Here is another post from my recent book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor whom I call the poor examiner.

It sounds difficult to believe, but some doctors are simply not good examiners of children. I do not mean that they were not properly trained or that they are incompetent; they simply are not smooth when performing an exam. You will virtually never find this quality in pediatricians or exclusively pediatric subspecialists, but you will occasionally meet physicians whose scope of practice spans the pediatric age spectrum but who are much more proficient in examining older patients than they are dealing with children.

Sometimes this problem is largely a social one; every parent knows it takes a special knack to put a toddler, older child, or adolescent at ease during a physical examination. Each of these developmental stages has its own particular nuances, and facility in examining children from infancy to young adulthood is something some doctors never really master. Even though a doctor’s examination may be effective in that she correctly identifies the problem, she may still make the child or the parents uncomfortable with how she does it.

If you and your child are dealing with a physician like this, your new knowledge that you obtained from this book of how doctors routinely examine children can help the situation. You can reassure your child about what is going on and what comes next, something the doctor ought to do but may forget, given her particular communication problem. You can help the doctor position your child for the examination, such as for a toddler’s ear check or a school-age child’s abdominal examination. In my experience, most physicians of this sort appreciate such parental assistance very much because they fully realize examining children, especially uncooperative children, is not their strong suit.

Much of the discussion about healthcare reform seems to presume that we need to break everything we have into little bits and start fresh. In a recent New Yorker piece, Atul Gawande points out the problems with this notion. At the most practical level, our medical care system (such as it is) needs to function 24/7, all the year round. We can’t just stop it for a while, put the whole country on hold, as we introduce a new way of doing things.

But beyond that, Gawande brings up another fascinating angle to the question. Anyone who has read about the issue knows that Britain, France, and Germany, for example, have established systems that differ from each other in fundamental ways. Only in Britain does the government run everything. Gawande asks the question: why have these countries done things differently? The answer, it turns out, is that each of them built upon the system (and citizen expectations) that already existed in that country. In no case did anybody tear down completely what was there and erect a totally new way of doing things.

Gawande concludes that whatever we do will necessarily be built upon what we already have. This will offend some people deeply, particularly partisans from both sides of the political spectrum. It will not at all be a system that a dogmatic purest of any ideological stripe would plan from scratch. Rather, it will inevitably be a series of compromises and tinkerings with the way we are doing things now. And we will need to be willing to trim our sails if needed, modify the system, when it is clear one or another aspect of it is not working.

Change will come, one way or another. We cannot sustain the rate of rise of medical care costs, which already consume 16% of our GDP, far more than any other nation.

It’s that time of year again in the PICU, time for a winter outbreak of respiratory syncytial virus (RSV). RSV is extremely common and highly infectious: its attack rate, meaning the chances of a susceptible person getting the infection if exposed to a case, is among the highest of any virus. Estimates are that as many as 125,000 infants each year are hospitalized with RSV, with many, many more infected less severely. The peak age for those children needing a hospital is between two and five months. It is so common that by early childhood virtually all of us have been infected at least once.

Much of the time RSV causes the symptoms of a cold — cough, runny nose, sometimes a low-grade fever. But in very young children, particularly infants, RSV can cause severe pneumonia or bronchiolitis. The latter disorder is an inflammation of the tiniest of the lung’s air tubes, or bronchioles. This inflammation blocks off the little tubes, making it difficult for air to get in, or most characteristically, to get the air out. Babies with severe RSV often need oxygen and some need mechanical ventilators to breathe for them as we wait out its course until it passes.

Every parent asks: can we do anything to treat this illness, make the symptoms better, make it go away faster? Sadly, the answer is no. I’ve been taking care of children with RSV for 30 years, and I’ve seen a long list of things tried — breathing treatments, anti-viral medicines, steroids, medicines intended to open up the small airways. None of them work. The research of the past few years is conclusive — all we can do is wait for the infection to pass, meanwhile supporting breathing as needed with oxygen, clearing the lungs of mucous, and sometimes a mechanical breathing machine in severe cases.

Since the dawn of the antibiotic era bacteria have been able to acquire resistance to these drugs. Some are better at it than others. Up until recently, though, antibiotic researchers have by and large been able to stay one jump ahead of the bugs. No longer. We are now seeing some truly frightening super-bugs — bacteria resistant to all known antibiotics. Equally disturbing is that there really aren’t any drugs in the immediate research pipeline that will help us.

There are two reasons this has happened. The first is that bacteria reproduce very, very rapidly — sometimes as rapidly as every 20 minutes or so. The result is pure evolution in action. Every time DNA, the stuff of our genes, reproduces itself there is a very small, but still real, chance that the DNA will not be replicated accurately. These random mutations are most often of no consequence. But sometimes they have major effects; they can alter the makeup of the bacterial cell by changing some aspect of it that was targeted by an antibiotic, rendering the bacteria resistant to its effects. So that antibiotic no longer works in an infection from that kind of bacteria. The offspring of such resistant bacteria are themselves resistant. Worse, in some situations resistant bacteria can pass their resistance on to other bacteria that are not even their progeny, or even the same species of bug.

The second reason for emerging resistance, as most of us should know, is the truly widespread use of antibiotics — in medicine, veterinary practice, and agriculture — when they are not needed, such as for colds. Antibiotics don’t help colds because viruses, the cause of colds, aren’t affected by them and never have been. This situation gives a selective advantage to those bacteria that are resistant over those that aren’t. It’s pure evolution.

So the scary situation we find ourselves in is party caused by biology and partly caused by us. The biology we can’t change — but we must restrict our antibiotic use to situations where they really work.

The debate is on over this question: does the financial hole we’re in make any healthcare reforms unaffordable in the near term? Most observers say we’ve got two major problems to solve — access and cost.

Many Americans don’t have access to care, primarily because they don’t have any insurance. Estimates vary of exactly how many people this is, as do explanations for why they don’t have insurance. Free market conservatives assert that the number of uninsured Americans is manageably small. Further, they believe that for a significant chunk of these people the reason they don’t have insurance is because they choose not to buy it. The more liberal viewpoint, which I share, is that the number of uninsured really is at unacceptably high levels, and the reason it is that high is that insurance costs too much. This especially affects the self-employed, who must buy insurance for themselves, or those who work for small companies, which increasingly cannot afford to offer their employees healthcare benefits. Tying healthcare to employment, the standard way of doing things, causes major problems and inequities.

It is pretty clear, as became apparent in Massachusetts when they enacted their own healthcare reform, that increasing access to care caused an immediate torrent of pent-up demand from people who had been putting things off because they had no insurance to pay for it. So in the short term, at least, costs clearly go up when you increase access. But the alternative is clearly unacceptable, at least to me — controlling overall healthcare costs by denying access to needed care is an inhumane and shortsighted approach.

The rub, of course, is that as a society we ultimately must deny some access to care because we cannot afford it all. Healthcare costs already constitute a higher proportion of our GDP than any other country’s, and the trend is getting worse. The key is to eliminate payment for those things that don’t work. Most experts agree that a huge proportion of our healthcare dollars go for things of marginal or no benefit.

Since all this will cost money, should we put it off in these difficult fiscal times? No, says the Obama administration and many other healthcare wonks. Their idea is that reforming healthcare is intimately bound up with any economic recovery package. And just speaking politically, times of crisis have often been times when people are more willing to make dramatic changes in how we do things — ordinarily, we resist change, something even Machiavelli knew, and which has been called the “law of reform.”