The Family’s Doctor

Being a doctor to your family is tough. I didn’t think so, at first, but it gets harder to deal with as time goes on.

When I first became a resident – an actual doctor, in some people’s minds – I was flattered whenever someone from the family wanted to know what I thought. But further in to training, I began to see how much of medical diagnosis is based on the systematic physical and historical evaluation. Family and friends just dropping questions about real problems on me began to feel overwhelming because I knew I couldn’t give them good medical advice. Furthermore, other than saying things were fine…I couldn’t help anyway. “Go to the ER,” or “All good, dude, don’t worry about going to the hospital…just don’t use that hand anymore” were about the only 2 things I could say. Then, they take your word for it because you’re a doctor and you should know about these things and you worry that something will go wrong.

I’ve found that this conundrum is even harder to manage in my immediate family. With 4 kids, things happen all the time that could benefit from a primary care doctor’s evaluation. Additionally, with me working constantly – taking care of other people’s kids, as it were – you can imagine how hard it is for my wife to take one kid in to see their actual doctor rather than just having me check them out. But in the U.S., there’s all kinds of ethical issues with doctors taking care of family members. We’re strictly forbidden to take care of family members whenever they’re in the hospital – bastion of regulation and compulsive ethics that it is. In the clinic, things are a little more relaxed, but not by much. The general thinking is that doctors won’t be able to make objective medical decisions about family members. As if the decisions before us amounted to, “Foul insurrectionist of the imperial realm…OFF with your hea-! *Gulp* Wait a minute, aren’t you my kid? Well, OFF with your pigtails, then!”

I can say that there’s some truth to this bias thing, although I wish there was some room for practicality. When my 3-year old daughter fell on a display rack at the grocery store and avulsed the tip of her left ring finger – her WEDDING finger, potentially – all I could think about was whether or not a new fingernail was going to grow back. As a doctor, I was worthless in the ER. Never mind distal tarsal functionality. Never mind osteomyletis or tendon rupture. WHAT ABOUT THE FINGERNAIL, YOU IDIOT KNOWNOTHING DOC!? SHE’S GOT 2 SISTER’S, YOU KNOW…FINGERNAILS ARE IMPORTANT AT MY HOUSE! Incidentally, it was around that time that I looked down at her pt. data armband and realized that based on the totally wrong birth date I’d given the front desk, my daughter was now in their system as a two year old male.

I also remember being quite an idiot for the birth of our 4th kid, which was via C-section. Just before the surgery started, I’m sitting in a chair at my wife’s head and a drape separates us from the surgical action about to start below. The doc says to me, “Hey, you recently finished med school, right?  We’re just about to get started here.  You can come down here an help or watch if you want” I about retched. Good GOD, man! Are you some kind of sadist? You’re about to eviscerate my wife! For the love of all that is holy, next time I want to watch someone commit seppuku, I’ll find it on You Tube! “Uhhh. No thanks.” I managed, severely nauseous and dizzy.

Many other countries see this issue differently. The idea that your son or daughter is a doctor means you have someone who you can implicitly trust in the medical field. You also have someone who you know will listen to you and give you the care you want (and won’t be bought off to kill you). Nobody’s going to sideline you or ignore you or mess something up if it’s your own kid who is taking care of you. In many countries, when children become professionals, there is cause for celebration because of how it will help the family, not the child.

I recently was wrestling around with my two oldest kids in our front yard. Just prior to ultimate triumph over both of them at the same time, my crafty 6 year old intertwined her entire body in mine and toppled me to the ground. In the process, I stepped on her wrist, which happened to not be in our yard anymore, but on the sidewalk. She cried, hard. In response, I performed “surgery” – a silly act where I make noises while pretending to be cutting and sewing.  This usually makes the injured tyke laugh while giving me a chance to actually examine the injury, and she seemed ok. No crying about it that night. But I a sliver of concern wedged itself into my comfortable analysis the next day when we noticed her trying to write and color with her non-dominant hand. “What’s wrong with your hand?” Mom asks, concerned. “It hurts where Dad stomped on it.  Better if I don’t move it.”

Great. I just broke my daughter’s wrist. In a perfect world, I could just call the radiologists (most of whom I know…except the contracted film-readers in Bhutan or wherever) and say, “Joohh! Hey, Geoff here. You remember my 6 year old from the BBQ last week? Yeah, need a quick zap of her left wrist. If you would, look for a distal ulnar fracture. Yeah, will send her right over. Thanks so much.” Kid gets zapped, rads reads, says minor fracture, I take kid into my clinic and wrap up her arm in a cast for a few weeks myself. Cost to me = some time and $0. Alternatively, Xray is negative so we skip the casting step and cost to me is less time and still $0.

This isn’t how it would work, though. I have to work, first off, so my wife (all alone) would need to do the following: Take all 3 kids to clinic. Scream at two littlest ones as they expand their imagination in the waiting room.  The youngest is dragging his tongue along every surface he can reach…for some reason Freud described having to do with sex that nobody understands. I pass my family 2 or 3 times, unable to help in any way because I’m busy. Eventually, another doc who knows about as much as me – but “scrubbed” of bias – sees daughter. Youngest has now partially swallowed a reflex hammer. Doc learnedly proclaims, “Daughter needs an XRAY!” Film ordered. Wife stops at hospital financial aid office to explain that said hospital pays dirt and we need assistance. 45 minutes later (youngest now gnawing on some old guy’s cane), cheap(er) Xray is granted. 2 hours later, Xray is positive. Child needs cast. Clinic closed. Not sure what kind of break. Best evaluated by orthopedic doc. Ortho doc (avg income $700,000 per year) does not give financial assistance (“Doesn’t your husband work with me in the OR sometimes? Coool. Here’s your bill, mam.). Normal break, needs cast. Kid heals. All done. Total bill = $3500 because of Dad’s stupid, clumsy feet. Dad now eyed suspiciously by CPS drones who wonder what kind of father figure would initiate non-sexual contact with their child.

In Israel, where I trained, there is a term roughly pronounced “protexia”. It means that if you work at the hospital, you get a break. It’s understood that you’re helping out as many people as you can, and when you need help, the organization pulls together to get you taken care of. Not here. You do it by the book. The book written by Americans with American medical ethics.

So we didn’t take our daughter to the doctor, despite the irony that she lives with one. We decided instead to just sit around biting our nails about the issue, hoping she’s alright. Just like most Americans with crummy or non-existent health insurance who work full-time. But at least the bone doc’s doing alright.

Pregnant with Hepatitis C…A Problem?

I have a pt. who is about 15 weeks pregnant. She has Hepatitis C. She’s one of my favorite patients, although I suppose I’d like her more if she knew less about medicine. It’s always a bit unsettling to try to help a patient who basically knows more than you about her medical conditions. Actually, I’m kidding. Patients who educate themselves (she lives on the internet…she’ll probably read this within the first 10 minutes of posting) are the best to work with because they often partner with their doc in taking care of themselves.

So the two of us are working on taking care of her Hep C problem at the same time as her pregnancy. The question is whether or not Hep C while pregnant is a problem.

The answer – from what I’ve gathered after reading and talking with GI specialists – is that Hep C is a problem in general, but pregnancy doesn’t have much bearing on it. The only big issue is trying to prevent the new baby from getting it. And like most things with Hep C, we humans don’t have too much control over that outcome.

Hep C is a virus (see funky-cool pic), so we can’t kill it. There is hep A, B, C, D, E and probably F,G, and who knows how many others, each quite different from the others. Hepatitis infects the liver, as the name suggests. It causes an acute infection, which isn’t usually a big deal and is over in a few weeks. But it also causes a chronic infection that isn’t a big deal either…for about 20 years. Then it’s a real drag. Imagine being told that – as of today – you just swallowed a time-bomb that might or might not explode sometime in the distant future. Bummer for you, dude. Have a nice day.

That’s Hep C.

El Problemo is that the acute infection usually leads to a chronic one, which over time causes cirrhosis (basically, a rotting liver). Hep C is the most common reason for liver transplantation in the the U.S. And in case you’re wondering, the liver is important. If you want me to talk about how your liver does positive things for your life, I’m happy to do that. Suffice it to say that the liver is not like a fibula, or funny bone, or navel or second testicle. It’s called the liver ’cause you can’t live without it. And when a person goes into liver failure, the experience is disfiguring, painful and often very bloody.

“Hmmmm.” You think, “So, what’s the bad news, Dr. A?”

The bad news is that the baby can get it too. There isn’t good information on how the infection happens (called vertical transmission), or what causes it to happen to some kids and not others. Currently, smart researcher types believe the biggest risk for vertical transmission is when the mom is also infected with HIV. Another problem is if the mom’s viral load is high (it usually isn’t if the mom is chronic). If neither of these things are present, the limited studies done on this topic suggest a relatively low transmission rate…something like 4-8%. On one hand, this is nice, because you can flip that number around and say that there is a greater than 90% chance that the baby won’t get Hep C from mom. On the other hand, it’s still close to 1 in 10 babies who get it. It’s a half-empty/half-full perspective kind of thing.

The virus has been found in colostrum (part of the breast milk), but there’s no evidence that babies become infected by breastfeeding, e.g. if you swallow a gnat, it doesn’t mean you’re now infected with gnats. “What about C-section?” You might ask. “Can’t you just zap the kid right out of there and keep it from all that birthing mucky-muck?” There has only been one small study comparing C-section to vaginal delivery and, statistically-speaking, there was no difference. It makes sense to keep the baby away from mom’s infected blood as much as possible. But if you’ve been in on both vaginal deliveries and C-sections, you know that until the day when we can just reach up there and put the kid in a zip-lock bag and pull ’em out, birth is just going to be a bloody affair no matter what route you choose.

So, after all that, what I can say is that we aren’t going to do anything for my patient. We’ll test her new baby for Hep C during the first year of life. But that’s about it. It makes for an intellectual but otherwise normal pregnancy.

After talking up the bad, here’s some cool stuff: The few studies on this subject show that infection doesn’t affect pregnancy. One small study suggested, actually, that pregnancy was beneficial to the long-term odds of mom progressing to liver failure. Also, it appears that even kids who do manage to pick up the virus from their moms tend to do pretty well. Some clear the virus entirely. Those who don’t usually aren’t affected at all during childhood.

There’s lots more that can be said here about Hep C, about pregnancy…about how smart my patient is (she’ll probably write in correcting me on something in this post). But those are the basics. Hep C is the social security of medicine…we worry about it blowing up in the future, but we have this sneaking suspicion that if we take care of things now, things will turn out ok.