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Tuesday, May 2nd, 2006
7:36 pm - work update
Just got back from a lovely weekend -- my cousin's wedding in Gloucester, and then visiting friends in NH and a quick meal with Kelsey's parents on the way back. Fantastic weather, great people; all in all, a pretty successful trip.

Got back to a pain-in-the-butt rotation at one of the community hospitals where we spend some time doing pediatrics. The hours are kind of long, we're constantly covering multiple areas of the hospital, and there seems to be pretty poor coordination with other employees. It seems that this is inevitably a side effect of community hospitals, and I think it stems from the fact that we are there relatively rarely and that there are relatively few of us there at any given time. Both of those aspects are relevant -- not only are we each unfamiliar with the nuances of the local system, politics, etc., with relatively poor information transfer from one team to the next and continuity from previous experiences, but the needs of residents are also relatively easily overlooked in the overall hospital system. Nurses and other services and sometimes even our own attendings all seem kind of unfamiliar with our role, and there is a fair amount of time wasted by trying to figure out who should do what. This kind of thing is inevitable with any system in which people rotate through different roles, because there's always a learning curve for each new rotation, but it gets a bit frustrating at times. But hey, the good thing is that it's a relatively short stint -- I have only a total of 3 months left in all of residency over there.

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Sunday, April 23rd, 2006
10:11 am - child development
I've been thinking a lot this month about children and child development -- this rotation has been very educational. Normal child development and behavior are not things that medical schools really teach. There's the token intro to the Denver, and then you're on your own. I've always felt like a hypocrite giving advice to parents when it comes to things like "I can't get him to go to sleep" or "she never listens to me" or even "he's always running -- I think he has ADHD even though he's only three."   I've also had a few really difficult run-ins with parents over these issues, and, yes, dread them.   I feel a little more at ease now.  Similarly, I had a basic concept of developmental milestones prior to this, but I feel much more sure of myself than I did when it comes to which things to actually act on.

Some things that have come up that I think are interesting:
  • Pediatricians and many parents have a "wait and see" attitude that is totally at odds with those of people like special ed teachers and speech therapists, who aim to create the most severe diagnosis possible in order to allow for the highest level of services.  I am a little conflicted about this -- I think that in general, those services are in short supply, and advocating strongly for each individual child is important.  On the other hand, this attitude may contribute to the short supply, and "overlabeling" children can also be dangerous, as it can set up a self-fulfilling prophecy of "need" that may be unnecessary.  There really is a range of "normal" and I'm not sure I know where the cutoff point is between accepting that some kids are at the low end of that range and thinking that if we can improve their status with interventions, we should.
  • Discipline seems to be hardest in the 2-5 set.  I wonder if that's just because they're home -- once they go to school, they're largely someone else's problem.  It does seem like preschoolers are particularly challenging though, especially since you feel like you have to "break" them into good habits early.  They're finally old enough to understand you when you tell them something, so it's infuriating when they exert their independence.  And even though they do understand you on some level, and vice versa, I think it's hard to get to know a kid in this age group, and figure out how to connect with them, because they are still so different from an adult.  It seems like the highly verbal kids do better, which makes sense.
  • Some kids are just harder to parent than others.  I'm not even counting the truly different kids, with disabilities or mental health problems.  We spent a rather long time discussing the concept of "temperament," and I'm finally coming around.  It seems like that may actually be the best way to talk about this -- initially, it seemed like a useless concept, sort of like calling someone's low back pain "lumbago" or something in order to validate the problem without doing anything to help them.  Dr. Chamberlain's line was "some kids are difficult, and it takes specialized skills to parent them" when I had one of these in my office.  That seems to be a theme -- it's just that the "goodenough" parenting that works with most kids well enough just isn't enough for some.  I think the real value of this way of thinking is that, like developmental delays, it's probably helpful to "catch" a kid with a "difficult temperament" early, so parents can learn to deal with them before things get out of hand, so they can still develop a relatively healty parent-child relationship.  It takes some of the pressure off the parents, and that might be all that's necessary to salvage the relationship.  The whole "sensory processing" thing that sometimes gets lumped in with this topic I'm still a little skeptical about.  It's a "disorder" invented by an occupational therapist that's only treatable with OT.  Always a questionable setup.  Again, saying that a child is easily overstimulated is probably a little better than saying he's "sensitive" or just that he's "difficult" because it does potentially point at a possible intervention, but mostly just puts different words to it.
  • I think that parents do largely have the same goals for their children, and that most of what gets in the way of good parenting is not what can truly be called intentional.  That said, a lot of it does come from failure to recognize what's going on and act appropriately.  That failure sometimes comes from ignorance, stress, or lack of resources, and probably really does come from selfishness or laziness at times.  It's hard to be a parent.  Children in this society take a lot out of our lives-- they take a ton of energy, a lot of emotion, and quite a lot of money.  One of my teachers this month tries to establish trust and consensus with "difficult" parents by saying to them "I've never met anyone who wakes up in the morning and says 'How can I screw up my kid today?'"  But that said, a lot of the parents I've met seem to want, at least in the immediate situation, for their children to be small, cute, quiet robots, that follow them everywhere and do what they say, and then somehow grow up into responsible and creative adults who never mooch money or have problems.  It's perhaps hard for me to avoid dismissing the concerns of parents who seem to have such unrealistic desires, just like with patients who want a magic pill to make their colds or sprained ankles to go away.

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Saturday, April 22nd, 2006
10:27 am - medical marijuana
Okay, one thought for the day. Not even a new thought, but a rant in response to the ridiculousness of what gets labeled "controversial."

Yesterday the FDA again released a statement against the medical use of marijuana, which apparently is still a controversy for some reason.

An ideal drug, from the perspective of a prescriber would:
  • be very effective, ideally curative (such as an antibiotic or chemotherapeutic agent)
  • be easily administered (e.g. prefer an oral agent over injected, prefer easy storage and long shelf life, prefer once daily or less frequent dosing, must have reliable effects, etc.)
  • have few side effect "symptoms" and no long term adverse effects.  Along with this, ideally it should be easy to start and stop, which includes having a low potential for addiction
    • time to onset is problematic -- for many drugs, that can increase perceived effectiveness, because the patient still remembers taking the medicine when he/she starts to feel better.  Unfortunately, this is usually associated with a shorter duration of action, and it increases its potential for dependency.  As a prescriber or a patient, I'd think a long-duration drug would ultimately be preferable to one that works quickly and then fades, because it means that the patient always has to be thinking about the medicine.
Smoked marijuana fails ALL of these, particularly the last.  There are claims that it is effective, but no one claims that it is completely or even very effective, and it certainly isn't curative.   The two medically relevant uses would be as an antiemetic (anti-nausea/vomiting) and as an appetite stimulant (primarily for cancer and AIDS patients), and while I'm sure it has some effect, I doubt it is better than other things that are actually approved for these uses. It is relatively difficult to administer, although I'm sure this could be improved if people were allowed to work on this.  But most importantly, its side effects are prohibitive -- smoking ANYTHING causes short and long term damage to lung tissue.  It causes alterations in mental status and mood (which, of course, is why most people smoke it) that we would not tolerate in other medications.  It has a short time to onset but very high potential for dependency.

I will point out that Marinol, which is a synthetic cannabinoid, is approved for the purposes above, and I've prescribed it with moderate success to chemo patients, despite its central nervous system side effects.  It doesn't have as quick an onset but doesn't appear to be as addictive, and doesn't seem to have any other long term adverse effects.  I don't have any objection to research into extracts or synthetic forms that might be medically appropriate (which does seem to be a problem with the FDA's current position) but the idea that smoked marijuana should be approved for medical use seems totally ridiculous to me. 

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9:58 am - First post
So enough people that I know are using this that I thought I'd give it a try.  Nothing really interesting to say today, however, and since I have a project today, I don't think I'll spend all morning on the computer. 

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