Making Great Conversationalists: Chapter One - Part Two

Before my son was born, I was a slightly-above average user of the medical system in the US.  I got an annual physical and a few same day appointments for rashes or various minor ailments that I was a bit concerned about.  Additionally, I'd need 2-3 urgent care visits for asthma, injuries or rashes that seemed to be going systematic.  (I'm a 21st level Eczema Goddess.)  About once every 5 years, one of my legs goes wonky and I return to physical therapy for a few weeks to a few months.

Since Jack's been born, I've become a medical appointment guru.  I've met so many specialists, generalists and therapists that I have difficulty listing them all.   Because of this, I feel plenty confident to discuss Steven and Teri Maxwell's odd take on "Making Great Conversationalists" at medical appointments.  Let's jump into the first "typical" example:

You are missing work to take your 14 year old son, Gerald, to a doctor because of a stomach ache he has had for the last week. You and he have been waiting in silence for 20 minutes, and now the doctor comes into the examination room.

" Hi, Gerald, my name is Dr. Grote. What can I do for you today?"

Gerald looks at you as if you were going to answer, but you nod so Gerald says, "Well, my stomach hurts."

" How long has it bothered you?" Doctor Grote queries.

" Well, I'm not sure, you know, ah, it's been a while," Gerald manages.

" It's a week yesterday, Doc," you add.

" Show me where it hurts and describe the pain."

" Right here, and it really hurts. You know?" Your son shows the doctor where it hurts.

" Would you describe it as sharp, aching, cramping, or throbbing pain?"

" Oh, maybe, no, let's see. I guess I'd say sharp," Gerald half mutters.

"Did it start quickly or gradually?"

" I don't know for sure." At this point, you are wondering what Doctor Grote thinks of your parenting skills when your teenager can't respond to him any better than this.(pg. 11)

Similarly to my critique of Cynthia's parent, the only person who is behaving neurotically in this sketch is Gerald's dad.  Personally, I foresaw that having children would mean taking them to a doctor from time to time - especially since minors need permission from a parent or guardian to receive most forms of medical treatment.  Similarly, if my spouse and I had more than one kid and both of us worked, fitting medical appointments into working schedules would require that the primary breadwinner would take time off every now and again for kids' medical appointments.  I feel like the queen of obvious for stating this - but parenthood brings mostly responsibilities and a handful of rights.  I know this - so why doesn't Steven Maxwell, the father of eight children?  His implication that Gerald's father has been greatly inconvenienced by taking his son for a needed medical appointment irritates the hell out of me.

Speaking of inconveniences - why is Gerald required to amuse his dad with conversation while Gerald's dealing with a long-term stomach ache? If I was nervous before a doctor's appointment, I tended to talk nonstop.  If I was actively feeling sick, on the other hand, I curled up into the most comfortable chair and tried to sleep until the medical assistant or doctor came in.   As I was typing this, I realized I'd never really thought of the amount of conversation I had when I was a waiting patient in a medical office.  My parents and spouse never seemed to care if I wanted to talk the entire time or attempt to sleep; they were fine either way.  This boggled my mind for a full minute before I remembered the obvious - none of us pride ourselves on being cut off from popular media.  If the sick person wanted to sleep, their driver would pull out a book, grab a magazine from the rack, enjoy the antics of healthy young children playing or watch the TV that was on.   There was no reason for the driver to be beholden on the sick person for entertainment (and expecting the sick person to do so would be viewed as childish, selfish or simply crass in my family.)

I am disturbed by the fact that a teenager still defers to his father before responding to a direct address from a doctor.  I went through a phase when I didn't know if doctors wanted to hear from me or my mom.  I was between the ages of 8-10 years old.   By the time I was a teenager, my parents had long convinced me that if the doctor addressed me that meant the doctor wanted to hear from me - not them.  Since married women don't work outside the home in CP/QF land, the parent accompanying Gerald can be assumed to be his father - and we can also assume that Dad hasn't been around 24/7 for the last week.    That's why I find Gerald's father's interruption to explain that Gerald's been sick for a week to be odd.   Gerald might have been sick for a week - or Gerald might have realized that he's been dealing with less severe, but similar symptoms for two weeks or two months.  That's why it's best to let the patient answer the question.  I've added additional information before when my husband (or parent) has been ill enough that I'm worried they missed part of the doctor's question - but that's pretty rare.

I highly doubt Dr. Grote has questioned the parenting skills of Gerald's father since Gerald's not showing any signs of abuse or neglect and Gerald is acting like a perfectly normal teenage patient.   Doctors know that patients come in a wide range of ability when it comes to describing symptoms.  It is so normal for the average patient to not know the answer to all of the doctor's questions - and doctors can make reasonable estimates of the answer sometimes.  For example, the fact that Gerald doesn't remember the sudden onset of severe, stabbing pain in a localized spot in his abdomen makes a decent case to assume the pain came on gradually.   I'm sure doctors like it when they can figure out most of the medical clues from the discussion with the patient - but the doctor also uses a physical exam as well as blood tests to confirm the doctor's diagnosis.

My final two cents - Gerald's dad is more worried about what the doctor thinks about the dad as a father than he is that his son has been having sharp abdominal pains for a week.  That's seriously messed up. 

Let's look at the "ideal" conversation:

Let's look at how the interaction could go if Gerald has learned how to talk to others, answer questions, provide information, and carry on a conversation.

" Dad, I sure hope Dr. Grote will give me something for the stomachache. I really don't want to miss choir practice tomorrow night. I already missed last week's practice."

" Son, I hope so too. What songs are you learning in choir right now?"

Your father and son conversation goes on for the 20-minute wait, and then Dr. Grote enters the room.

" Hi, Gerald, my name is Dr. Grote. What can I do for you today?"

" Well, sir, I've had this sharp pain in my stomach for the last week."

Dr. Grote nods and asks, "Why don't you lay back on the table here and point to where exactly it is hurting?"

" It's right here. It hurts the worst for about an hour after I eat. Then it is better, but it never really goes away. I have tried taking TUMS for it, but that hasn't helped. My mom thought I should try the BRAT diet which was bananas, rice, applesauce, and toast. I did that for two days, but there wasn't any difference."

Gerald's interaction with Dr. Grote is one with which you could be pleased. He answers questions, gives extra useful information, and is easy to understand. The time before the doctor came into the room was profitable fellowship between you and your son. (pgs 11-12)

See, Maxwell likes the second situation much more because the father gets entertained for 20 minutes followed by having his son perform well for the doctor.   Ironically, the conversation between the doctor and son has revealed less information in the second conversation than the first one.  In the first conversation, the doctor learns the place and severity of the pain, the fact that the pain has been around for at least a week, but possibly longer and that the pain came on gradually.     In the second conversation, the doctor has learned the position, severity of pain and length of time the pain has been present - but the implication changed so that the pain started clearly one week ago and nothing has been said about if it was gradual or sudden. 

  Now, Gerald offered a whole bunch of information about his eating habits and the effect on the pain - but not all abdominal pain is related to food.   I have this mental image of Gerald pointing at an area of his lower abdomen that could be related to things like his bladder, appendix or prostate while reciting how his family has been trying to treat that using the BRAT diet and TUMS.  (Added bonus that Gerald is a boy; a similar spot in a girl could be one of a dozen issues with the reproductive system.)

Throughout this book, the Maxwells include tidbits that show incidentally how isolated they've become from interacting with other human beings.  The example here is that Gerald feels compelled to explain the BRAT diet to his pediatrician or family practitioner.  Trust me; Dr. Grote knows what the BRAT diet is.  Dr. Grote is more than capable of explaining why the BRAT diet works well at quelling certain gastrointestinal issues - and why the BRAT diet will make other issues worse.  If Dr. Grote works in a diverse practice, he knows how to adapt the BRAT diet for recent immigrants who don't regularly eat applesauce or toast.    I remember my mom explaining the BRAT diet to me when I was a teenager in terms of teaching me a form of good self-care when recovering from a stomach bug.  The diet made a lot of sense to me - and I assumed that most - if not all - adults knew the rough outline of the BRAT diet. 

I hope you enjoyed this section as much as I did - the best is yet to come!  The next post is on when your son calls the father of the girl he's sweet on to ask permission to court. 

Samaritan Ministry Is Going To Kill Someone: Part 1

Years ago - back when I was teaching full time at a high school - I ran into Samaritan Ministries through a reference on one blog or another.   Samaritan is a member to member health insurance cost sharing plan for Christians who want emulate how the early Christians lived.  The basic idea is pretty simple: instead of sending a policy payment to an insurance company every month, members send their monthly payment to a member who has had a large medical bill.  The member uses that money to pay the providers and everyone is happy.

Back then, there was only the plan that is referred to as "Samaritan Classic" now.  Members had a $500 deductible on each medical issue then the rest of the cost of treatment could be reimbursed up to $250,000.  The plan has some exclusions around sexual health in that abortions, problems resultant from an abortion and STD testing were excluded from being funded.  At the time, my only concern was for women or men who had a spouse who had an affair and needed to get STD testing because of that; it felt like punishing the innocent spouse.  My gut assumption was that people who were attracted to Samaritan would not be seeking abortions for any reason.

Fast forward to last month when I got pulled into the rabbit hole again when researching something about the Maxwell Family businesses pulled up a blog post on how Samaritan Ministries covered the medical bills for Nathan Maxwell's daughters Susannah (who was born with terminal brain damage from unknown causes) and Abigail. 

As I was looking at their section on  "Maternity and Newborn Care", I saw three sections that scared me from a medical standpoint: ectopic pregnancies, home births and vaginal births after cesarian -sections (VBACs).  This post will cover ectopic pregnancies.

Ectopic Pregnancies:
An ectopic pregnancy is a pregnancy that implants anywhere outside of the uterus.  The most common site for ectopic pregnancies is the fallopian tube - but rarely it occurs on the ovary, the outside of the uterus, the intestines or the cervix.  Fallopian tube ectopic pregnancies will either end when the fetus dies from lack of blood supply or will end when the fallopian tube ruptures causing the fetus to bleed to death when the placenta detaches long before viability is reached.  The danger with a tubal rupture is that it can cause massive internal bleeding for the mother and often requires a more complicated surgery to stop the bleeding and mitigate the damage to the mother's reproductive system.  Women do die in developed nations from ectopic pregnancies but it is rare because doctors  treat ectopic pregnancies by chemical or surgical removal as soon as they are diagnosed.  In developing nations, the fatality rate of diagnosed ectopic pregnancies is around 3% - and is probably higher since women who die away from medical facilities would not be reported.

To be clear, NO pregnancies have survived to viability from a fallopian tube ectopic pregnancy.  A handful of ectopic pregnancies outside of the fallopian tube have surivied to viability - but the most common outcome is fetal death from lack of blood supply.  Delivery of an ectopic pregnancy outside of the fallopian tube is a life-threatening surgery for the mother; the placenta has infiltrated blood vessels of organs that do not have the muscular response to contract when the placenta is removed.  This can lead to catastrophic bleeding that has lead to maternal death - and can do so long before viabilty is reached.

 Samaritan's Policies:

Expenses Shared—Procedures related to a ruptured fallopian tube (including post-operative recovery of the mother, follow-up care, and treatment of any complications), and, where an ectopic pregnancy is diagnosed before a rupture, all pre-operative tests and consultations and expenses related to keeping the mother under medical care while determining what care should be offered for the mother and child.

  Expenses Not Shared—Procedures directly related to the termination of a living, unborn child and/or removal of the living, unborn child from the mother due to an ectopic pregnancy are not shared (e.g. methotrexate, salpingectomy, salpingostomy), unless the removal of the child from its ectopic location was for the primary purpose of saving the life of the child or improving the health of the child.

Issues: Samaritan is mandating that women choose the popular among QF Evangelical route of "Watchful Waiting" where women diagnosed with ectopic pregnancies wait until either the fallopian tube ruptures (or something similar if it is another organ) or the baby dies before removing the pregnancy.

This is a horrible idea based on flawed premises.  The rationale goes that women in the US and Europe have a really low rate of mortality from ectopic pregnancies so it's not dangerous for women to put off treatment of an ectopic pregnancy as long as they are being carefully monitored by their doctors.

The reason that developed nations have low rates of mortality is because doctors interviene in ectopic pregnancies prior to rupture - even if the fetus is still alive.  I'm Catholic and the Catholic Church has recognized this basic principle for as long as doctors have been able to diagnose ectopic pregnancies.  There is no chance of survivial for the fetus and ~25% chance of a potentially lethal rupture for the mother so the Church allows for the fallopian tube to be removed.  Yes, this kills the baby - but the purpose of the surgery is not to kill the baby but to prevent a ruptured tube so it is not immoral.  I find the rationale a bit hackneyed - but women have an option to end the pregnancy.

The QF believers will reply "But we don't really know how long a Fallopian pregnancy can survive because doctors won't let nature take its course!"

Here's a sane reply: Ectopic pregnancies have been killing women for centuries.  Doctors have been doing autopsies on dead women for 150 years.  They've collected plenty of data from dead women with dead babies that shows that ectopic pregnancies in the fallopian tubes will rupture by 16 weeks and that the later the rupture happens the higher chance of maternal mortality or injury. 

OB/GYNs like babies.  They like delivering healthy babies to healthy mamas.  They would love to figure out how to save ectopic pregnancies - but it's not possible until we can build a placenta from scratch and attach it in the right place.

There will be another post on this topic soon. :-)