07 October, 2014

The social unacceptability of being a pediatrician-mom

When my son was born, I had visions of brilliant new friendships formed over lazy mornings at the nearby playground, each of us alternating who picked up locally-roasted pour-over coffees, which would then carefully rest in cup holders clipped to our BOB strollers.

Then I remembered that I am an introvert.

So I replaced that vision with one of the bonds of friendship gradually blossoming through many weeks of baby yoga, survival swimming and Kindermusik classes.

That also did not happen.

In fact, as of my son's second birthday, I had acquired no new friends through parenthood. Sure, I had friends with kids - 90% of them were also pediatricians or pediatric nurses, or were married to pediatricians. And I had a handful of friends outside the medical field, though all of the ones with kids had been my friends for a decade or more, dating back to my pre-doctor days.

The n of the non-medical friends-with-kids I acquired after becoming a pediatrician?

One. My Pilates instructor.

It's partly because, yes, I'm still an introvert. I'm cautious when meeting new people. I work a lot, and at the end of the day, I'd usually choose one-on-one time with my son over any other option. I like to take him to the aquarium or go for a run in the park, but I'm more likely to lie in the grass and point out interestingly-shaped clouds than to to strike up a conversation with anyone else.

It's also because (1) parents who aren't in the medical field don't really want to be friends with a pediatrician, and (2) I don't like being in the position of not knowing whether I should share my medical expertise, or worse, knowing I absolutely shouldn't, that my opinion would be unwelcome and make a whole social outing extremely uncomfortable.

I've discovered there are different levels of awkward socio-parental encounters:

1. The major public health issue on which I have a firm, factually based point of view that is not open to much discussion. 

By which I mean, of course, vaccines.

I actively avoid situations in which I might have to listen to a vaccine-refusing or -reluctant parent. I am not an eloquent spokesperson for the (extensive) merits of vaccination, though if you presented me with a parent who accepts the science behind vaccination but wants to have an intellectual discussion of the ethics of vaccine refusal, I'd be jumping up and down in excitement. And I'd be happy to recommend a variety of authors who have written elegantly on the subject, including Eula Biss' new book of essays, On Immunity, and Paul Offit's Autism's False Prophets.

If cornered, I will quietly share the story of an old friend's daughter, who died from pertussis at three months old, or describe my grandmother's shock when she learned that delaying or declining immunization was popular. Her youngest brother died from diphtheria (the 'd' in DTaP and Tdap) in the 1930s, when he was about five years old, and she recently told me that she thought her mother (pictured in last week's {this moment}) grieved his loss for all of her 97 years of life.

Clearly, telling stories that require me to hold back tears is probably not the best way to make new friends.

I have seldom actually done this, but on one occasion, I was countered with a story about someone's nephew's devastating regression and diagnosis of autism, and I snarkily - probably rudely - replied that I had cared for far, far more children with autism than the storyteller had ever met, or would ever meet, and was absolutely, epidemiologically certain that these cases were not linked to vaccines.

I am not suitable for public consumption, some days.

2. The major public health issue on which I have a firm, factually based point of view but serious respect for the challenges of practicing what is preached. 

In the parking lot, recently, another parent noticed that my son is still in a rear-facing carseat at aged two and a half. The data on the greater safety of rear-facing carseats for older children is awesome, with many studies coming from Sweden where my understanding is that a rear-facing four-year-old is standard practice. (Please check out the website The Car Seat Lady if you're interested in a practical, well-sourced information on car safety for infants and children.)

And after two major car accidents in my youth, I take seriously the dangers of driving. So even though it involves a lot more coaxing, crying and communal frustration than the alternative (not to mention the fact that I sometimes bribe him to get in by allowing him to keep his pacifier, to our dentist's consternation), my son is rear-facing for the indefinite future. (He rides in a Clek Foonf, which is certified rear-facing until 50 pounds and/or 43 inches.)

As ardently as I feel about the greater safety of rear-facing carseats, I try to avoid talking to parents of older children, because I have never convinced anyone to turn their child back, once they were forward-facing (not even an ex-boyfriend when it came to his own daughter). I'm happy to talk to parents with infants, who want to know more, but socially, it doesn't usually come up unless it's someone noticing how my son rides…and that it's not the way her son rides. Plus, although the AAP has been recommended children stay rear-facing until at least two years (and preferably as long as possible based on the car seat being used) for a couple of years, the law in most states hasn't caught up yet.

3. The common pediatric problem in which we have new evidence that suggests we've been doing it wrong for the last 50 years.

I am a person who uses, "Well, the evidence doesn't really support that," in daily conversation.

And yes, I know that this makes me weird, or at least a member of a weird minority.

At another time, I'd love to write about the extent to which science is itself a belief system, but for now, let me just say that I believe in the validity of experimentally-empirically acquired evidence and I rely on it regularly to make decisions.

A more practical reality is that "evidence-based medicine" is still relatively new in the history of medicine. For most of human history, what qualified as medical advice was rooted in tradition, common sense and anecdotal evidence passed down from teacher to student. Once physicians are out of training, the extent to which they stay on top of the latest medical research varies widely. And, of course, every physician is different in how they interpret the evidence and use it to counsel patients.

So one of the most frequent situations I found myself in socially, as a parent, was listening to another parent recount part of their child's medical history. This became fraught with tension (in my head) when the other parent relayed some bit of advice or diagnosis that made no sense based on the most recent consensus of pediatric experts.

Not uncommonly, I kept my mouth shut but went home and frantically flipped through medical journals to confirm that I was right and their doctor was quackish. Or something. And then enjoyed a brief few seconds of satisfaction before agonizing for the next several weeks over whether I should have said something.

Often, these are little things like another parent telling me that their pediatrician recently told them it was okay to start feeding their nine-month-old jarred baby meats.

I cringed inwardly.

There is very little evidence in favor of any particular pattern of introducing solid foods, and different strategies have come in and out of style. When I was training, the only firm recommendation was to introduce one food every four or five days, in order to allow parents to pinpoint potential food allergies. As I was finishing residency training, new data was being published suggesting that there is a "critical period" for the introduction of new foods, after which children are at greater risk for food allergies. Some of my instructors were suggesting introduced meats first. So I did.

A more traditional approach was to start with puréed vegetables, between four and six months, (because adults worried, based on no evidence at all, that children fed fruit first would develop a sweet tooth), then move to fruits and finally meats last. However, there was no evidence behind this approach. It was pure tradition and what passed for common sense at the time.

I fed my six-month-old homemade puréed braised lamb. With olives and coriander.

I also ate sushi and drank coffee in moderation while I was pregnant (both supported by the latest American College of Obstetrics and Gynecology recommendations) and I let my toddler eat sushi too.

Here are some topics that have come up regularly in social situations, advice that pediatricians used to accept, but which has been replaced by newer science. It is hard…this stuff is a moving target, and so I try not to be dogmatic about any of it. Medical school lecturers love to joke that half of what they teach is wrong, but unfortunately, no one knows which half. There is some truth in that.

(1) We used to think: Exposing infants to peanuts and peanut products increased the risk of peanut allergies.

Now we think: Introducing peanuts early (6-8 months) actually lowers the risk of peanut allergies. Researchers discovered this in a cool way, by noting that Israel had a very low rate of life-threatening peanut allergies, but most Israeli babies ate a popular baby food that contained peanuts (a peanut "puff"). 

(2) We used to think:  If ultrasound late in pregnancy suggests a baby is getting very large, labor should be induced early, before the baby gets too big.

Now we think: Birth weight is extremely difficult to predict based on ultrasound; the margin of error is as much as plus/minus one pound. Also, induction of labor in a patient who isn't ready often leads to Caesarean section.

(3) We used to think: Some people develop the flu right after getting the flu shot.

Now we know: The flu shot stimulates your body's immune system to make substances that will fight off the real flu later on, if you are exposed. Sometimes that sensation of the immune system "turning on" feels like flu but it is not the flu. This usually happens fairly soon after the shot and not lasting very long.

Other types of vaccines (the ones called "live attenuated", meaning they are made from weakened but still living viruses) can cause mild cases of diseases they protect against. For that reason, most children in high-income countries (U.S., UK, etc.) get a "killed" or inactivated version of the polio vaccine, meaning the virus can't replicate and cause symptoms or spread to other people. The live attenuated polio vaccine is slightly more effective but more likely to cause rare cases of polio. The risk of polio in high-income countries is so low that the risks of the live attenuated vaccine outweigh the advantages. In other countries, where polio is resurgent, the live attenuated vaccine is still used.

Does that all make sense? Please ask a question!

(4) We used to think: Ear infections were largely bacterial and needed to be treated with antibiotics in order to prevent spread of the infection, potentially leading to mastoiditis or meningitis.

Now we think: Antibiotics wipe out healthy bugs, along with the infection-causing bugs, changing the body's natural "microbiome" - the constellation of normal bacteria that keep it functioning well. Children who receive antibiotics for a first suspected ear infection seem to be more likely to get another ear infection than children whose parents and pediatricians took a "watch and wait" approach. So many docs now avoid treating milder ear infections and symptoms (for instance, pain without fever; or fever and discomfort in the setting of a cold, without visible pus behind the ear drum) and give parents of toddlers the option of waiting a couple days before filling a prescription, to see if symptoms improve without treatment. 

So what's a girl (pediatrician-mom) to do? 

I am personally (in that I experienced medical mistakes with my dad's health care) and professionally aware that there are substandard, unethical, and/or impaired physicians out there practicing in the community, so I feel an obligation to be attentive to what other parents are saying, in case it happens to be a situation where I am truly compelled to speak up.

But let's be honest - that's rarely the case at a neighborhood picnic. Just because I think someone's pediatrician over-treats ear infections doesn't mean he isn't a good doctor, the right doctor for this particular family, and maybe even correct in their approach. I don't usually get the full story (and definitely not a physical exam) from play group chatter. Sometimes, the stories are second- or even third-hand. It troubles me to hear that a family is completely reorganizing their lives and hugely restricting their child's diet over a diagnosis that isn't supported by any kind of medical evidence or expert consensus, but I'm not going to change the situation by telling their cousin's part-time babysitter's yoga teacher that they should get a second opinion. (Although...I actually still said it, in that case.)

A lot of these things "matter" on a population level: it matters to the huge problem of life-threatening food allergies among American children whether introducing foods at certain times early in life decreases the risk. I can't promise, or even quantify, how much it will help this parent's child to eat peanut butter before age one.

And no one asked me to.

Most of the time, I try to change the subject or allow myself to be pulled away into another conversation that doesn't have a medical angle. It's difficult because I really love pediatric medicine, and find the whole history and philosophy underlying medical research and progress to be really fascinating, and I like to talk about how we got from willow bark to aspirin, and leeches to laparoscopic surgery. It's not so much that I need to be "right" or be seen as an authority, or that I feel some wildly overblown obligation to protect each and every child in the world from having their microbiome altered.

It's a lot more selfish.

It's just that this is such a huge part of who I am that holding it back leaves me a pale imitation of my usual self. For someone who is already introverted, it is a social obstacle that I haven't yet figured out my way around. In the end, pressing my lips together, sitting on my hands to avoid jumping in enthusiastically and with my characteristic dramatic gestures (I am quite dangerous with a glass of red wine), kills my ability to share who I am and connect with other people. Potential friends, even if their kid might reveal to my kid that some two-year-olds get to look out the front windshield.

Finn listening to the band at the Pearl Street Farmers' Market,
how he and I usually spent quiet Sundays together, September 2013.