Another letter to my nieces

September 28, 2018

I was thinking about you again today as I watched something that brought me to tears: a woman describing, in a room full of mostly men and to a television and Internet audience of many millions of people, how she was sexually assaulted as a teenager. You may remember when I wrote you about my fears for you and other girls in the wake of an ugly 2016 presidential campaign that brought the issue of sexual harassment into the spotlight and revealed persistent attitudes toward women’s status and rights that were at best prehistoric.  At the time, I told you I hoped things would get better.  I’m not so hopeful today.

There are a lot of things that made me sad – and angry – as I watched a terrified and distressed Dr. Ford tell her story, but I’ll focus on two. The saddest moment for me was learning why, after 30 years of keeping this to herself, she finally told her husband and therapist what had happened.  When they were remodeling their house, she insisted on having two front doors.  Two front doors – who ever heard of that?  She finally had to explain that when she was 15, two older boys got drunk, locked her in a room, climbed on top of her, grabbed her all over and tried to take off her clothes, and clamped a hand over her mouth to keep her from screaming for help.  She thought she would be raped; she thought she might be killed.  When they finally gave up and stumbled back downstairs, she had to go back past them to escape from the house, and she was afraid she would be trapped.  I can’t imagine going through something so scary that 30 years later I would literally tear my house apart so that I would have a way to escape if anything like that happened again.  Many people have said what happened to Dr. Ford was just “horseplay,” and have wondered what the big deal is.  The president even opined that if it was really “that bad,” she would have called the police.  After hearing her, I now know it wasn’t that bad; it was worse.  I want to keep a copy of the video to play for anyone who ever dares to wonder if sexual assault of any kind is really “that bad.”

What made me angry is the fact that she had to sit in that intimidating room and answer questions from a prosecutor in the first place. She is the victim – why is the prosecutor questioning her?  Even more widespread than the sense that sexual assault isn’t a big deal is the attitude that it somehow reflects on the victim.  Everything from “she was asking for it” to “she’s unreliable” to “she’s making this up for personal gain.”  I have no doubt that some people have fabricated stories of this kind of assault, just like people commit insurance and banking fraud.  But most people don’t.  Why if a man calls the police and says his car was stolen he is automatically believed, but if a woman says she was sexually assaulted, she is automatically doubted?  And after seeing the disruption in Dr. Ford’s life, the threats to her and her family – after seeing the raw fear and anguish on her face in front of that crowd of (mostly male) senators and others – who can any longer wonder why someone might hesitate to say anything, even if it is “that bad”?

So back to you. You are only 3 years younger than Dr. Ford was when this happened, and there are a lot more things that could happen now than back then.  (If you can believe it, we didn’t have cell phones or Instagram or even the Internet.)  I worry about you, and your friends, and all girls.  Fortunately, thanks to brave women like Dr. Ford and many others, it’s no longer a secret that these things happen a lot.  I don’t know if that makes it easier to stop, but it’s a start.  Don’t accept anything that makes you uncomfortable as just something that guys do.  They don’t, not the good ones.  The good ones are going to do what we can to raise awareness and call the creeps out.  And know that if you ever need to talk about anything like that, you have people you can talk to: your mom, your aunt, me.  People who will listen.  People who will believe you.  As I’ve told you before, never think you are less capable, or strong, or smart, because you are a woman.  You are strong.  As strong as Dr. Ford.


This Is What Remarkable Looks Like

July 18, 2018

My medical school roommate would travel all the way across Durham, to North Carolina Central University, to get his haircut. “There are no barbers on this side of town who know how to cut black people’s hair,” he told me.  Now historically the city was fairly segregated, but that was no longer the case; there were plenty of African-Americans at and around the Duke campus.  In a truly free and unbiased market, businesses should have arisen to meet that demand.  But it didn’t happen.

There are far more consequential examples of such systemic racism in the healthcare system. We now have large numbers of adults living with diseases that used to kill people in childhood: cystic fibrosis, hemophilia, and of course sickle cell disease.  In the past, few adult physicians knew how to take care of those conditions, but now, a growing number of specialists serve those patients.  Except for those with sickle cell disease.  In the Twin Cities, there are almost no adult hematologists for the burgeoning number of adults living with sickle cell disease, which disproportionately affects people of color.

Fortunately, as reported on MPR recently, there are those advocating for this unmet need, especially Children’s own Rae Blaylark, sickle cell patient health advocate in our Center for Cancer and Blood Disorders and President and Founder of the Sickle Cell Foundation of Minnesota.  She knows from personal family experience the struggle to find care for adults with sickle cell disease.  Her advocacy highlights the significant disparities in care for those adults. Not only do they lack access to specialists in this community, but they face barriers and biases in the health care system as a whole.

While I lament this example of health inequity, I am so proud to have someone like Rae here at Children’s, working to address systemic racism and improve health and justice in the community. Thank you, Rae!


Happy Doctor’s Day 3/30/18

March 28, 2018

AS A MEMBER OF THE MEDICAL PROFESSION:

I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

I WILL RESPECT the autonomy and dignity of my patient;

I WILL MAINTAIN the utmost respect for human life;

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;

I WILL RESPECT the secrets that are confided in me, even after the patient has died;

I WILL PRACTICE my profession with conscience and dignity and in accordance with good medical practice;

I WILL FOSTER the honor and noble traditions of the medical profession;

I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;

I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;

I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

I MAKE THESE PROMISES solemnly, freely, and upon my honor.

Many of us recited some version of these words of the Hippocratic Oath upon entering the profession of medicine. When I read the copy hanging on my office wall, I am reminded of the awesome commitment we all make, and of the profound trust that is placed in us.  Medical education and training are not a pathway to status and wealth; they are a covenant obliging us to serve our fellow beings.  Not many physicians can live up to the example set by our colleagues in Doctors Without Borders.  But in everything we do, whether in direct practice, or doing research, or in administering the health care system, we need to ask whether we are living up to this oath.  Did I respect the autonomy and dignity of those who seek my help?  Did I treat them with compassion and authenticity?  Did I consider the health and well-being of patients first and foremost?  It would be easy to feel daunted, but instead I feel grateful – grateful for the privilege of being able to serve, and for the honor of being part of a community of individuals who share that call to service.


Disparities

January 26, 2018

Quick quiz: where is an infant more likely to die, in Bulgaria or north Minneapolis?  The correct answer, sadly, is the latter.  In fact, if the black population of Minnesota were its own country, it would rank 80th in the world in infant mortality, around the same as Thailand and Croatia.  White Minnesota would be about the same as Denmark.

Minnesota children of color lag behind white Minnesota children in many measures of health.  While our state consistently ranks among the best for children overall, it also has among the biggest health disparities.  Infant mortality, immunization rates, poverty, school readiness – all are worse for children of color, in some cases by an order of magnitude.

To draw attention to this problem, Gov. Dayton declared January Health Equity Month.  While it’s great to raise awareness, eliminating health disparities will require action, bold action.  Only 20% or less of health outcome is related to medical care.  The remainder is affected by environmental, social, and behavioral factors.  The health disparities we see in Minnesota (and frankly the rest of the country – they’re just more marked here) are due to deep underlying issues around poverty and inequality.  Issues that are so deep it can seem impossible to fix them.  What can those of us who care for kids do?  One thing Children’s Minnesota has done is to begin to focus on all those social determinants of health in our patients.  Our Community Connect program, launched in our St. Paul primary care clinic in 2017 and now rolling out to other areas, screens patients and families not only for medical issues like immunizations and allergies, but also non-medical ones such as poverty, housing and food insecurity, joblessness, and immigration issues, all of which have a direct impact on a child’s health.  When needs are identified, we can refer families to community resources for help.  So far we have screened nearly 2000 families.  Unfortunately, insurers don’t generally see this as a billable medical expense, but our program has been generously supported by philanthropy, including grants from the Children’s Hospital Association and U Care, among others.

We also need to take a hard look at ourselves.  While social issues predominate, racial and ethnic disparities in medical care itself have also been identified.  For example, children of color with appendicitis are less likely to receive pain medication than their white counterparts.  When we saw a similar issue in our own emergency department we implemented education and guidelines to help correct it.

But just as with patient safety, we need to look at the root causes.  Health disparities arise from the same issues of historical oppression and systemic racism that underlie a host of other issues.  Referring people to food banks and educating doctors about pain protocols is like giving ibuprofen to someone with an infection; it treats the symptom, not the disease.  If our children of color are to thrive as much as our white children, we need to dig far deeper, and advocate for real change.  January is a start, but it’s going to take much more than a month.


Leading from Below

December 18, 2017

“How would you describe your leadership style?” It’s a pretty common question, almost a cliché.  Mindful of the scorn heaped on President Obama for his “leading from behind” concept by some of the more bellicose talking heads who thought it sounded weak, I hesitated.  “I’d call it leading from below.”

Let me explain. Rather than a military analogy, as Obama’s was, mine is a musical one.  For many years I had the great fortune to play tuba with a group of wonderful Milwaukeeans far more talented than I, in a brass quintet called esprit d’Brass.  The modern brass quintet features 2 trumpets, French horn, trombone, and of course tuba.  There is no conductor.  So who leads it, you might ask?  Go ahead, ask.  OK, I’ll tell you.  You might think it’s the first trumpet, which most often carries the melody, but in fact, it is the tuba.

First, we’d decide on what to play, and I was the one who had to remind everyone where in our collection of music books the piece was. Literally making sure we were on the same page.  Next, we’d tune.  And not to some nasally oboe.  In a brass quintet, as in a concert band (like the charming Minnesota Freedom Band I currently play with), the tuning note is played by…the tuba.  The rest of the band tunes to my B flat.  When my horn is cold from sitting in the car all day it’s closer to an A, but they have to tune to it.  That’s power.

Now, the tuba rarely has the melody or a solo. In many pieces, the tuba simply plays the downbeats.  But in the absence of someone waving a baton in the front, that downbeat sets the tempo.  Playing that bass part requires careful listening, so that if someone is straying a little ahead or behind, I can subtly emphasize the beat to restore the desired tempo.  Also pretty powerful.  (Of course, if I wanted to I could intentionally speed us up or slow us down too much, but that would be an abuse of power.)

Note that unlike the conductor of an orchestra, who may be familiar with how to play many different instruments, I would never presume tell the trumpet or horn how to play their instrument. I simply provide the right environment and let them do what they do well.

So, setting the direction, getting everyone on the same page, setting the tone and the tempo, and letting the experts excel. It may not sound sexy, but that’s leading – from below.


Live And Let Die

November 8, 2017

My adult son and I watched the most recent James Bond movie the other day. The level of violence and mayhem is, of course, astounding, so it’s a bit surprising that it is rated PG-13. On the other hand, such violence has become such a part of our culture that perhaps it doesn’t even make sense to try to “shield” kids from it in our entertainment.  And one could also ask, does seeing a violent movie even make a difference given the pervasiveness of violence and guns in the America of 2017?

According to a fascinating recent study in JAMA Pediatrics, the answer to this is yes, it does matter.  Researchers at Ohio State studied 104 children ages 8-12.   All children were individually shown a 20 minute clip from one of 2 PG rated movies (The Rocketeer and National Treasure, in case you were wondering).  Half the children were randomly selected to view a clip with guns, and half saw a clip without guns.  After the movie viewing, a pair of children (who had both watched the same movie) was taken to a different room with toys, and told they could play with any of the toys while they waited.  Also in the room was a cabinet with a 9-mm handgun (modified to be unfirable).  During the 20 minute waiting period, researchers and parents monitored the child using a hidden camera.

Thanks to the randomization, there was no difference between those who watched movies with and without guns with respect to their demographics, prior media watching habits, aggressiveness, or attitudes toward guns. Overall, 83% of children found the gun, and almost half picked it up.  There was no difference between gun-watching and non-gun-watching participants in regard to finding or picking up the gun.  But children who had just finished watching a movie containing guns held the gun 3 times longer, and pulled the trigger 22 times more often, than children who saw the gun-free movie clip.  Kids who had watched the movie with guns were also more likely to point the gun at the other child in room and use threatening language.

This is a single study, with inherent limitations, but the findings are startling and provocative, albeit none too unexpected. Seeing violence begets violence, whether in real life or on the screen.  The morning after we watched 007, I read in the paper about the latest mass shooting (26 people killed in a church in Texas).  I couldn’t help but wonder about the connection.


Papa Was A Rolling Stone

October 12, 2017

It was the third of September

That day I’ll always remember, yes I will

Cause that was the day that my daddy died…

Papa was a rolling stone

Wherever he laid his hat was his home

And when he died all he left us was alone

 

Few issues define the cultural divide as sharply as one’s stance on family structure.  Senator Ron Johnson, for example, in a presentation I heard at Children’s Hospital of Wisconsin, placed the blame for America’s fiscal and other woes on single parent families.   (This didn’t go over so well at a workplace that is overwhelmingly female and with more than a few highly successful single parents.)  A fascinating recent article in Pediatrics may shed some light on this debate, or may simply generate more heat.

Researchers from Michigan and Princeton looked at the association between loss of a father and telomere length, a chromosomal marker of stress that is itself associated with a variety of adverse health outcomes.  (Telomeres shorten with age, and when they become sufficiently short cells die.  Thus telomere length has been called a “biological clock.”)  In this study, children who lost a father for any reason had significantly shorter telomeres than those who had not.  This effect was strongest for the death of a father, somewhat less for incarceration, and least for separation or divorce.  And it was stronger for boys than for girls.

Traditionalists might use this as evidence for the superiority of raising children in a two parent (specifically, mother and father) home.  But not so fast.  This study only examined those children who started out in a home with a mother and father, and then lost the father.  Loss and absence are not necessarily the same thing.  Also, at least for loss due to separation or divorce, nearly all of the effect (95%) is explained by lost income.  So one could as easily say this is evidence for the superiority of a living wage, and equal pay for men and women.

These findings also support the need for a change in the mass incarceration policy in this country.  The millions of men in prison – many of them men of color – are leaving behind millions of children who we now know suffer not only emotional but biological damage as a result.  This public policy crisis is creating a public health crisis.

One other tidbit in this study was intriguing.  The effect of loss of a father on telomere length was strongest among those children with a genetic variant in molecules involved in processing certain neurotransmitters.  How one copes with adverse events, like the loss of a parent, isn’t simply a matter of one’s character, or the strength of one’s support system.  Biology may not be destiny, but it sure tilts the playing field.

A rolling stone may gather no moss, but it can sure leave a lot of havoc in its wake.


%d bloggers like this: