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Thursday, December 10, 2015

Post #43 My Father the Pediatrician

I recently wrote a new book geared to help parents have more meaningful conversations with their pediatrician and which will hopefully save them a copay or two as well!  As I reflect back on the five year journey in writing this book, I wanted to highlight the contributions of my biggest influence – my dad.

In the summer of 1973, my father, thirty years at the time, boarded a plane with his best friend to fly overseas for the very first time in his life.  Having recently finished medical school and his mandatory army training in South Korea, he was headed to the United States to begin his residency in Passaic, New Jersey.  He would leave his recently espoused and pregnant wife behind to pave the way for a better life in the land of opportunity.

On a layover in Tokyo, a fancy new camera caught my dad’s eye.  Japan at the time was light years ahead of Korea in terms of technology and my father reckoned that electronics were cheaper in Tokyo than they would be in New Jersey.  He and his friend saw an easy opportunity to arbitrage a quick profit and spent what little money they had in hopes of selling the camera as soon as they immigrated into the States.  As fate would have it, the camera was cheaper in America – is a good deal ever to be found at the airport other than possibly duty-free goods?

With even less money now but a fancy state-of-the-art camera to chronicle his adventures, my father began working long hours and preparing for the arrival of my mother who was ready to give birth to moi soon.  The camera was an inauspicious start that would belie the incredible blessing that the United States would be to our family.

My parents both took huge risks (most have paid off better than the camera) and made many sacrifices to give my brother and I a better life.   As a father of three now, although I am much more cognizant and thankful for what they must have encountered to establish life here in America – learning the trade of medicine in a foreign tongue, racism, no nearby family support, and the lack of any good Korean restaurants in Passaic (the travesty!) – I will likely never fully comprehend their early difficulties.

My father actually completed two separate residencies in America.  When he first arrived in the United States, he trained as a family practice doctor and for a while after moving to Virginia, my family enjoyed a comfortable life.  But as a foreign medical school graduate, my father was not allowed to sit for the board certification exam for family practice and so he decided to pursue a second residency in pediatrics (who did allow foreign graduates to sit for board certification).  I will forever be grateful for his career change!

We returned to New Jersey, replete with a new little brother having been born in Virginia, and for three years the four of us lived on the meager salary of a pediatric resident.  We lived in the bottom floor of a tiny two-bedroom duplex that had a scrumptious bakery at the foot of the hill we lived on.  Although we were poor, my brother and I were always happy, catching fireflies in the summertime and throwing snowballs and eating warm pumpkin pies from the bakery during the cold winters.  After finishing his training, my parents were eager to start their future elsewhere, so we headed south to Houston, Texas.

My father’s first practice was on Bingle road next to a diner that served the best chocolate ice cream shakes.  I still remember the antiseptic smell that would overpower you as Donna the nurse would walk you to the back, tempting you to lose the recently consumed shake.  There are many memories of me wailing as I received various vaccinations and penicillin shots – a tradition that my daughter has taken to new depths of sobbing. 

My father opened his first solo pediatric practice in 1985 at Memorial City hospital on Frostwood road in Professional Building One.  My mother served as the office manager and ran the business operations and the never-aging Masako, who still works for me today, was one of their first new hires.  Many of my friends from church worked for my father at one time or another, a tradition that I still carry on today.

I finished my own residency training in 2002, and after a short mission trip to Vladivostok, Russia joined my father’s practice – a true mom and pop organization with their newly minted pediatrician son in tow!  In late 2004 my father retired to go to the mission field in Yanbian, China, after which Dr. William Pielop and I started Blue Fish Pediatrics which just opened its third office in Katy and hired its thirteenth doctor this year. 

Looking back at my career and life, it is easy to appreciate the outsize influence my dad has had on me.  I love the Lord.  I married a beautiful Korean woman.  I am mildly OCD.  And I love my work as a pediatrician.  Lucky for me and because of the sweat equity that both my mom and dad put into his practice, I never had to flip a camera to get my start in medicine. 

Dad, thank you for your hard work, sacrifice, and your love for the Lord.  For everything you have done for me, I would like to dedicate my new pediatric book to you.  Without you, I would never be where I am today.  

Sunday, August 9, 2015

Post #42 A book review - Being Mortal: Medicine and What Matters in the End by Atul Gawande

In his breathtaking book, Being Mortal: Medicine and What Matters in the End, Atul Gawande (one of my favorite authors) elegantly describes three different modalities of patient counseling that doctors employ. 

The first is the oldest and most traditional approach, a paternalistic relationship.  The doctor not only has the knowledge to guide the patient, but also possesses the experience and wisdom to make decisions on their behalf. 

The second type of relationship is termed "informative."  Here the doctor informs you about the facts and figures related to your medical problem, along the lines of a talking Wikipedia page donning a white coat, but allows you to make your own decisions in regards to your health. 

And finally, the third type of relationship is called "interpretive."  Here the doctor asks a series of probing questions to discover your priorities and assists you in navigating the medical maze to achieve your goal. 

Methodically, Gawande utilizes a small gamut of actual patients he has encountered in real life, including his own father, and through their life stories he takes the reader step by step in his maturation process as he evolves from a mixture of initially employing the first two approaches - leaning heavily towards the informative style - to an actualization of becoming an "interpretive" doctor.
At times, along the way, Gawande has to remind himself of what he has learned from palliative experts and even Daniel Kahneman's research on kidney stones and colonoscopies (another favorite of mine! - the author not the procedure), to stay true to his new "interpretive" approach, which over time he recognizes as being a clear cut above the other two modalities. 

His most moving example is his own father, who is diagnosed with a  spinal tumor and begins losing first his grip in tennis and later his grip over day to day activities.  His father, also a physician (as is his mother - slacker family the Gawandes), seeks the counsel of two neurosurgeons, both of whom have excellent pedigrees and reputations. 

The first doctor goes into information overdrive overwhelming both Atul and his father, and despite being doctors themselves, they struggle with the tsunami of facts and statistics which leaves them feeling rudderless with no sense of direction; the neurosurgeon himself advocates operating right away.
The second doctor, takes the time to listen to the father's desires and goals in life, especially his optimal endgame, and helps the family to formulate a plan which will maximize his ability to achieve what is most important to him at the given moment in time.  The interpretive doctor exemplified. 

Rather than jumping at surgery which could lead to further complications - together, the neurosurgeon and the Gawandes arrive at the decision to wait on surgery, which although promises some relief of pain and restoration of function, also carries with it the risk of leaving the elder Gawande a quadriplegic. 

Although one of his hands is slowly becoming numb, in his time following the initial consultation where he decides to forgo surgery, Gawande's father throws himself into his role as newly elected Rotary district governor and precedes to follow through on a goal to speak at the meeting of each of his district's fifty-nine clubs, not just once but twice to each group.  (If the Gawandes make you feel insufficient, join the club.)

Over time, the tumor takes its toll and several years after the initial diagnosis, and several important life goals later, Gawande's father finally decides to submit to surgery.  The surgery goes well, but in 20/20 reflective hindsight, it becomes clear that had they followed the advice of the first surgeon, the scalpel would have been utilized several years prematurely and the hand of unnecessary risk would have been forced sooner than required. 

Even in pediatrics, although on a much less dire scale, I personally see how the interpretive doctor modality is superior to simply being informative or paternalistic. 

Although, I understand the natural history of an ear infection, and how 80% of ear infections in children over two years of age will improve without antibiotics, albeit with a slightly longer course of pain; I don't know the family's schedule (unless I ask).

Perhaps there is an important wedding they need to fly to over the weekend or maybe the family has a vacation coming up that has been in the works for several months.  While these are not life or death situations, I can fully appreciate the importance of preserving the quality time of a much needed break for the family, especially if it is a once-in-a-lifetime trip to Disney World which has received an immense amount of planning and a considerable portion of the family budget.

This would certainly push me to recommend antibiotics over watchful waiting.  Certainly, we should be judicious about antibiotic use when at all possible, but how can one weigh the risk of a 10 day course of amoxicillin and its small contribution to the scourge of antibiotic resistant bacteria vs. the preservation of a once-in-a-lifetime trip to Disney World. 

It is impossible to weigh in terms of any sort of risk assessment or even epidemiological probabilities.  Even my nerdy Pi-loving math professor brother would struggle with this.

And that is precisely the point.  I can't quantify the decision by myself, but by understanding the family's immediate goal and knowing the studies and treatment options for an ear infection, I can help a mom and dad to decide what is best for their family in the given situation.

These are ideas that have been floating around in my head for a while and as he so often does, Gawande's timely prose has helped sharpen thoughts that needed some coaching and fine-tuning.

Being Mortal is well worth reading for anyone who has grappled not just with medical decision making but is interested in a strategy for approaching the end of one's life and maximizing their personal goals with the assistance of the modern medical community who has hopefully read this insightful book.