whom I might not have mentioned except that four days after he was born, his father was diagnosed with leukemia which eventually took his life a year ago. It’s the context that makes every patient in a private practice so special; he’s not just a kid with a cough, he’s part of a family I know, with a lovely older sister, a heroic mother, extended families in Italy and the USA whom I met at Dad’s funeral.

The other day a new mom called about her second baby, who I knew had a heart murmur with a tiny hole between the major chambers. He was “very irritable and struggling to breathe” – no further questions were needed. The baby was at the office minutes later, inconsolable, ashen grey with a heart rate of about 280 (really uncountable). Fortunately the Emergency Dept. is a hundred yards away. His abnormal rhythm was corrected with a drug and after a nervous night in the hospital, he is home on digitalis and doing well.

Do you still think practice is dull? It is if you don’t look for challenges. To me every checkup is a chance to find something that can make a difference in a child’s life. I’m known as a good diagnostician, the outcome of wonderful teaching and my years at CDC and LA County/USC. The other night we were watching “Mystery Diagnosis” on TV and a teenaged boy was brought to an ED in Texas with a 105 temperature and a relentless pneumonia that threatened his life. He had been rock-climbing in Colorado with a pal. I like to impress my wife so I flippantly said, “Sounds like hantavirus.” What the heck is THAT, says she. I explained that it’s a mouse-borne virus recently discovered in that part of the country. Turns out he and his buddy found a mouse in their truck while eating lunch, and he indeed caught hantavirus, which is rare (34 cases in the country last year) but fatal 50% of the time.

I really should have gone on Jeopardy.