Life Lessons from Memorial Day Past

Siblings are a part of you before they are born and remain in your heart long after they are gone.  I was five and a half years old when my mother first told me she was expecting.  After 36 years, this particular childhood conversation is crystal clear in my mind.

My mother had a beautiful baby boy in September 1980 and he grew up to become an extraordinary young man.  It seems so long ago, but his time here went all too fast.  He took his final breath, due to an accidental fall, nine years ago.  Those of us who knew him and loved him have yet to catch our breath and probably never will.  It is hard to believe nine years have passed since I last looked into his sparkling brown eyes.

Much is written about grief accompanying the loss of a child, spouse, or parent.  When it comes to losing a sibling, however, the literature is oddly scarce.  No other relationship mimics that between siblings.  It is a unique closeness forged in happiness, anger, love, frustration, and understanding, altogether coupled with similar genetic ingredients. 

I naively believed lightening would not strike twice.  My parents already buried one child, my older sister, who drowned when she was two years old.  As the oldest of the remaining four, I was fiercely protective of my three younger brothers.  As we embraced adulthood, we relished the fact we were the best of friends, partners in crime, and confidantes. 

These three young men shaped the woman I became while giving me a glimpse into the often elusive male world.  Siblings are supposed to be our partners for life.  One brother has been with me for almost 40 years, the youngest clocks in at an impressive 30 years and Laith was with me for 26 and a half before his untimely death.  Many people are not even married that long, no matter how many times they try. 

But nothing remains perfect and nothing lasts forever.  That is the first of many lessons I have learned.  Unavoidable obstacles sometimes cause time to run out for some far earlier than expected.  There is no map and compass to guide us through the tragedies along the way. You just keep putting one foot in front of the other, moving forward because you must.  The sun rises and sets each day despite your wishes to the contrary.  Time never stops. 

I never imagined saying goodbye to my younger brother so soon.  His tragic death has left a deep wound that will never completely heal.  It has scabbed over, but gets ripped off unexpectedly sometimes serving as a reminder of our unbearable loss.  Ironically, my husband and I were married one month after my brothers’ death.  On my wedding day, he was missing.  His birthday in September brings me to tears.  I will never hear that voice I miss so much.  I will always remember the last time we hugged and said, “I love you.”  It was the final goodbye that never should have been. 

A few weeks after his belongings had been sorted; I found a Ziploc bag in which he kept things most precious to him.  He collected letters from his first serious girlfriend, pictures of friends, and a few birthday cards from Mom and Dad.  Then I discovered assorted postcards, notes, and pictures from me.  He kept those mementos, picked them up from time to time, and knew how much I loved him. 

Something that cannot be lost is almost 27 years of shared memories.  His smile is indelibly imprinted on my brain, his laugh can be found tucked away deep inside my soul, and his infectious personality is intricately woven into each story I share.  Preparing him for those job interviews, giving him advice about a girl he just met, and helping him clean his always messy apartment are experiences to be cherished for the rest of my life. 

His tennis team at Purdue University felt his impact so strongly, they established the Annual Alumni Tennis Challenge in honor of him.  http://www.purduesports.com/sports/m-tennis/spec-rel/in-memory-of-laith-al-agba.html

The most important lesson learned for me over the past nine years is how unpredictable life can be; there are no guarantees.  After having four children of my own, my parenting goals are now simpler than they might have been before this tragic event. The “best-I-can-do” parenting is good enough; everything does not have to be perfect.  My little brother grabbed life with both hands and experienced everything he possibly could in the moment.   I strive to make the most of each and every day with my children and be grateful for that time, in honor of my little brother.  He would not have wanted it any other way. 

Thriving After a Pediatric Stroke

The other day I received a message from a patients’ mother I took care of more than 15 years ago, during my residency.  “He made it.  Medically, mentally, physically, and academically, he did it!”  She also attached his graduation picture.  He is a man now.  Where did the time go?  Max is a child who grabbed my heart in a very special way from the moment we met.  By that time, he and his family were well accustomed to the hospital atmosphere; everyone knew Max and loved his smile.  He is still one of the most adorable children I have ever known. 

He was almost 2 years old when I met him on the inpatient unit after admission for an infection.  His mom had this air of confidence about her because she knew her son better than anyone in the world, yet she put up with those of us who were inexperienced residents still learning.  During her pregnancy, ultrasound detected a small heart defect.  At 6-8 weeks of age, he was taken to the catheter lab to have the defect fixed.  He was still symptomatic after surgery, a repeat echocardiogram found a hole between the upper chambers of his heart, known as an Atrial Septal Defect or ASD.

He was two and half months when they performed open heart surgery to repair his ASD and during that operation, he sustained a stroke.   The recovery was lengthy.  The risk of stroke in children is higher in males and highest during the first year of life.  Of those who survive, 50-80% have permanent neurologic deficits.  Long-term disability is common including cognitive and sensory disorders, seizures, speech and language delays, poor attention, behavioral problems and poor quality of life.  Max was in the hospital and quick diagnosis helped him not only to survive but ultimately, thrive.

Having a congenital heart defect is one of the major risk factors for stroke in children.  Misdiagnosis is common because the symptoms are very different when compared to adults.  In newborns, the first symptom is often seizures involving only one arm or leg.  Max had other setbacks to overcome along the way including an arm abnormality which required multiple operations and other health issues complicated by his history of stroke.  It seems like yesterday he was two and three years old and would come bounding into my clinic for well child and sick appointments like he owned the place. 

There are a few reasons I decided to write about Max.  First, I would like both him and his mother to know how proud I am of all they accomplished over the last decade and a half.  He will graduate soon and plans to go on and attend an Art Institute out of state.  Second, I hope this story gives hope to parents of children with congenital heart defects, prematurity, or any other disease or disability you feel stands in the way of your child achieving their dreams.  Anything is possible.

During my final year of residency, I received an award for the Best Continuity Clinic.  As a pediatrician who planned to return and practice in my hometown, it is an accomplishment of which I was proud.  Max is part of the reason I received this award. He and his family taught me about the full spectrum of pediatric care:  seeing him in my clinic, admitting him to the hospital a handful of times, and after one hospital discharge on a holiday weekend, making my first official “house call” to check on him. 

In my opinion, the physician-patient relationship is the most powerful force existing in medicine today.  It has kept my love for this career alive even on the worst days.  Being part of a childs’ life and changing it in some small way for the better is something to treasure.  Thank you for sending me school pictures over the years and thank you for letting me share this story.  “Medically, mentally, physically, and academically, he did it!”  Max has many more triumphs ahead for Max, there will also be many for other children who struggled early in life to survive.   

Money Talks: Survival of the Small Pediatric Clinic

Recently, my front desk staff asked if they could “guest” write on MommyDoc.  So with some edits from me here are their collective words.

We often hear “I love our doctor so much, I would not go anywhere else, but that front office is so rude asking for money when we walk through the door.”  Whether it is in regard to a co-payment, deductible, or other outstanding balance, there seems to be a miscommunication as to why the front feels so strongly about collecting money owed before appointments. 

We care as much about the people we see on a monthly or yearly basis as the doctors we work for.  Revenue collection IS our job and without this, you would not receive the personalized, in-depth care you enjoy in a small, private practice environment.  The days of physicians driving fancy sports cars and living in mansions are long gone.  Reimbursement from insurance companies has continued a steady decline.  Physicians are now unable to support private practices without joining larger groups.

Imagine for a moment we are at a Starbucks and the physicians are your daily coffee; you approach the counter and order your favorite drink, Dr. Niran is a whole milk Peppermint Mocha and Dr. Saad is a sweet Vanilla Latte.  Would you order your drink and then pay a few months down the line “if and when you have enough to cover the bill?” Better yet as you pick up your warm drink, would you say “I am not sure if there is money in my account, but trust me, you will get paid sometime?”   Insurance companies pay claims 30-90 days after the service, assuming we had the correct insurance information from our patients at the time.  Would Starbucks still actually be in business if they allowed this kind of payment delay?  Of course not, this is no different than paying a co-pay each time you see your doctor.

A man called our office this week and asked what WE charge for co-pays.  What the what? Copays and deductibles are what YOUR insurance requires you to pay according to your contract.  They consider it “your investment” in your health care.  We were asked the other day whether the copay really makes a difference in our bottom line.  You bet it does!  It makes up a significant portion of total income for our business and keeps us afloat. 

Copays pit your physician against your pocketbook.  Insurance companies want to chargeyou $30 when you see your primary care doctor, $75 if you are seen at an urgent care facility, and as much as $150 when you go to the ER.  If an insurer “allows” $100 per visit to the doctor, they actually pay only $65 and stick you with the other $35.  So on average, your co-pay makes up 25-30% of primary care physicians revenue.  If any business went without 25% of their revenue, they would go bankrupt. 

So many insurance plans are available that consumers must be savvy shoppers to make sure they understand exactly what their plan is offering.  People are surprised when they pay little in monthly premiums, thinking it is a great deal, to realize later their insurance will not pick up the tab until the beneficiary (you) pay a substantial “out of pocket” amount, known as the deductible or patient portion. 

If you are a family with a couple of small children who will be coming to our office at least several times per year for well child exams, immunizations, illnesses, or injuries then a plan with a high cost for each visit might not be the right plan for you.  You might be better off with insurance and a higher monthly premium or smaller deductible when your child is ill. 

Over the past 5 years, a number of physicians in Kitsap County have gone out of business for financial reasons, retired much earlier than expected, have declared bankruptcy and closed, or have been forced to join larger corporations.  This means physicians will have less time to spend with you and must increase the volume of patients seen each day to make ends meet.

We definitely understand patients not wanting to be hassled about payments, especially when your child is ill, but we NEED to stay in business.  This means we must collect payments big and small.  Personally, we feel extremely uncomfortable asking people for money when they come in, knowing a parent will protest or refuse to make a payment and demand to be seen. 

The bigger picture is:  unless our physicians get paid, they cannot afford to continue as our physicians.  If we let people come in without collecting revenue owed, the likelihood of collecting money owed drops significantly.  There are costs to mail out bills and if we begin losing more than we take in, the staff and others employed by this practice will be out of jobs.  If our physicians are not able to make a living, we will close.  You lose the doctor your children love so much and we lose our patients.  Thank you for reading our plea.  We hope you can understand.  We at the front desk, look forward to seeing you soon. #‎BusinessOfMedicine

How A Physician Suicide 30 Years Ago Still Affects This Physician Today

Physicians have one of the highest rates of suicide of any profession; nearly twice the rate of the general population.  400 physicians commit suicide each year in the United States.  The stress of being a doctor is constant and unrelenting.  The majority of us are perfectionists with a strong work ethic – your classic Type A personality.  Maybe we set ourselves up for failure and then cannot accept when it inevitably occurs.  Failure is a part of medicine because it is a part of life. 

I was 12 years old in 1987 when the first physician I knew committed suicide.  My father was the seventh physician to join The Doctors Clinic in 1971.  I was raised attending summertime backyard picnics at other physicians’ homes and remember most of their families and children.  It was a close-knit community of medical providers back then; something that may have prevented more tragic events like this from occurring. 

He was an excellent internal medicine physician, revered by many in Kitsap County.  His wife was beautiful, kind, and could sew the best Halloween costumes in town.  I still have a picture of the Snow White costume I borrowed one year; it was as beautifully made as my wedding gown.  He had two darling daughters, one my age and another two years older than me.  They had horses out in front of their house.  I remember being in awe of them. 

There was more camaraderie between physicians than there is today.  This doctor had a great sense of humor from stories I have been told.  He had a nurse wheel him down to my dad’s clinic (the bottom floor of the Wheaton Way building where Peninsula Community Health Services resides now) in a wheelchair.  He was pretending he passed out and gave his colleagues quite a scare. 

I do not know why he committed suicide.  It was a gunshot to the head at that same building on Wheaton Way where they had played jokes on each other.  He asked another physician to meet there to talk minutes before completing this final act.  The physician arrived to find his friend and colleague dead.  As what happened to his friend dawned on him, he went to throw up, and then dialed 911. 

It has been nearly 30 years since this heartbreaking event unfolded, yet it occurs every single day to other physicians in the United States.  These struggling doctors are mothers, fathers, sons, daughters, husbands, wives, colleagues, and friends.  I have known other medical providers that have committed suicide, even one of my medical school classmates. 

At one time, ALL of these people had applied to medical school and the day they were accepted was likely amongst the best of their lives.  What happened to those bright eyed and bushy tailed medical students they once were when their journey began?  How did they reach the point they felt suicide was the only way out of their disillusionment?

The business and administrative responsibilities of running a practice are vast, let alone the overwhelming stress and fear of making a mistake and inadvertently someone dies at our hands.   We carry this burden with us on a daily basis.  If we cannot cope with the uncertainty of medicine, it can manifest as depression, anxiety, alcoholism, or suicide. 

Finding balance is the only answer to surviving many decades in this grueling profession; it is different for each physician.  For some of us it is picking up our children from school every day and discussing their day on the drive home.   Making sure I meet the needs of my children to the best of my ability helps keep me grounded while I acknowledge and accept unhappy or unsatisfied patients in my office. 

Stepping back and looking at the big picture, I always ask myself if whatever is happening will matter in five years.  If the answer is no, I refuse to take it personally and try to let it go.  In five years, it is the talks while snuggling my babies every night I will remember best. 

I have thought so often of this family over the last three decades and wonder where his wife and daughters are today.  I am certain they have started families of their own and I hope they have found balance and peace where their father could not. 

Here is what I have learned about avoiding burnout and trying to find true balance: life is extraordinarily precious; do the very best where you can and do not waste a moment on anything outside of your control.  Words I live by.

  

Power Bars and Post-it Notes

Growing up, I watched other children pull out their packed lunches that included napkins with special messages from mom on them about having a good day at school.  I always wished my mom would have put a note in my lunch box even if it was “you forgot to do the dishes this morning.”  I had a nice childhood and my needs were always met, so I am not exactly complaining. 

However,  I promised myself when I had children of my own, they would get occasional notes in their lunches.  Last week, I put a power bar in my oldest son’s lunch for his snack that day (it is his all-time favorite.)  He thought we were out of power bars, so I taped a message written on a post-it note to the “surprise” bar.  I thought he might like to know how much I loved him that day.  


When I picked him up from school, he came walking out to the parking lot with a note taped to his chest.  I asked him when he taped my note to the front of his shirt.  He smiled and said he did it after lunch.  “Did you wear that for the rest of the day?”  “Yes”, he said with a huge smile and a nod.  “My teacher asked me about it and I told her it was a note from my mom.”


My husband and I recently returned from a rare one-week solo vacation, without our four children.  (Many thanks to both of my parents for taking on the huge task of babysitting for a week!)  My oldest son missed us both more than he or even I expected.  I have written about him before because he is constantly teaching me about life and to look at things from a different perspective.

He is extremely insightful and reflective, yet independent at the same time.  Sometimes, he can be a man of few words, but his actions spoke loud and clear.  He knows how much I love him and does not mind a small reminder taped to his food in the middle of the school day.  He literally wore his heart AND mine on the front of his t-shirt.
 

Experts say teaching children to express their feelings comfortably helps to build self-esteem.  Sometimes as parents, we feel it is our job to build confidence in our children, by constantly reassuring them, complimenting them, or guarding against anything that can interfere with feelings of self-worth. 

In my opinion, we need to nurture our little saplings and provide a supportive environment to help them to grow strong on their own and avoid pruning their branches too early.  


For whatever reason, right now, my son wants more of my time and reassurance, which I am happy to provide.  I appreciate that he is not afraid to ask for what he needs.  I am proud of the fact he would wear a note from me on his shirt all day at school and not think anything about it, other than how much I love him.

I admire his confidence in himself and his unwavering loyalty to his siblings, parents, and grandparents.  I am lucky to be his mother and so grateful he is my son.  I plan to always stay well stocked up on power bars.  They are symbolic to me in a whole new way!

MOC: How the American Board of Pediatrics Failed this Nursing Physician

To the American Board of Pediatrics:

I took and passed my recertification exam in Washington State last fall and would like to express my sincere gratitude to your organization for setting up more hoops for pediatricians to jump through under the guise of helping us stay up-to-date.  The first hurdle was the exam application and the second was the testing day experience, which was one of the most demeaning of my entire life.  Below are my thoughts.

My daughter would be 9 months old and still nursing when I took the exam.  The recertification test duration is six hours with a 20 minute break for lunch. When I inquired about adequate time to pump and store milk, your office informed me I was the first and only pediatrician in the United States to request an accommodation.  Consideration for 20 extra minutes required application as a “disabled” physician.

My “disability” request involved submitting a letter by me outlining my needs, obtaining a second letter detailing the same from my Obstetrician, to include his CV, medical license, and credentials.  Obviously, this application process was instituted to discourage anyone from requesting schedule variances.  My heart should have been bursting with delight when you allowed me time to pump milk to feed my daughter. 

While swiping our credit cards to fund this atrocity known as Maintenance of Certification, maybe your group could take a few moments to streamline your rigid and archaic application process?  It is not exactly rocket science or is keeping track of so much money simply too exhausting? 

The morning of the test I left my home at 6:30am in order to reach the testing site by 10am, which required travel across the Puget Sound by ferry.  Upon arrival, I was allowed only one small locker for my things with no exceptions for those with additional necessary medical equipment.  My $1200 breast pump had to be placed on top of the bank of lockers with no assurances it would remain there throughout the testing period. 

The staff was unwilling to put it anywhere else for safe keeping.  We were warned not to leave valuables inside our vehicles, because the testing site was in a high crime area.  Desperate to keep both valuables, I tried putting the pump motor and my wallet in the locker but to no avail. 

The alternative option was to place the pump inside the locker and my purse with my credit cards and identification on top. Figuring it was less likely my breast pump would be stolen; I took my chances and placed my purse inside the locker.  Why couldn’t an exception be made for storing necessary medical equipment?  In light of my “disability”, is that even legal?  

The very intensive search process ensued as I presented my driver license, turned out each and every pocket in my clothing, and was “wanded” like a common criminal.  I have more sympathy for them now that I have been subjected to such measures.  Finally, testing began.  Emerging three hours later, I was relieved to see my breast pump still sitting on top of the bank of lockers.

No room was available for pumping, so I was told to use the bathroom.  I ate lunch, went to the restroom, and discovered one plug next to the sink.  Unable to use the counter with others needing to wash their hands after using the facilities, I would have to sit on the floor.  I returned to the waiting room mulling over how to resolve this situation. 

Finding a plug in the waiting room, I began to set up my pump and put on my hands-free pumping bra.  The room contained about 20 young men waiting to take their truck driver tests, hairstyling certification exams, and other trade competency assessments.  Horrified, the testing center attendant jumped up and demanded, “What are you doing?”  My answer was, “If you are unable to find a private room for my activities, this waiting room is going to witness quite a show.”

Surprisingly, she went to find the site manager and they found me a more private location.  Isn’t there a federal law that guarantees nursing mothers are provided appropriate accommodations, with one electrical outlet far enough from a water source to ensure safety from electrocution?

Basically, I am a hard-working pediatrician with 12 years of post-high school education and 14 years in practice.  By 7:30pm, I returned home feeling beaten down and humiliated.  Why would any physician submit to this degrading process to “recertify” board competency?  It is absolutely unacceptable. 

All testing sites should have adequate storage for required belongings, a testing site should be within 30-60 minutes of our home or workplace, and in compliance with federal law, adequate facilities should be available to properly attend to our medical needs.

Many female physicians, including me, postponed their child bearing in order to complete our educations.  I had three children aged 4, 2, and 9 months when recertifying.  These regulations place undue burden on those of us who have young families.  If we are “disabled”, then why are we not accommodated in compliance with federal standards? 

Is the American Board of Pediatrics as callous as they seem?  Maybe individuals on the Board of Directors did not breastfeed their young children and cannot spare a drop of empathy for medical needs of fellow physicians?  Maybe things would be different if pediatricians could prevent the American Board of Pediatrics employees from paying their bills and feeding their children?  Wait, we actually could do that if we refused to comply with your unreasonable demands.  Hmmm…

Sincerely,

Niran S. Al-Agba, MD, FAAP

Silverdale Pediatrics, LLP
‪#‎MOCReform‬

Using Index Cards as Medical Record Tools

During our dermatology section in medical school, a classmate recounted having had Henoch-Schonlein Purpura as a child. Over a holiday break, he visited his primary care physician and asked if he could review his records out of curiosity. His family physician pulled out the index card that served as this man’s medical record. Yes, you read that correctly. It was not a chart or computer printout; rather a 4 x 6 white index card, exactly like those we used in grade school.

My classmates’ name was written at the top of the card and on each line were dates and diagnoses. Halfway down were the words: HSP – “classic” rash. My classmate was disappointed he could not analyze his clinical presentation in more detail; nonetheless, he brought back a copy to show us. An index card as medical record tool is so extraordinarily simple, it is awe-inspiring. No insurance company to satisfy, no chart to be audited, and no computer screen between the physician and patient. Back then, a physician’s time was spent taking a history, performing a physical examination, and having a conversation.

My father has been a practicing pediatrician for the last 46 years. When I told him about the index card, he smiled and reminisced how much he loved index cards too; when physicians were compensated for practicing medicine and not just ‘documenting’ their practice. Combining the art and science of medicine is what many of us love most about being physicians. Why have we allowed bureaucrats and EMR systems to take away the very thing that brings us the greatest joy?

75% of diagnoses can be made on the basis of history alone, 10% from physical exam, 5% from basic tests, 5% from more invasive testing, and 5% cannot be answered by any of the above. This family physician was so confident in his diagnosis, he wrote it on one line. As physicians, we have completed 11 years of post-high school education at a minimum. The information we accumulate during a decade spent immersed in science and the human body is vast. Our mind is our most valuable asset, yet we are not paid based on what our minds can do. We should be compensated for completing thorough histories, physicals, and making diagnoses. We should be reimbursed for listening to patients, providing comfort and conversation; especially when it results in a trusting relationship, with improved patient compliance and better outcomes, which will be inevitable.

As pediatrician in my hometown, I attended high school with my patients’ parents; I know them. Does it improve my diagnostic abilities to inquire about their family history at each visit? Has any physician actually found anything informative after a review of systems? I have my doubts. Why do I have to prove my diagnosis required a high level of decision making on a computer screen to be adequately compensated for my depth of thought when my time is better utilized listening to patients and sharing my knowledge?

My father and I are still using paper charts; I am not certain he could handle an EHR. He still has difficulty sending email. Our charts are pink and have four dividers: the first section holds dictations, the second lab results, the third has radiology results, and the back section contains consult notes from specialists and records from other physicians. It is easy to review quickly, allows us to provide

comprehensive care and be efficient at the same time. How on earth does clicking boxes on a computer screen improve actual medical care, increase a patient’s trust, or improve their compliance?

My favorite part of being a physician is using the history and physical exam to diagnose, problem solve, and treat my patients. Disease can often be diagnosed on the basis of history alone, which is a notable feat after years of training and experience; however, we must have time to ask the right questions to be successful. In reality, a focused history and physical are essential to the delivery of high quality medical care. They are cost-effective and avoid unnecessary waste of resources at the same time.

So many physicians are frustrated with the healthcare system today, with high levels of dissatisfaction and burnout running rampant. We rescue this profession by standing up and forcing insurers, politicians, and administrators who control healthcare delivery to make changes that specifically benefit physicians and patients. Do not forget, we have more years of education and experience than those individuals who are making the rules. Why have we allowed them to essentially manage our profession?

Physicians revel in listening, comforting, teaching, and healing others; in fact, we flourish in these circumstances. Maybe the best place begin taking charge again is by insisting on documenting care our way – whether using old-fashioned white paper or EHR systems better suited to meet our needs. Since “meaningful use” standards are being revamped, let us indeed ‘throw the baby out with the bath water’. We might rediscover the tangible reward of being healers along the way.

Let us go back for a moment to ponder this ingenious idea of using an index card as a medical record tool. Low cost, top quality medical care is the Holy Grail for which everyone in the field of medicine is searching. Is it conceivable we already found it, used it for more than a century, and abandoned it in light of its simplicity? Possibly. Nevertheless, it is a reminder we should only settle for a system that allows physicians to determine our own destiny and practice medicine in a more fulfilling way.

Greetings from Art of the Pie Camp 2016

MommyDoc posts tend to focus on healthcare anecdotes about trying to survive and thrive being both a mom and doctor.  Today, I wanted to talk about another slice of my life (pun intended.) After all, there is an art and science to making pie, just as there is to practicing medicine.  

“Mommy, lets make pie!” My daughter and I have a few special activities we enjoy doing together.  Pie making is one of them.  Last May, I spent 5 days learning everything you never knew you needed to know about making crust, filling, and baking the perfect pie under the expert instruction of Kate McDermott.  

It was one of the most amazing experiences of my life.  So imagine my excitement when I was invited back this year to help instruct a new group of pie makers from around the country for Pie Camp 2016.  I jumped at the chance to return and refresh my skills. 

Practicing medicine and baking pies take patience, practice, and the end results are truly a labor of love.  After returning from camp, my daughter and I began making fruit pies together. She loves mixing fruit filling, pouring it into the pie pan, and covering the top with lattice strips. Her specialty is brushing on the egg white wash and lightly dusting the top with sugar before it goes in the oven. 

 My boys even get in on the action when they see me put gingersnaps into a plastic bag and bring out the rolling pin to make another favorite:  Buttermilk Pie (popular during the Great Depression) with a gingersnap crust. That means it is time to beat gingersnaps into fine crumbs.  Oh how they love to hit things repeatedly until they are broken into tiny little pieces. 

 After the pie goes into the oven, they all wait patiently to watch it come out of the oven and see the fruits of their labor.  However, as our year became busier with school and activities, pie-making was pushed to the back burner (pun intended again.)  Driving up north Wednesday, I was looking forward to spending time with my hands immersed in dough made from scratch and working with fruit of “pie worthy” quality.  However, doubt creeped in as I contemplated if my skills were adequate to assist Kate teaching others the art of making pie?  

Throughout medical training we are told the best way to acquire a new skill is to “see one, do one, and then teach one.”  I spent time seeing pies made, doing it myself, and then teaching my children some of the steps in the process.  Passing on this knowledge by teaching was the logical next step in my journey.  

This week has reminded me the science and art of making pies, like medicine, can sometimes be unpredictable but the time spent teaching others a skill they can share with their loved ones is priceless and the stuff of which beautiful memories are made.

Be Low-Tech When You Can… Internet and Gaming Addiction

A New York Times article entitled “Steve Jobs Was a Low-Tech Parent” discusses how tech executives set tough limits for their own children regarding the use of technology.  The author concludes they must know something the general population does not.  They are the experts, aren’t they?  What both technology folks and pediatricians know is limiting access to video games allows children to find pleasure in everyday life activities—engaging with friends and family, reading, playing outside, and achieving in school.  They learn the true value of a hard day’s work.  Isn’t that what we all want for our children?



Internet companies are learning that addiction makes for a solid business strategy.  When a human being is suffering from addiction, they relentlessly search for situations associated with pleasure; video games and smartphone use can provide these instantaneous rewards for the incompletely developed adolescent mind.   Addiction is epitomized by complete denial of experiencing any negative consequences. Teenagers especially, insist they are fine despite evidence to the contrary their world is falling apart.  Addicted teens quit caring about friends, sports, schoolwork, and even their families.   



Brain imaging reveals video games and trigger release of dopamine, a neurotransmitter in the brain with similar effects on the body as methamphetamines.  Gaming provides immediate fulfillment and a sense of accomplishment unlike the delayed gratification experienced in real life. There is even something known as “phantom smartphone buzzing” where our brains are tricked into thinking our phone is buzzing when it is not actually happening.    

During puberty, the brain’s reward center (a.k.a limbic system) becomes highly activated, and then gradually settles down as they reach maturity.  The prefrontal cortex is in charge of executive function, including impulse control and support for planning and organizing behavior. Society considers children to be adults at the age of 18, yet their prefrontal cortex is not fully mature until age 25.  Imagine what constant immersion in rapid, flashing images and repetitive violence does for the immature connections in the not yet mature brain?

Addiction is a disorder of the brain’s incentive system (highly activated in adolescence) encompassing a strong desire to seek rewards despite adverse consequences.  Two things that characterize addiction are the activity is intrinsically pleasurable and the theory that “reinforcement” is present, meaning it is highly likely the person will habitually seek exposure. Signs of technology addiction include: sneaking and lying about time on the internet, demanding unreasonable amounts of time to surf the internet or play video games, or experiencing rage when access is restricted. 



“My son does not care about anything but using his phone or playing video games.”  Parents often pursue professional help when their previously loving, bright and engaging child becomes unrecognizable.  Their teen will not eat, sleep, or comply when asked to stop playing video games.  In 2013, a diagnosis known as Internet Gaming Disorder was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the encyclopedia of mental health disorders.  Internet Addiction Disorder (IAD) has not been formally characterized as a disorder according to the manual, however many pediatricians are concerned the number of afflicted children is increasing. 



“You must start him on a medication that will make him happier.” parents say.  If their child is happy, they mistakenly believe he or she will stop being addicted, but that methodology is terribly flawed.  Instead, parents must get rid of the gaming consoles or significantly curtail use of other technology in order for their children to find alternative activities they enjoy, like playing sports or musical instruments. 



Unfortunately, parents are terribly resistant to this approach for fear of upsetting the delicate balance in the volatile relationship with their teen.  Parental anxiety is frequently behind reluctance to remove video games from the home altogether.  They have already witnessed tremendous rage from their adolescent when barring video game use temporarily.  Teenagers can actually become violent or even suicidal; sometimes they have already been involved with law enforcement or the juvenile justice system prior to coming to my office for help.  Inevitably, teenagers show up at their first visit with me in wrinkled clothes always including a sweatshirt, and looking unkempt and exhausted.  The last place they want to be on earth is sitting in my office. 



The bottom line is no medications are available to “make someone happy” when they are suffering from a technology addiction.  It is nearly impossible to treat addiction for something easily accessible inside the home.  That is like treating an alcoholic by displaying liquor bottles on top of the refrigerator. In my experience, the grip of addiction can be nearly impossible to break once it has begun.  It is far better to prevent your child from developing an addiction in the first place. 



Experts are still compiling best recommendations to prevent addiction to technology in children and adolescents.   My thoughts raising my own children and treating addicted children are to focus early on using the internet mostly for school assignments, creative pursuits, or research.  A bedroom is not the proper location for a screen of any kind.   Keeping internet use restricted to specific high traffic areas of the home allows for close monitoring and establishing boundaries while they are young.  Limit time children spend playing video games or engaging in social interaction; emphasize producing content rather than mindless consuming. 

Steve Jobs had the right approach to limit access to technology while his children were being raised.  He knew of the dangers of internet addiction, but also the risks of cyberbullying and exposure to inappropriate content.  Technology can be a helpful adjunct for learning, but when your child becomes compulsive about internet use or playing video games and angry at the thought of doing something else, that is a red flag.   Adolescents are exceptionally vulnerable to activities associated with instant gratification and pleasurable experience.  Curtail those types of internet activities when possible.  Finally, if you observe symptoms of internet addiction disorder (IAD), internet gaming disorders, or see signs of anxiety or depression which may trigger internet addiction, please seek help from a physician or other profession experienced in this area.

Where Does the Story Begin For a Physician?

Where Does the Story Begin for A Doctor?

It is different for every one of us.  There is a well-known joke that circulated while I was a medical student.  What do you call the person who graduates last in their class from medical school?  A Doctor.  I certainly did not graduate last, but I was actually the last person accepted to the 1995 class at the University Of Washington School Of Medicine.  When I called to accept the position, the secretary in the Admissions Office said “Your tape was amazing.  Everyone in this office has seen it and loved it.  Welcome aboard.”  

Yes, I was accepted to medical school because I was a competitive baton twirler.  I devoted more than 10 years of my life to perfecting my performance and here is the letter my very gutsy 20 year old self sent to the Dean of the Medical School more than 20 years ago.  Recently, an older video of my performance was posted online and I thought posting the ONE that really mattered in my life was worthwhile to share.  Here is where my journey into medicine truly began, and where I learned to stand up for what I believe in.  A lesson I carry with me today.

June 15, 1995

Dear Dr. Samson:

I am a medical school applicant on the waiting list at the University Of Washington, who met briefly with you yesterday. I was quite disappointed with our meeting and feel you might be less apt to make jokes once you learn something about the sport of competitive baton twirling.  You mentioned I had not done anything extraordinary to stand out from the other medical school applicants, like playing basketball or the violin.  You are correct that I have participated in neither of these activities; however I would like to show you what I consider “extraordinary.”   I have enclosed a video tape of my final World Baton Twirling Competition in which I placed second.

I find it hard to believe someone of your educational level was so quick to judge something you knew so little about.  Your attitude toward baton twirling is a common one people have toward a sport to which they have never been exposed.  I assure you this sport demands the relentless dedication, desire, and the countless hours of hard work as does any goal worth achieving. 

Hopefully, I have piqued your curiosity enough so you will take three minutes out of your busy day and watch the Silver Medalist at the 1990 Eleventh World Baton Twirling Championships, in which 17 countries participated.  It is unlike anything you have seen before and equally as “extraordinary” as playing basketball or a musical instrument in my humble opinion. 

Sincerely,

Niran S. Al-Agba

P.S.  I should mention the Dean of the Medical School became a good friend of mine.  He said he could not believe a student would tell him he needed an education.  He returned the VHS tape to me upon my graduation day from Medical School in 1999. 

The Ominous Rattle Of Pneumonia

I saw two cases of bacterial pneumonia this week and thought it would be worthwhile to share a story and follow up with information and advice. Last winter, my worst pneumonia case involved a school-aged girl whose mother is a very close friend of mine. First off, I would like to mention, she rarely calls me with medical questions; sometimes, I wish she would call me a little more often, especially that particular Sunday night.

She said her daughter had been sick for about 10 days, starting with a day or two of fever 100-101 and typical virus symptoms, cough and runny nose. She was better day 3 to 9 with slight cough still and then woke up Sunday morning (day 10) with decreased appetite (bad sign #1), fatigue (bad sign #2), and now had a fever of 104 (really bad sign.) She had pneumonia, I knew it right then and there on the phone. No exam, no labs, just the story. My heart sank. Hoping I was wrong, I told her to come in first thing.

Monday morning at 9am, she looks pale, has a deep cough, and crackles in her lung, also known as “rales” derived from the French word for ‘rattle.’ Rales sound just like crinkling cellophane wrap when a child takes a deep breath. I heard it, my ears know that ominous sound. A chest x-ray confirmed her diagnosis of a ‘consolidation’, which is a ball of pus in the lower lobe of her lung.

Understanding the difference between bronchitis and pneumonia is very important for parents. Bronchitis is that wet, juicy cough your kids get; it sounds impressive, yet there is no fever after day 1 or 2 and they are usually coughing while running outside and playing tag. It is most often caused by a virus. These kids are full of energy, hungry, talkative, and look like normal kids do.

Bacterial pneumonia is a deep, hacking, persistent cough; the child is pale, tired, and has a high fever, often 7-10 days in the illness timeline. The ball of pus is often located in a lower lobe of the left or right lung, just above the diaphragm, which is the muscle separating your chest from your belly. Children often vomit or refuse to eat because the diaphragm gets irritated by the pus ball which in turn causes stomach upset. Children sometimes need to be hospitalized.

Pneumonia can be debilitating once you are officially to the pus ball stage. My little girl needed heavy antibiotics, rest, and chest physical therapy with instructions to see her in the morning. I worried about her all night. She looked slightly better the following day, but still had a long recovery ahead. In total, she missed two weeks of school, could not participate in her normal physical activities for a month, and will always have a small scar in her lung from that dreadful infection.

To look at her today, you would never know she had pneumonia at all; however both her lungs and I will remember. They have repaired themselves to the best of their ability; however microscopic weakness remains in the lung tissue itself. She will be more prone to get another infection there in the future.

A younger girl presented with bacterial pneumonia this past week and I had this same discussion with yet another mother. I started thinking parents need to know when to wait and watch or bring your child to their healthcare provider. Children can decompensate so quickly. They look good, literally until the very moment they do not. So here are some guidelines.

Viral respiratory infections have associated fevers on Day 1 and 2 of symptoms, then their temperature normalizes. Symptoms peak around day 4-6 including runny nose, cough, fatigue, decreased appetite, and watery eyes, then settle down by day 7-10. If a child worsens after day 7, develops fever above 101 degrees, complains of pain when they take a deep breath, they need to be seen and evaluated. If they are short of breath, cannot stop coughing, look lethargic, or your “parent” warning bells are going off, they MUST be seen that night.

I try to teach my families the importance of listening to their own “gut instincts.” You know your child and when you sense something is wrong, trust that sixth sense. Do not ignore those feelings, your child’s health, now and in the future, depends up on it. I hope many of you find this helpful.

When Can You Introduce Solid Foods?

Based on statistics in my practice, 85% of my patients are nursing with more than 50% making it to 12 months. In light of that, my solid food recommendations are tailored to nursing mothers, but can apply to every baby. My advice is based in my own experience and is not “evidence based,” I believe in looking at each infant individually.

Between 4-6 months, most babies will watch you, start reaching for your food, and trying to put it in their mouths. Some babies are not interested until they are a little older, which is normal. As long as they are gaining weight and growing well, there is no reason to force introduction of solids.

Firstly, I am not a fan of infant cereal; the recommendation to start with cereal comes from the need to supplement babies with iron, stores of which reach a low at 4-6 months. Infants absorb only 6% of the available iron from cereal, as compared to 90% from beef, and 95% of the iron available in human milk. However, not enough iron is present in breast milk to provide all the infant needs. Europe starts infants on beef and vegetables, because babies absorb iron adequately from food with beef, and it is a protein unlikely to cause allergy.

Why is Iron important? A child who becomes iron deficient has been shown to develop mild cognitive delay by the time they start kindergarten. Even if supplemented with iron once deficient, they cannot get back the IQ points they lost. That is why I feel so strongly about the provision of adequate iron in an infants diet. Only one or two teaspoons per day of beef are necessary to meet their needs.

Second, I recommend making your own baby food. My all-time favorite book is Top 100 Baby Puree’s by Annabel Karmel, I have made most recipes in there. I learned how to use parsnips, leeks, scallions, and even how to make salmon puree. I would double the batches, grind it all up on a weekend and then store it in the freezer. She provides no recommendation for beef puree, so I made up my own. I give this out 3 times per day, so figured it would be good to write it down.

Dr. Niran’s Beef Puree Recipe:
Chop up 3 lbs of round steak into stir-fry size and boil in a large pot with water for 3+ hours. Add one or two beef bullion cubes to the water for taste. Using a food processor, grind up the meat and use the juice in which it was boiled to get it to the right consistency. Then freeze it in ice cube trays and use as needed. (You could also make in a slow-cooker.)

My children loved a teaspoon of beef mixed with a tablespoon or two butternut squash, sweet potato, or carrot puree, and lots of butter. The other favorite from the book was chicken, apple, sweet potato puree, which is also amazing. As they grow, you can grind it up more coarsely so there are lumps, and then they can learn to chew different textures, and slowly advance their skills.

Third, after 6 months, introduce tastes of creamy peanut butter, whole milk yogurt, and then as they get to 9 months introducing eggs, both whites and yolks. Your child is 10 times less likely to have food allergy when you follow this early introduction approach, which is backed up by excellent studies. Be careful of foods they might choke on however.

To sum it all up, I recommend using your gut instinct and watching your child for cues, letting your child nurse on demand, and eating solid foods when they are hungry. A parting thought: Some of you are vegetarians and as you know I respect your wishes for your own children. Above is just my opinion about feeding infants and what I did with my own children. There are no right or wrong answers, only what is ‘right’ for your family. Happy Eating!   ‪#‎IntroducingSolids

The First Month of Life: Salmonberry Birth Center

Salmonberry Birth Center is offering families in Kitsap County more birthing options than ever available before. Mothers can now deliver infants at a hospital, birth center, or at home.  While not endorsing one specific method, I will say choice is a wonderful thing and should be embraced by our entire community. 

What about care provided after birth?  The World Health Organization recommends postnatal care from a provider within 72 hours of birth, between days 7-14, and then 6 weeks after birth.  Nursing difficulties peak around 3-7 days after birth and women are often discharged home by this time.  The postnatal time period can be dangerous because infants face difficulties such as inadequate feeding, rapid breathing, lethargy, fever, or jaundice. 

When available, home visits have been shown around the world to decrease infant mortality, a number the United States is working hard to decrease.  A home-visit nurse, lactation consultant, or midwife skilled in navigating breastfeeding challenges can make strides toward helping mothers nurse successfully.  In our community, mothers followed by midwives receive outstanding post-natal care already.  Those who deliver in hospitals do not necessarily have access to these same services.

In the US, about 76% of women initiate breastfeeding after birth while in the hospital, but the nursing rate drops to 38% by 6 months of age.  An evidence-based nurse home visitation program was recently evaluated in Florida and found women had a breastfeeding rate of 80% initially, and 56% at six months!   All participants reported the program helped them continue to breastfeed and felt satisfied with additional hands-on support.

The last 6 months in my clinic we have breastfeeding rates at or above 85% initially and more than 65% at 6 months. Dozens of mothers in my practice are nursing infants well into their second years of life.  I was one of them less than a year ago still nursing my son into his second year.  Physicians with personal breastfeeding experience benefit the communities in which they live and practice by increasing this number. 

We have always seen new infants in our practice within that 3 day time period because it is critical to establish adequate milk supply and ensure infants have a proper latch to nurse successfully.  Home visitation is an integral part of a pro-breastfeeding healthcare model and I have long hoped to see these services delivered locally.

With that goal in mind, I am halfway toward making this a reality for patients of Silverdale Pediatrics.  Starting March 1^st, EVERY newborn infant will be provided one home nurse visit post-partum. 

This is going to be such an exciting year as we continue to try new things that provide children in Kitsap County better care.  Thank you for your continued support and referrals.  I am so excited that home-visitation a reality for our patients! #mydocrocks #medicinematters