Checklist or choke list?

Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.

Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then. How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care. Each one has their own set of checklists, many only slightly different, and none of these lists actually improve diagnostic accuracy; this is somehow taken for granted, or perhaps not addressed because the creators of these checklists, as non-physicians, simply have nothing to say about that aspect of healthcare.

Gawande writes: “There are good checklists and bad….Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brain off rather than turn them on.”

A very simple way to “turn on” or focus providers’ brains is to adhere to a structured format of clinical assessment, but to avoid unnecessary rigidity after that. After all, in my world we have 15-30 minutes at most with every patient for a fee of $50-150. You can only cram so many prescribed agenda items into that kind of time frame before your time is up.

Today’s checklists would have me ask every patient, apart from figuring out what is wrong with them, if they are homeless, home bound, safe from domestic abuse, if they have scatter rugs, firearms in the house (not a legal question in Florida, however), if they are a caregiver and several more things I can’t remember. I am sure the architects of these templates meant well, but the end result of long lists like this is that physicians risk not paying attention to the forest because of all the trees. A more appropriate checklist could summarize all these items in one question: “Have you considered the patient’s home environment?”

One item I haven’t found in my new EMR is what we in Sweden always used to include in our medical histories, “Epidemiology”. This simple word prompted the question “Do you know anybody else with the same symptoms as yours?” It is a question I overlooked at least once that I will always remember:

I was fresh out of residency, working in a small town in Maine. A middle aged man came to see me about nausea, loss of appetite and abdominal pain of more than a week’s duration. I didn’t know what was wrong with him, so I ordered some labs and an upper GI series. His CBC was mildly abnormal and while I was waiting for his x-ray to get done, my partner and employer ran into him in the grocery store one Saturday. Doctor Joe approached me the following Monday and told me not to bother with the x-Ray: “Mr. Billings’ dog was just diagnosed with lead poisoning. You might want to check a lead level on him”.

Talking to Mr. Billings, he had been scraping paint off his old farmhouse with his Golden Retriever faithfully waiting at the bottom of the ladder, inhaling the dust from the dried and cracked paint. It never occurred to me to ask about “epidemiology” the way I had been taught, because I had dismissed infectious causes of Mr. Billings’ symptoms almost subconsciously and never considered environmental exposure, which also falls under the “epidemiology” heading.

A similar but more dramatic incidence in “The Checklist Manifesto” involved a surgeon who thought he had all kinds of time to get ready to explore and repair a small stab wound inflicted at a Halloween party. Suddenly the patient’s blood pressure bottomed out and as the surgeon hurriedly entered the abdominal cavity and found it filled with blood, he remembered he had neglected to ask about the weapon that had caused the stab wound. He later found out it was a bayonet, which turned out to have lacerated the abdominal aorta – he had only assumed it must have been a pocket knife.

Obviously, no check list can be complete enough to include questions about scraping lead paint for every person with abdominal pain and asking about having been stabbed by a bayonet in every laceration – only more general and somewhat open-ended questions will get you all the answers in a reasonable amount of time.

Quoting Gawande again, “The checklist cannot be lengthy. A rule of thumb some use is to keep it between five and nine items, which is the limit of working memory.”

As I contemplate how to continually improve the care I deliver while also addressing the increasing demands for fulfilling and documenting the Government’s requirements, I think I can use my computer and my EMR to streamline the way I meet all the requirements. But I think it’ll be up to me to create my own clinical checklists, because the Government issue doesn’t seem to be my size, which reminds me of another set of Swedish experiences I had – boot camp, blisters and learning to march in formation and follow orders without complaining.

Hopefully, the “official” checklists will evolve over time as people have a chance to assess their impact. Again, quoting Dr. Gawande:

“…no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart….and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Welcome to the real world, any time you wish to see what it’s like, Mr. President, Ms. Congresswoman, Mr. Insurance Executive, Ms. EMR vendor!

Requests Denied

In my mind I was debating whether the woman in front of me was my second-ever case of a brain abscess or if perhaps during one of her recent falls, she might have suffered an intracranial bleed. She was taking warfarin for atrial fibrillation and her frontal headaches and nausea with vomiting had been getting worse over a four week period. My own father almost died in his fifties from a chronic subdural hematoma. This woman looked like something between my brain abscess patient and my father just before he was diagnosed.

Gwen Garfield was congested and blamed her nausea and vomiting on her purulent post nasal drip. She was clearly not a complainer; she split her own firewood and walked with a severe limp from childhood polio. Her regular physician, Dr. Landry, is out this week, but his nurse has been helping Autumn out, and she told me that Gwen wasn’t her usual self at all. She had even asked a friend to drive her in because of how poorly she felt.

Both her maxillary sinuses were tender and she had nasal congestion and her forehead was wrinkled over lowered eyebrows in a static gesture of concern. Her neurological exam had no specific abnormalities, but she seemed just a little vague for a woman with her reputation. She fumbled with her keys and reading glasses and dropped them on the floor, but her finger-nose coordination was surprisingly normal.

I prescribed her some cefuroxime for her presumed sinusitis but also told her I felt she needed a CT scan of her brain before the three day weekend, especially since she lives alone far from town and “off the (electric power) grid”. “We have to rule out a bleed and an abscess”, I told her.

Because her insurance, Aetna, requires prior authorizations, I typed and clicked my office note and put the CT request in as quickly as possible and had Autumn call the referral coordinator to get the prior authorization request going.

I sent Gwen and her friend to the pharmacy and told them to check back with us in a little bit. By 1 pm we got word that her CT scan was denied. I felt concerned enough and it was already late enough in the day that I wasn’t going to risk wasting more time with an appeal with the long weekend coming up. Besides, I was the only doctor covering our whole clinic with an overbooked schedule and also responsible for the large nursing home in town; I know how long the insurance companies can keep you on the phone when you try to appeal a denial.

I told Gwen and her friend to drive down the road to the emergency room, because they don’t need prior authorizations for CT scans. Then I called Jim Anderson, the ER doctor on duty, and told him I hated to dump on him but my patient needed a scan that her insurance wouldn’t pay for.

“Well, they will pay for it now”, he said laconically after I painted my thumbnail sketch of Gwen’s history and exam.

Two hours later we got a fax saying that, after further review, Gwen’s CT scan was approved. By that time Autumn was able to get the results from the hospital computer – no bleed, no sign of an abscess. Jim added a steroid nasal spray to my antibiotic for her sinuses. Aetna ended up paying for my office visit, the CT scan and an emergency room visit I would have wanted to avoid.

The afternoon flew by. Everybody was patient with me for running behind. The nursing home did call a few times to make sure we had received the faxes they had sent us between 2 and 4 pm. As I worked my way through lab results and requests for decisions about coughs, fevers, urinary tract infections, hallucinations and other odds and ends, I gasped internally when I came to the last one.

It was actually a stack of pages, all about the same thing: A dying man had been prescribed subcutaneous injections of morphine and lorazepam placed under his tongue, two staple drugs of “comfort kits” used by hospitals, Hospice agencies and nursing homes all over the world to ease the discomfort of dying patients. The patient’s Medicare D plan, WellCare, had already denied coverage for these two generic drugs. Another provider doing rounds at the nursing home yesterday had filed an appeal, and this appeal, too, had been denied.

The nursing home asked me to write a note to WellCare to appeal.

I usually manage to retain a fair amount of what Sir William Osler referred to as aquanamitas, the seasoned physician’s unflappability, but at 4:30 this afternoon I had already had enough of arbitrary and insensitive insurance companies lacking common sense and human decency. I wrote:

“In my thirty years as a family physician, I have never seen such cruelty as denying a dying man the relief of his final agony with basic, generic drugs like morphine and lorazepam.”

I don’t know yet if that did any good. The nursing home has a supply of these drugs on hand, so for now the patient has been getting what he needs, but to me, this struck at the core of what we all have the right to expect our insurance companies to cover.

Osler, the father of modern medicine, said: “To prevent disease, relieve suffering and to heal the sick – this is our work.”

This is unfortunately not quite the work of the insurance companies.

It’s Time We Talk About Who Should Do What in Healthcare Teams

 

“Team based care” is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the “team” can bill for their work.

Few people seem to be concerned with the simple but essential question of how physicians spend their time and how medical offices are paid. As a primary care physician who doesn't do any major procedures, and who in 2014 is essentially paid fee for service, I should bill around $400 per hour – $7 per minute, to put it bluntly – for my employer to stay afloat and for me and our support staff to stay employed.

Physician review and oversight of the team’s efforts, which is a medical and medicolegal necessity, is an unreimbursed activity. So, how much enthusiasm do the healthcare experts really expect to see for schemes that have computers, apps and non-physicians gather information for physicians to act on without seeing the patient – and thus, without the clinic collecting a fee?

But also, taking a medical history, for example, is not necessarily a simple task that can or should be delegated to team members with little or no training for it. Just like employers who interview prospective new employees themselves, or at least have a seasoned Human Resource professional do the job, doctors do more than just ask questions and record the answers. They pay attention to the person’s posture, attitude, facial expressions and willingness to provide the information.

Would a journalist have someone else interview a politician and then feel he could write a credible feature article based on the other person’s notes?

How truthful and accurate are the answers our patients give in the mandated depression screenings our medical assistants administer in our clinics? How many patients just barely even tell their doctor their innermost feelings and thoughts?

The reality in medicine is that the licensed professionals need to do the bulk of patient interacting and decision making, because that is what they are trained to do. Other team members need to be part of the process by preparing for visits, facilitating the plan that is outlined in the medical record, fielding questions and carrying out standing orders. I don't advocate for less involvement by support staff, but actually more. For example, I feel the front desk staff needs to know which patients and which types of symptoms require more time and which ones require less, in order to be able to schedule appointments intelligently and make the best use of physicians’ time. I also think each provider’s primary nurse or medical assistant should read all office notes after they are completed, so that if a patient calls back with a problem the medical assistant has an immediate awareness of how this patient can best be helped.

Similarly, if a patient is fit into the day’s schedule, a team member who reads the chart in order to make sure pending reports are available and who scans the phone messages and other things that have happened since the last visit can help the physician “hit the ground running”. Also, making sure at check-in that the patient doesn't have an immediate and different concern that may change the plan for the day avoids wasting everybody’s time in the visit.

Team members in a primary care office who know the patient and know what usually happens in typical situations are invaluable. Most primary care offices don't have team members with professional licenses that allow them to make clinical judgements, but just by being facilitators and advocates, they can easily double a physician’s productivity.

Which team effort moves the care forward most efficiently? Having medical assistants give depression screenings and smoking cessation counseling or making sure everything needed for the visit is available? Patients with urinary symptoms need to have a urine test, wound care visits must have all necessary supplies at hand and hospital follow-ups must have not only the discharge summary but also the consultations and all test results available, or the practice loses $7 for every minute of wasted physician time. It may seem mundane to today’s healthcare visionaries, but such efforts keep the doors open.

There is a strange cliché in use here, “working to the top of your license”. This has been used to justify letting support staff take over screening and education duties. It has not been applied to freeing physicians from clerical tasks like entering data that used to be done by transcriptionists.

I am not afraid to clean exam rooms after my visits are done, or anything else that keeps the office flow going. But I get a little frustrated when non-medical people opine that taking histories, doing physical assessments and counseling patients is so easy that anyone can do it. Sure, I can wire a three-way light switch and solder a copper pipe, but electricians and plumbers do it better, faster and neater. That isn't something for me to be embarrassed about – they have more experience doing it, just like I have more experience taking medical histories than nurses and medical assistants, because it is what I do for a living.

I do support making use of special talents; we once had a medical assistant who was a natural motivator. She took courses in motivational interviewing and became our smoking cessation counselor. But a blindly applied “working to the top of your license” is also known as “the Peter principle” – push everyone to their limit, where they can no longer do what is asked of them.

I don't know if I am just less aware of this in other “industries”, or if this is something unique to non-medical policymakers’ vision of medicine: There is less and less respect for professional training, skill and experience. If this were declared as a social experiment or an “equalization” effort, I would understand (after all, I grew up and trained in a Socialist country), but that is not quite what I hear.

My next topic in this series will be doctors, nurses and nurse practitioners – who should do what?

A Swedish Patient

I introduced myself and continued “and you are Annika LeBrun?”

“Ja, det stämmer”, she answered in perfect Swedish.

I had suspected from her first name that she might be Swedish. She continued in an accent that suggested roots near Stockholm, the area where I was born:

“With a last name like that and a license plate in Swedish, I knew where you were from.”

We continued the visit in our mutual mother tongue. I had to think fast to find the right Swedish medical terms after working as a physician for thirty-three years in this country and not having spoken Swedish for a couple of years except a few phone calls to a couple of aunts in Sweden.

My new patient had also been away from Sweden for several years, and she ended up asking me how to describe a few of her medical concerns in Swedish.

The word “cataract” came up, and it took me a few seconds to retrieve “grå starr”, and I couldn’t help myself but went on to also talk about “grön starr”, glaucoma.

Swedish has two medical nomenclatures, one newer internationalized one, where “cataract” is “katarakt”, and an older one with Swedish or Germanic words.

The word “starr” dates back to the 1600’s and derives from ancient Germanic words for “stiff”, and indirectly also to “stirra”, which means “stare”.

A cataract affected eye has a gray pupil due to clouding of the lens, whereas glaucoma, a term derived from the Greek “glaucos”, which means “blue-green”, may have a greenish hue, but sometimes may look normal or cloudy.

We finished our visit, and I struggled for a split second to find the right words for “stop at the reception desk and make a follow-up appointment”.

I mused silently about all the quaint Swedish medical words I haven’t heard or used for thirty years: “bukspottkörtel” (belly spit gland) for pancreas, “ros” (derived from Dutch and German words for red), for erysipelas, “bältros” for shingles. The English word “shingles” is derived from the Latin cingulus, which is a straight translation of the Greek “zoster”, meaning “girdle” (from the way the shingles rash can encircle half the body; the Swedish prefix “bält-” means “belt”, just like it sounds).

Later, on my way home, I thought about how you can use your second language so much that your first language, even though you may have a deeper understanding of it, can seem harder to use in some situations. But, to be perfectly honest, sometimes it is still my first choice, for example when counting.

I arrived home feeling as if I had traveled far today – 3,000 miles to Stockholm and thirty-odd years to my early days in medicine. It’s been a long but interesting day.

 

It’s Time We Talk About What Healthcare Really Is: Public Versus Personal Health

 

The general debate about how healthcare should be organized, measured, evaluated and paid for is about as useful as arguing about whether all food should be served hot, cold or room temperature.

Healthcare can be so many things these days, that I’m not even sure we agree on the definition of healthcare. We certainly have seen disagreements on what we expect our insurance policies to cover. This is an especially thorny question as we in the United States spend twice as much as any other country, and yet are worse off than the other industrialized nations in infant mortality, life expectancy and chronic disease burden statistics.

OBESITY AND SMOKING ARE NOW QUALITY INDICATORS, BUT ARE THEY TRULY THE DOCTOR’S RESPONSIBILITY?

The lines have blurred between public and personal health, and there have even been a couple of role reversals between medicine as we were trained to view it and what we used to think of as public health. For example, ancient physicians like Hippocrates put great emphasis on nutrition advice in sickness and health, but during my lifetime the government started telling us how many glasses of water to drink and what nutrients are good and bad for us. This was when the beginning obesity epidemic was blamed on high fat intake several decades ago by someone in the government. Since then, fat consumption has decreased steadily while obesity rates have increased. In a clever reversal of its stance, the government has now lobbed the ball back in the physicians’ court, since the official strategy misfired so profoundly. And they have cleverly built in a punitive mandate to make sure they don’t get handed back the responsibility for the epidemic they fueled with their ignorance. How?

Medicare now demands that physicians document a follow-up/action plan for every single obese patient they see. Is that really a priority for the individual doctor-patient encounter? Especially since there are no truly effective medical treatments for obesity. It is best treated with diet (higher fat, lower carbohydrate) and exercise. Or is it perhaps something better handled in the public health arena again, this time with better science behind it? When there is talk of shortages of primary care doctors as the baby boomer generation enters their senior years, as we struggle with high hospital readmission rates, and as we wring our hands over lack of access in primary care and inappropriate emergency room utilization, should we turn sick patients away because we are busy counseling even our most unwilling patients one by one on the dangers of soft drinks and breakfast cereals?

Similarly, smoking has been viewed as a public health problem, but it has now become a yardstick in healthcare, too. Doctors will now fail their quality metrics for any diabetic patient that smokes, regardless of their blood sugar, cholesterol and blood pressure control. Is that a fair and realistic way to measure physician performance? Will it cause “noncompliant” diabetics to lose access to care? I worry that it will.

Even gun safety has been put on the physicians’ shoulders. The Maine Medicaid well child visit templates have gun safety as a prescribed topic to cover. What the political parties have failed at, we are now supposed to do as an add-on item in our fifteen minutes with our patients. Interestingly though, a 2011 Florida law, which was upheld in a legal challenge this year, specifically prohibits physicians from asking their patients about gun ownership. So why is healthcare defined differently at the opposite ends of US Route One?

ARE IMMUNIZATIONS HEALTHCARE OR PUBLIC HEALTH?

Obvious Public health activities such as immunizing against contagious diseases were traditionally done by doctors’ offices in this country. In Sweden, where I trained, physicians in primary care did not usually administer childhood vaccines. Instead, publicly funded nurse-run clinics handled immunizations and routine screenings of infants and young children.

The difference I see between immunizations given in a government run clinic and in a physician’s office is that physicians, by nature of their training, tend to be patient focused and sometimes will support their patients’ decisions about forgoing immunizations, for example some of the newer, less studied vaccines that have much less than 25 years of study (it took about that long to find out if post menopausal estrogen decreased heart attack risk as it had been speculated – it actually increased it).

Now national pharmacy chains are giving adult immunizations with forceful promotion and obvious profit motives but physicians, who in some cases are losing the revenue from giving the shots, are still required to spend their time keeping track of who got what shot.

THE DIFFERENCE BETWEEN PUBLIC AND PERSONAL HEALTH

Public health puts the individual second and societal health, finances or well-being first. Doctors, just as in the example about immunizations above, have traditionally had an obligation first to their own patients. The more we are expected to be public health officials, the more our relationship with each patient may be challenged. We are also getting sucked into a pseudo-accountability that is more political than scientific. Just like we are measured by how many of our heart disease patients are on beta blockers and how many diabetics are on ACE inhibitors, both of which are considerations with some controversy and many exceptions, our public health and common-sense recommendations are now measured in absurdum. Even when it comes to what we say behind closed exam room doors to patients who drink too much or exercise too little, we are being measured as if we are the only ones on the planet who can tell our patients these things.

By holding physicians accountable for many of the global ills of our society, from obesity to smoking, alcohol use, distracted driving and sedentary lifestyles, we have entered an environment where others are doing or being considered for the jobs we were trained to do: Pharmacists treating hypertension, nurses dosing blood thinners, Nurse Practitioners seeing our sick patients at Walmart or CVS clinics. This will be the topic of my next post in the series “It’s Time We Talk…”

 

And Then, What Happened?

 

In these virtual pages I have written about medical mysteries, the frustrations of today’s healthcare, and the human dramas we encounter in the practice of medicine.

Below are updates to three previous posts, one from each of these three categories: “The Great Imposter”, “Calling Mrs. Kafka”, and “Invisible Ties”. Readers who don't remember these posts may want to follow the links to catch up on the beginning of each story.

 

A TALE OF RED HERRINGS

The Great Imposter” ended in clinical uncertainty:

“And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.”

The other day I saw Dr. Brown walk Norman Sprague down the hall. Afterward, I asked whatever happened with his possible shingles, gallbladder pain, lung nodules and mediastinal lymph nodes.

“The PET CT looked pretty benign”, said my octogenarian colleague, “and nothing came of that pimple you saw on his back. He still has his gallbladder and Roger White is pretty sure it's sarcoidosis. Interesting, though, that the Lyrica samples you gave him when you thought it was shingles cut his pain at least in half, but the pain is on both sides of the midline…”

“I don't know why it's working, then”, I said.

“Neither do I, but I kept him on it. He's meeting with Roger next week to discuss treatment options, probably steroids.”

“Pretty sure, huh”, I muttered to myself.

 

A PYRRHIC VICTORY

In “Calling Mrs. Kafka”, I went to bat against the insurance company for Harriet Black. She really did have a terrible case of shingles, and Lyrica was the only thing that really helped her pain; the gabapentin and her regular pain medication had not been enough.

After my call to the surreal Mrs. Kafka in the Prior Authorization department, I asked Autumn to call Harriet and tell her the drug was approved. She was very grateful on the phone. Some time later she came in for her follow-up appointment.

“How’s your shingles pain”, I asked.

“Still pretty bad”, she answered.

“I thought the Lyrica was working pretty well”, I said, confused.

“I can't afford it. The copay is too high”, Harriet said, her voice trailing.

So much for getting a medication approved by the insurance company…

 

MOTHER AND CHILD

Four years ago, in “Invisible Ties”, I described how Kirk Donner, adopted at birth, went to the State Capital to look for his birth mother after he turned eighteen. He knew she had an unusual name, Suann:

“Kirk took the elevator to the fourth floor. He was alone. As the door slid open, he stepped forward and almost collided with a tall, dark-haired woman with designer jeans and a plain, white blouse. Her eyes met his as he stopped and apologized. They were large and kind. She flashed a smile as he swerved around her, embarrassed and eager to get to the registry.

He walked up to the receptionist and stated his errand with words he had practiced in his mind the whole trip.The clerk handed him a form and as he reached for a pen he saw a stack of similar forms in front of her. Reading the top one upside-down he saw the name: Suann Walker.”

Mother and child made contact soon after that day, and each found peace in knowing what had become of the other. Kirk met his half-sister, also raised by an adoptive family.

Suann and her fiancé attended Kirk’s college graduation in May, and this summer Kirk spent a lot of time at their house while he took a summer course in the southern part of the state.

“Finding her and learning what she is like has helped me understand myself better, it makes me feel more whole”, Kirk has told me.

 

Many of my vignettes on this blog end with unanswered questions or unstated uncertainties, just like any typical physician’s patient encounters. These updates moved the plot forward in just three cases, but even these are not the final installments in the history of each patient’s own journey. Medicine, even practiced over many years of physician-patient continuity, is but a glimpse into the lives of a few fellow humans.

 

A Rash of Rashes

This week I suddenly felt transported back to my earliest years in medicine back in Sweden. In the last few days I have seen almost a dozen children with rashes. We have a Hand, Foot and Mouth epidemic in our little town, hitting the second and fourth grade children hardest.

One eleven year old boy had looked like an early strep throat a few days ago, but he came back today with subtle red spots on the palms of his hands. He was in the room across the hall from his two-year old cousin, who had a full blown case of HFMD, the worst I have seen all week. His aunt had sore, itchy palms with no rash. I don’t know if it’s a sympathy reaction or if she is next to come down with it.

Mixed in with the rest of them was a two year old from out of town with a sketchy immunization history and a bad case of chickenpox, and a handful of children with colds and worried parents. One little boy with a runny nose had one single macular lesion on his thumb – too soon to tell whether he is coming down with Hand, Foot and Mouth disease or not.

Working acute care in Sweden, I saw a lot of rashes, and in those days we did not have all the immunizations we have now. I remember feeling pretty confident with my differential diagnosis of rashes – measles, German Measels, scarlet fever, things we don’t see much of anymore. Scarlet fever, associated with streptococcus infections, was common then but is rare these days. We also saw enough post-streptococcal nephritis that I routinely brought strep patients back for a urinalysis after their sore throat had resolved.

I remember the varied reactions among parents during the small epidemics I witnessed in those early days. Most parents took things in stride, expressing gratitude that their children got their “normal childhood diseases” over and done with. Some parents even sought out chickenpox cases in their neighborhoods and had chicken pox parties in order to have some control over when their children got the disease. I just read somewhere that the Swedes still aren’t immunizing children against chickenpox, apparently for cost reasons.

When I worked in student health here in the U.S. in the late 1980’s, we had a measles epidemic at the university. Because the students had been immunized as children, they tended to get milder and atypical forms of the disease. I remember being called in to see my colleagues’ cases all the time as the local expert on the rashes of “childhood diseases”.

Hand, Foot and Mouth disease was first described in New Zealand (or Australia by some accounts) in the 1950’s. I don’t remember running into it often back when I used to see measles and German measles. I remember just calling it a coxsackie virus rash. Recently I have read that the Swedes call the disease “höstblåsor”, or “autumn blisters”. I do remember seeing more “herpangina”, which looks the same and is also caused by a coxsackie virus, but is limited to the mouth.

There is no widely available vaccine against Hand, Foot and Mouth disease, and antiviral drugs are ineffective against it, but it tends to be a very benign illness. Some of the eleven viruses that can cause the disease are more aggressive, and in other parts of the world, for example Vietnam, the disease can more often be associated with neurological complications, from minor twitching to convulsions.

The way our society reacts to the mild form of the disease that we usually see is interesting. People worry about second graders missing a week of school – something I have a little trouble with. The economic burden of working parents missing work is a valid concern, but with so few “childhood diseases” left to contend with, a week of reading, watching movies or playing games at home isn’t the end of the world.

Our few remaining “childhood diseases” take the time they take to get through, and we have no shortcuts. They offer us an opportunity to understand that we can’t control everything in our lives.

Hand, Foot and Mouth disease usually only strikes once, so unlike the common cold, it has not become big business for purveyors of useless remedies, and unlike influenza, we have no big-ticket disease modifying drugs, so we are left to practice good home care, humility and the ancient art of just “being sick”.

America’s favorite mid-century pediatrician, Dr. Benjamin Spock, wrote the following about the “childhood diseases”:

“There are only two things a child will share willingly — communicable diseases and his mother’s age.”


Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share

Mailbox

contact @ acountrydoctorwrites.com

RSS A Country Doctor Reads:

  • More on Bribing Doctors
    The going rate for physician bribery seems to be around $100 per act. In Great Britain it is slightly less, about $88, or £55. In one recent American case, I was offered $100 for putting a hypotensive diabetic patient of mine on an ACE inhibitor (“Incentive, Bribe or Kickback?“) Now my British fellow GPs stand […]
  • Celiac Disease and the Gut-Brain Axis
    Gluten free diets have become somewhat of a fad lately, and many people say that they are not offering any health benefits for most people. But, given the wide range of symptoms and conditions that seem to be associated with celiac disease, it makes you wonder. I had been aware of the physical symptoms claimed […]
  • Ebola and the EMR
    When I heard about the Ebola case in Texas, I was impressed that the doctor made the diagnosis. But according to The Healthcare Blog, the diagnosis was missed and the patient was sent home. Two days later a family member called the CDC and was told to bring the patient back to the ER. The […]
  • Three Little Words
    Newly minted physician Pranay Sinha, opening up about early professional doubts, writes about the comfort a senior colleague’s three words gave: “Dude, me too!” “We need to be able to voice these doubts and fears. We need to be able to talk about the sadness of that first death certificate we signed, the mortification at […]
© A Country Doctor Writes 2008-2014. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.