As a physician, mother and patient, I have seen the role of physicians from many sides. There are many stories about good and bad doctors, I am striving to be one of the good ones. But what actually makes a good doctor? There is no foolproof formula for being a good doctor, but after years in practice, here is what I have learned and consider important:
Having a solid knowledge base
We all want our doctors to have good basic knowledge of medicine, and particularly, the conditions we want them to treat. Basically we want “the nerdy doctor” (as one of my friends once told me). The doctor who spent all her time studying in medical school rather than the “party girl.” So let’s discuss what doctors are going through to get to the point of practicing as a physician:
After college, we go to medical school for 4 years, the last 2 of which include actual clinical rotations working in a hospital under the supervision of physicians. We often work overnight shifts while also studying for our boards. Once we pass 2 steps of licensing exams, we start residency and work overtime for very little money, “enjoying” very little sleep. The length of residency depends on the specialty (e.g., 3 years for pediatrics, vs. 5 years or more for surgery). After residency, many physicians will complete a fellowship for a subspecialty such as pediatric dermatology, cardiothoracic surgery, or allergy.
This may seem like a long time and a lot of work to get there, but the long years of training are necessary for what good doctors will be facing. And – as crazy as it sounds – I actually enjoyed my training time! But being a good medical student does not mean the same as becoming a good physician as pointed out in KevinMD.
Keeping up to date
But that is not the end of it. After passing the certifying exam (at the end of residency/fellowship) and getting a license to practice medicine, physicians are required to participate in ongoing learning activities. We need to get 100 Continuing Medical Education (CME) credits every 2 years. This can be achieved by participating in online activities, reading medical journals and answering questions about the subject, or by attending medical conferences or live lectures.
The internet and social media has changed the way how physicians keep up to date. We are now much better connected to other physicians and also experts in our field. I have the option to post a question for an expert on the AAAAI website and usually get a good answer within 1 week. Through the Physician Mom’s group (PMG) on Facebook, I also have access to female physicians of many specialties and often get an answer to my medical questions within minutes. Don’t worry, this group is only accessible to member physicians, and no confidential health care information is ever posted. Every physician has to determine by themselves which authority to trust, but so far, my experience of help from my online colleagues has been very good.
Being a good listener
Most patients want a physician who takes the time to listen and will consider your fears and thoughts about what may be wrong.
One of my good friends recently found out that her child had leukemia. For weeks, she had a feeling something was very wrong with her child–he kept losing weight, was pale, and felt tired. She brought it up several times at the pediatrician’s office, and asked for blood work to be done. Instead, my friend was counseled about better nutrition for her son. She kept pushing, however, and when blood tests were finally done several weeks later, they revealed low levels of red blood cells, white blood cells, and platelets. Those findings suggested a bone marrow problem, and after a few more weeks of tests, a diagnosis of leukemia.
How could this happen? Pride may get in the way of listening to the patient or the parent, or admitting we were wrong about something. As physicians, we sometimes reflexively tend to feel we must know better than the lay person. After all, we spent so much time studying and training, so we must be smarter than “Dr. Google” and whatever the parents have read online.
One of the first things I was told in pediatric residency training was to always take the parents’ concerns seriously. Parents know their children best, and are very sensitive to changes in their behavior. It is surprising how much we can diagnose just by taking the time to listen carefully and letting the parents/patients talk. Imagine how much better medical care could be if every doctor spent just a few minutes or more listening carefully to each individual patient or parent!
Being a good listener is not only important for establishing a diagnosis, but also for coming up with a good treatment plan. For example, nasal sprays and pills are both effective for allergic rhinitis, better known as hay fever. But maybe a patient just can’t stand the thought of spraying something in their nose, yet would happily take a pill; if I treat them with the “one-fits-all” approach and order a nasal spray without discussing it first, that patient may not take the medicine and they may never admit it to me out of embarrassment or guilt. The hay fever won’t improve, and nobody wins.
And this leads right to the next point:
Working as a team
Physicians who include patients in the decision process about their treatment are more successful in getting good compliance (i.e. do they take the medicine) and better control of the disease. If a patient feels her/his preferences are taken into account and her/his particular lifestyle is being considered, they will also pitch in their part of the deal. In the end, less medication may be required.
I treat many patients with chronic conditions such as hereditary angioedema (HAE). Patients with HAE get severe sudden swelling of the abdomen, face, throat, and extremities . They suffer severe pain during episodes, and it can be debilitating and render them unable to work. In between episodes, they may be completely asymptomatic and live a normal life. Most of them come to me after having lived with that disease for 10-20 years. They know more about what would help make their life easier than me. How could I have the audacity to determine the right treatment for them without considering their preferences? I know about the disease process and the treatment options available, but I need to include them in the decision process. I can outline what medication is available and how and when it needs to be given, and then the patient can decide what option fits best for their lifestyle. The patient needs to be guided but ultimately feel in control over their treatment options.
I think that many patients have given up on being treated as “part of the team” by physicians, and have therefore moved on to alternative health care providers. This brings me to the next and final point:
Unfortunately, we often encounter conditions which are not curable. Of course everybody thinks “cancer” immediately. But even hives – despite being harmless – can be extremely frustrating and debilitating. I have to admit that hives are not only frustrating for the patient, but also for the physician. Physicians get frustrated when we can not find the cause for something. In those cases we need to be even more patient and compassionate. It is understandable for someone to be depressed and angry when they can’t sleep due to the severe itch, or when they fear breaking out in hives in public (e.g, a wedding ceremony), that must be taken seriously. If physicians can’t feel for the patient and their quest for “a cure,” then no wonder they get disillusioned and go off to alternative health care providers.
For the record, I don’t want discredit alternative medicine. In fact, it can often be helpful. For example, acupuncture provides substantial relief for chronic back pain, migraines, and even helps labor pain. Herbal medicine can be used instead of commercial medications, but sometimes may have similar side effect profiles. Massage, meditation and prayer has shown to reduce pain, anxiety and speeds up recovery from any conditions. In fact, prayer was found to be the most commonly used alternative medicine. While not all studies show a medical benefit of prayer, there are some surprising findings, including several studies suggesting that prayer improved outcomes in women undergoing fertility treatment.
In conclusion, a good doctor should know her field and be passionate about practicing medicine. At the same time, she should be humble and compassionate and spend the time to listen to her patients. If the patient feels safe, understood, taken seriously, and well taken care of by a physician, they will do better overall.
For many years, the guidelines from the American Academy of Pediatrics recommended introducing peanuts later in life (not within the first 2-3 years, at least). In the United States, we have seen an increase in peanut allergy despite (or maybe because of) these recommendations.
Other nations, such as Israel, have lower rates of peanut allergy. Israeli parents often feed their babies Bamba (peanut puffs) early in infancy.
New studies (EAT and LEAP) have now confirmed that early peanut exposure is beneficial. It should not be the first solid food given, particularly not whole peanuts. Breastfeeding (or infant formula feeding) is still recommended as best nutrition until at least 4 months of age.
Here is a summary of the consensus statement on early food introduction:
Healthy babies (low risk for allergy):
Babies without any signs of allergy (no eczema or egg allergy) should start peanut containing foods around 6 months of life after other solids foods have been tolerated. No specialist visit is necessary.
The best time to introduce peanut is when the baby is in good health – not when (s)he is suffering from a cold or infection. It’s better to give the first peanut feeding earlier in the day so the baby can be observed for any symptoms during the waking hours.
Peanut butter or peanut puffs such as Bamba or Peanut Butter Panda Puffs are some of the best tolerated peanut products. Peanut butter can be diluted with milk or water, if preferred. Alternatives includes soup with ground peanut. Whole peanuts are not a good choice, as they can be a choking hazard in your infants.
Infants with severe eczema or egg allergy should ideally start peanut in their diet at age 4-6 months. They should see an allergy specialist who can determine if peanut can be introduced safely. In order to find out, skin testing may be necessary. For some infants, the safest first exposure is in the allergist’s office, so if there is an allergic reaction, treatment is available.
Children with with mild or moderate eczema do not necessarily have to see a specialist. They should start peanut consumption around 6 months of age. Peanut can be introduced at home.
Once peanut is introduced, consumption should be regular: a small dab (2 grams) 3 times per week. Regular exposure is particularly important for the children at risk for allergies. As mentioned before, risk factors include eczema and egg allergy.
It’s that time of year again when itchy skin becomes a problem. As an allergist, I see many patients with the complaint of “itchy rash”. But allergies are not always to blame. The first question I ask is “is there a rash?” An itch without a rash is rarely caused by allergies.
The next question is about the appearance of the rash. Is it red only, bumpy red, or does it look like “mosquito bites” which would suggest “hives”. Or is it oozing and crusting, which may suggest a contact allergy (like poison ivy).
Then how about the distribution of the rash on the body? The location of the rash helps us get a better idea about what may be causing it.
So what is the cause? Here are the 5 most common reasons for skin itch:
1. Dry Skin
This is probably the most common cause of an itchy skin rash. The rash resulting from dry skin often appears on the legs, arms and looks bumpy and may feel a little like sandpaper. It worsens when scratched and can start bleeding after a lot of scratching. Using mild soap such as Cetaphil and applying moisturizer immediately after every shower or bath helps to avoid dry skin and itch. It typically gets worse during the winter months when the air is dryer or when exposed to chlorine water frequently (swimmers).
2. Atopic Dermatitis – Eczema
Eczema usually starts in childhood and can continue into adulthood. It comes and goes, and may heal up completely at times. Eczema usually gets worse in the winter. It is typically located in the flexor area of legs or arms (behind the knee, in elbow area, wrists, ankles) and can be in the face of small children. Diaper area and moist areas (such as armpits, groin) are usually spared. Typically presenting as a bumpy, dry red rash, it can get irritated by scratching and can leave hypo- or hyperpigmentation (lighter or darker skin) and thickened skin after healing.
Good skin care is essential in dealing with eczema. Using mild soap and emollients is very important, but in addition topical corticosteroids (like hydrocortisone) may be necessary. Atopic dermatitis may have an allergic origin. Young children often have food allergies (egg, peanut) making the eczema worse. An allergy to dust mite, animals, or pollen can also contribute to exacerbations. Skin testing can be helpful to identify the causing allergen and targeted avoidance may reduce the need for steroid creams.
3. Contact Dermatitis
Contact dermatitis usually presents with a localized red oozing rash. It could start out with bumps which then become blisters and is very itchy. The location of the rash may point to the offending allergen. (If it’s in the diaper area, baby wipes may be the cause. A location on the hand of hair dressers or cosmeticians points to coloring or cosmetic agents as the cause). To find the cause, an appointment with an allergist (who can do a patch test) may be helpful. Treatment consists of a strong steroid cream in addition to avoiding the causative allergen.
Itchy wheals which usually look pale and can take on all kinds of shapes. Sometimes, they are lines or patterns; in that case, we talk about “dermatographism” (writing in the skin). There is a Brooklyn based artist, Ariana Page Russell, who actually turned her condition of dermatographism into a unique art form. Hives are usually harmless but very annoying. They can appear all over the body and sometimes cause swelling of the lips and eyes. Hives can be caused by food allergies, drug allergies or environmental allergies. However in most cases they are “idiopathic” – which means we are unable to find a cause. Sometimes hives appear as a consequence of autoimmune conditions such as Thyroid autoimmunity (Hashimoto thryroiditis or Graves disease), hepatitis, Lupus or hematologic conditions (lymphoma – rare). Treatment is based on avoidance when possible and antihistamines (Zyrtec, Allegra, Benadryl etc).
5. Viral Rash
Many viruses such as cold viruses or gastrointestinal viruses (Coxsackie virus, adenovirus, parvovirus) can cause rashes. This is actually the reason why so many people are thought to have a penicillin allergy. They receive treatment for a febrile illness (most commonly caused by a virus), develop a rash, and – of course – they blame it on the penicillin. In any case, most viral rashes will disappear by themselves. Symptomatic treatment with antihistamines to remove the itch may be helpful.
Finally, what if there is no rash? The “itch without rash” requires further investigation into internal origin such as hepatitis, gall bladder, or renal disease. Lab work may be helpful to identify the cause.
Why are allergies on the rise? Why do so many children and adults have food allergies, asthma and hay fever? What are we doing wrong?
Here we discuss 10 reasons contributing to increased allergies in our modern society.
Delivery by C section seems to increase risk for allergies in children. Passing through the birth canal with exposure to bacteria may be good for shaping our immune system.
Formula instead of breast milk
Feeding infant formula leads to a less favorable composition of intestinal flora in the infant. Breastfed children develop less upper respiratory infections, early wheezing and less eczema.
Early use of antacids for reflux reduce the breakdown of proteins in the stomach. Therefore more whole proteins will be absorbed from the gut and may induce allergies.
Early use of antibiotics
Antibiotics can change the composition of “the good bacteria” in our gut. And these changes can lead to higher risk of allergies particularly in the immature immune system of young children.
Upper respiratory infections
RSV and rhinovirus (two common cold viruses) are linked to development of asthma and early wheezing in children.
Delayed introduction of foods
For many years the AAP guidelines recommended to delay introduction of certain foods (milk after 1 year, egg after 2 years, etc). Newer studies however show that late introduction may lead to more allergies. Particularly peanut allergies are more common in the USA compared to other countries (Israel) where they did not go by these earlier guidelines.
Low vitamin D
Vitamin D deficiency is a problem particularly in darker skin individuals or babies who are not exposed to sunlight and increases risk for asthma, skin and other allergies.
“Living too clean”
The hygiene hypothesis suggests that children growing up on farms and who are regularly exposed to farm animals have a lower risk of allergic diseases. Therefore having certain pets (dogs) early in life may be protective.
Early exposure to certain allergens
Cockroach and dust mite allergen in particular seem to be an early risk factor for development of allergies. Cockroach is an important inner city allergen and responsible for a large part of inner city asthma.
Parental smoking and home smoke exposure leads to increased respiratory disorders in children including allergies and asthma
Of course this list is by far not complete. Other factors such as pollution and dietary factors beyond Vitamin D intake also play a role. For more detailed information you can read a great summary in the New England Journal of Medicine from 2006.
As you can see from this list, our immune system gets shaped early in life. For some of these points we have no choice of changing them: C sections are often necessary for the safety of the child or the mother. There are however people (we hear about actresses in the glossy magazines) who schedule C sections without any indication another than preference for a set date and not having to go through labor. Some mothers are just not able to breastfeed despite their best intentions. But there was a time in the 70s when breastfeeding was considered inferior to formula. Not every ear infection needs to be treated with antibiotics and not every fussy child needs an antacids. Knowing the risk factors may help you make modifications and “shape the future of your child”.
Every year the American Contact Dermatitis Society elects a “contact allergen of the year”. These are contact allergens can be found in cosmetics, jewelry, household and work products. We often have no idea that these contact allergens may be a problem. Not everybody is affected by contact allergy, only people who are sensitized. That means that the same lotion, cream, nail polish or hair dye may be fine for one person, but may cause a nasty contact dermatitis rash in another. This could be a long term blistering, a dry skin or even a bumpy rash all over someone’s body.
Contact dermatitis can be treated with steroid cream, lotion or ointment, but can be a long-term problem if the source is not identified. Your allergist can help by applying a patch test to test for the most common causes of contact allergy. For further information about contact allergens you can also check the website of the American contact dermatitis society or also check out Derm net New Zealand.
Here is a list of the Winners in the past 10 years with a description of where they can be found:
||Cobalt —-found in in paint, glazes, Vitamin B12 supplements, orthopedic or dental implants
||Formaldehyde —-found in finish treatment for textiles (durable press), cosmetics, cleaning products
||Benzophenones —found in sunscreens, perfumes, soaps, lip balm, nail polish, hair spray and dyes
||Methylisothiazolinone —found in sunscreens, cosmetics, desinfectants, wipes, suncreens, tanners, make-up removers
||Acrylate — found in bone cement, coating for plastics, artificial nails, laquers, anti-freeze, medical spray adhesives
||Dimethyl fumarate — found in leather goods and packaging for transport of leather items
||Neomycin —- found in topical ointments, ear drops, eye preparations
||Mixed dialkyl thiourea —found in neoprene rubber gloves, wet suits, orthopaedic sleeves, swim goggles, waders for fishing, insoles of athletic shoes and keyboard wrist supports
||Nickel—found in earrings, watches, jeans stud, also in many foods
||Fragrance—- many cosmetic products
||p-Phenylenediamine—-hair, cosmetic, fabric dyes, temporary tattooes