I wrote about this topic a few years back, but the recent outbreak of measles has once again ignited the debate of just what the government has the right to do or not do in compelling individual actions in support of public health. This is an old question, and it’s worth considering it in historical context.
One aspect of the endless vaccine debate is the aspect of coercion some parents feel about requiring children to be vaccinated before they can go to school. Vaccination is mandated for school attendance in all states. But this isn’t really an absolute requirement. Although all 50 states ostensibly require vaccination, all but 5 (Mississippi, West Virginia, and more recently California, New York, and Maine) allow parents to opt out for religious reasons, and 15 states allow this for philosophical reasons. (See here for a current list.) Still, in general vaccines are required unless the child has a medical reason not to get them, such as having a problem with the immune system. Is this an unprecedented use of state power? I don’t think it is.
In fact, historically there have been many examples of the government inserting itself into healthcare decisions of individuals and families in order to protect the public health. Some of these go back many years. Quarantine, for example, goes back to medieval times, centuries before the germs were discovered. It has since 1944 been a power of the federal government; federal agents may detain and send for medical examination persons entering the country suspected of carrying one of a list of communicable diseases. Quarantine has also been used by local and state governments, particularly in the pre-antibiotic era. Measles is a good example, as you can see from the photograph above. Quarantine can be abused, and has in fact been abused in the past for discrimination against certain minority groups. A paper from the American Bar Association details some of those instances here. The paper even questions if it should be abolished for these reasons. But the practice is a very old one.
Seaports have long been sites of quarantine enforcement. In colonial Pennsylvania, for example, ships bound for Philadelphia had to stop at an island in the Delaware River for up to 30 days to ensure they were not carrying any disease. Note that an island was chosen since it is easier to isolate ships there. During the cholera epidemics in the mid-nineteenth century the quarantine of ships arriving from abroad was common. It should be noted though that, prior to the acceptance of the germ theory, enforcement of quarantine was at least as concerned with the cargo as it was the persons on the ship. But the legality of the practice was well accepted.
Laws requiring mandatory vaccination have been around for over a century. Some opposition to them has been around just as long. The constitutionality of these laws was affirmed in the famous decision by the Supreme Court in 1905 — Jacobson v. Massachusetts. The case in question concerned smallpox vaccination, and of course we have many more vaccinations now. There have since been multiple cases concerning mandatory vaccination for school attendance; in all cases the courts have ruled in favor of these mandates. If you are interested in reading deeper into this controversy a good person to consult is Professor Dorit Reiss, a law professor at the University of California. She has devoted her career to examining vaccine law and politics. Here is a place where you can find links to some of her many publications on the subject. You can also read a nice review of the historical controversies over quarantine here.
Of course the government mandates many things for the protection of public health. Milk is pasteurized (although there are raw milk enthusiasts who object — and many of whom get sick as a result), water is purified, and dirty restaurants can be closed. Like quarantine, these measures restrict our personal freedom a little, but what about government-mandated medical treatment? That sounds a bit more like the situation with compulsory vaccination of children. As it happens, there are more recent examples of compulsory treatment, particularly involving tuberculosis.
A couple of decades ago I was involved in a case of a woman with active tuberculosis who refused to take treatment for it. Worse, her particular strain of TB was one highly resistant to many antibiotics, so if that spread it would represent a real public health emergency. The district judge agreed. He confined the woman to the hospital against her will so she could be given anti-TB medications until she was not longer infectious to others. At the time I thought this was pretty unusual. When I looked into it, though, I found that there have been many instances of people with TB being confined against their will until they were no longer a threat to others. The ABA link above lists several examples of this.
So it’s clear to me there is a long tradition of the state restricting personal freedom in the service of protecting the public health. Like everything, of course, the devil is in the details. To me the guiding principle is that your right to swing your fist ends where my nose begins.
The common practice in this country (although not everywhere—Europe, for example) has long been to treat all acute middle ear infections (otitis media) with antibiotics. This is not necessarily needed. We now know that for many children another reasonable approach is to wait a day or so to see if the symptoms get better on their own without antibiotics. Parents have an important role in making this choice. If you and the doctor decide to wait on antibiotic treatment, you can still treat fever and pain with acetaminophen (Tylenol) or ibuprofen (Motrin). There is also available a numbing ear drop that, when dripped down the ear canal onto the ear drum, directly relieves the pain there.
If you think about it, this newer understanding of the natural history of ear infections makes sense. Children have been contracting ear infections for many thousands of years, yet we have only had antibiotics for three-quarters of a century. The overwhelming majority of those children in the pre-antibiotic era must have recovered from the infection on their own.
You may have noticed that above I used the weasel words “not necessarily” in my statement regarding whether or not ear infections need prompt evaluation. There are a few times that they do. How can you know when that is? The answer is to look at your child in light of what else she is doing. She will have a fever and probably be fussy. But if she is alert, drinking fluids, and looks good otherwise, you can safely put off having her evaluated. On the other hand, if she is lethargic, glassy-eyed, and not taking fluids, then you should bring her in because those kinds of symptoms can be indicative of a more serious condition. If you decide to wait and see how your child does before bringing her to the doctor, how much time should you give it? Twenty-four hours is a reasonable amount of time to wait to see if the fever and pain resolve. If they do not, then it would be appropriate to bring your child to the doctor.
The American Academy of Pediatrics has revised their recommendations about treating ear infections to reflect this more nuanced approach. You can read the list of recommendations here, but the gist of it is that “watchful waiting” is a reasonable alternative to antibiotic therapy for children over 6 months of age, who do not appear seriously ill, and who do not have a temperature of over 102.2.
You can read more specifics about what causes ear infections here if you like.
An interesting article in the journal Pediatrics is both intriguing and sobering. It is intriguing because it lays bare something we don’t talk much about or teach our students about; it is sobering because it describes the potential harm that can come from it, harm I have personally witnessed. The issue is overdiagnosis, and it’s related to our relentless quest to explain everything.
Overdiagnosis is the term the authors use to describe a situation in which a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It’s not the same as misdiagnosis, meaning the diagnosis is inaccurate. It is also distinct from overtreatment or overuse, in which excessive treatment is given to patients for both correct and incorrect diagnoses. Overdiagnosis means finding something which, although “abnormal,” doesn’t help the patient in any way.
Some of the most controversial and compelling discussions of overdiagnosis come from cancer research. Two of the most common cancers, prostate cancer for men and breast cancer for women, run smack into the issue. As a pediatrician I don’t treat either one, but the concept certainly applies to children’s health. It is generally true early diagnosis and treatment of cancer is better than late diagnosis and treatment . . . usually, not always. A problem can arise when we use screening tests for early cancer as a mandate to treat them aggressively when we find them. The PSA (prostate-specific antigen) blood test was developed when researchers noticed it went up in men with prostate cancer. From that observation it was a short but significant leap to use the test in men who were not known to have cancer to screen for its presence. The problem is at least two-fold. There is overlap in the test numbers between cancer and normal, and many small prostate cancers, even when present, do not progress quickly. Since the treatment for prostate cancer is seriously invasive and has several bad side effects, the therapy may be worse than the disease, especially in older men. You can read more about the PSA controversy here. There are similar questions about screening for breast cancer; early detection is a good thing, but how early in life and how often should otherwise low-risk women be screened? You can read a nice summary of that discussion here. This issue also has caused fierce debates. There are other examples but these two serve to highlight the problem of finding a middle ground between overdiagnosis and underdiagnosis.
Children don’t get cancer very often, but there are plenty of examples of overdiagnosis causing mischief with them, too. The linked article above describes several common ones. A usual scenario is getting a test that, even if abnormal, will not lead to any meaningful effect on the child’s health. Additionally, an abnormal test then typically leads to getting other tests, which can lead to other tests, and so on down the rabbit hole. I have seen that many times. As the authors state:
Medical tests are more accessible, rapid, and frequently consumed than ever before. Discussions between patients [or their parents] and providers tend to focus on the potential benefits of testing, with less regard for the potential harms. Yet a single test can give rise to a cascade of events, many of which have the potential to harm.
In evaluating the importance of overdiagnosis in a condition at the population level, we propose focusing on the frequency of overdiagnoses relative to needed diagnoses, the ratio of potential benefits from needed diagnoses to potential harms from overdiagnoses, and the amount of resource utilization resulting from overdiagnosis.
This is kind of a new frontier in medicine, and the issue grows larger as the huge number of diagnostic tests we have mushrooms every year. For a parent, a good rule of thumb is to ask the doctor not just what the benefits of a proposed test are, but also the risks. Importantly, ask what the doctor will actually do with the result. We are prone to think more information is always a good thing, but that clearly is not the case. And never, ever get a test just because you (or your doctor) are merely curious. If you’re interested in some of the specific conditions the authors discuss there is a useful table in the article. Several of them, such as neonatal jaundice and gastroesophageal reflux, are quite provocative in their implications.
A large number of pediatric practices these days use after-hours call centers for parents who have questions about a sick child. I’ve been looking around to find some data about how common this is, but my sense is that the majority of pediatricians use them. There is no question these call centers make live easier for the doctor; having somebody screen the calls, answer easy questions, and only call you for important issues is a great boon. But that boon comes at a cost: the people staffing the call centers are not doctors. They are often experienced nurses, but that is not the same thing. So deciding what is important and what can wait can be a problem.
The call centers generally use predetermined protocols drawn up by experts to help guide decision-making. This is a good way to ensure consistent, quality advice. But not every child fits the protocol, and a set of guidelines is not a substitute for actual clinical experience. Really, these days a savvy parent can get almost as much useful guidance from consulting Dr. Google (or my latest book). A study presented at a meeting of the American Academy of Pediatrics examines another question: do these call centers send too many children to the emergency department?
My assumption would be that they do. After all, they are hard-wired to do so. If you call one, the person giving you advice not only is not a doctor, they do not know your child. Also, the decision-making protocols they use necessarily err on the safe side. So if there is any doubt about what to do they will advise you to take your child to the emergency department even though your child’s doctor often might not do that.
The study bears out this presumption. The investigators, from Children’s National Medical Center in Washington, D.C., examined the records of 220 children for whom the call center advised parents to take their child to the emergency department. They used a panel of evaluators to see if the visit to the ED was appropriate. They found that, for a third of the children, they could have safely stayed home.
After-hours call centers have made doctors’ lives less hectic, and I’m not suggesting we do away with them. They give thousands of parents useful advice. Plus, what we don’t know is if even more of those 220 children would have ended up in the ED if the call center didn’t exist: who knows, perhaps they steered a significant fraction of children away from an inconvenient and expensive ED visit. However, in my own anecdotal experience the call centers do increase ED use. I have had many parents tell me, after I’ve seen their child in the ED, that the only reason they came was that the call center told them to — that they were surprised by that advice and otherwise would have stayed home.
My own father was a small town pediatrician. He didn’t have an answering service. When parents wanted to ask about their sick child they just called him at our home. His phone number was in the directory just like everybody else’s. He didn’t have any sort of pager. If he wasn’t home, people called back or else called whatever number one of us kids or my mother told them where to call to find him. Those were simpler times, and not necessarily better ones. Now we have call centers, and we need to figure out how best to use them.
I’d be interested in any experiences, good or bad, that parents have had with after-hours call centers. Were they helpful? Were they a problem?
Asthma is a common childhood condition. Estimates are that around 8% of all children have it. The incidence had been steadily increasing for many years, but some recent data suggest the burden of the disease in children may have leveled off over the past couple of years. That’s encouraging, but the number of children with asthma is still huge. The peak age group is 5 to 14. The best way to think of asthma is that of an exaggerated reaction of the small airways in the lungs to common irritants, making them constrict and reduce airflow. These include viral infections, environmental triggers, and poorly understood things intrinsic to the individual. There is a strong familial tendency to developing asthma. Additionally, some things predispose to it, including sedentary lifestyle and obesity.
Over the past decade there has been an increasing push to recognize that asthma is multifactorial and that early interventions, things parents can do at home if their child’s symptoms worsen, can head off acute deteriorations that lead to hospitalization. The standard now is that every child with asthma have an action plan for the family to follow. The plans are designed to be specific to the child and concrete in their instructions about what to do. They typically divide into three, color-coded sections. Here’s an example of what they look like.
There is some research showing how useful these plans can be. The investigators looked at 3,510 children with asthma treated over the years at Primary Children’s Hospital in Utah. The notion was to see if increased compliance with asthma control measures by the family would reduce the number of hospital admissions. That turned out to be the case, significantly so. Interestingly, one of the biggest problems for the research project was to get physicians to accept and go along with the best current evidence-based information about how to manage asthma. I’m actually not surprised by this. Asthma management has changed over the years and current best practice is not what I was taught years ago. Things change, but many physicians don’t.
The key for any parent who has a child with asthma is to have a clear understanding of exactly what to do if your child has worse breathing problems. Many visits to the hospital could be headed off if all parents had such a plan, as well as a resource person to call if the plan is not working.
“In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.”
The decision in question concerned a patient who came to an outpatient facility and was evaluated by a nurse-practitioner, who thought the patient might need to be admitted to the hospital. She called the hospitalist (today’s term for physicians who specialize in only caring for hospitalized patients) at the hospital that practice generally used to discuss it and the hospitalist physician did not recommend hospitalization. The nurse practitioner accepted this recommendation and sent the patient home. Note that the hospitalist neither examined the patient nor had access to the patient’s medical record; he was not even physically present in the building. The patient later died from severe infection and the patient’s family sued both the nurse practitioner AND the hospitalist.
Physicians get what are often called “curbside consults” all the time. I may call a subspecialist at the nearby University Hospital to ask some questions about a patient and get advice about what I should do. I’m ultimately responsible, of course, for whatever I do or don’t do but I may just need some advice or sometimes just another person to bounce ideas off. Similarly, physicians in facilities around the region who want to transfer a child to my PICU always call me for advice about what to do before the child gets to me — it’s totally routine. Good medical practice absolutely needs these sorts of interactions to give good care. The university system I deal with, like many such facilities, even has a special phone number for me to call to get quick access for expert advice. Traditionally, in a legal sense the physician providing the curbside consult is not liable for the advice because he or she doesn’t have a formal relationship with the patient; they have never seen the patient, never seen the actual medical records, and never examined the patient. At first glance the decision from Minnesota has some ominous implications for this universal medical practice. But does it really?
Of course, as with most things, the devil is in the details, especially when considering how generalizable this court decision is to usual practice. I am not a lawyer, of course, but I did look at the actual decision here. The first lines of the decision reads: “A physician-patient relationship is not a necessary element of a claim for professional negligence. A physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.” That, to me, is a bit chilling. This is because the physician giving the advice is giving it based upon what he is told, and what he is told may be incorrect or incomplete.
It is important to point out that the Minnesota Supreme Court did not find for the patient. The court ruled only that the hospitalist physician could be sued and remanded the case back to the lower court. The language also stated the hospitalist “denied” the hospital admission. That’s a different thing than recommending against it. The decision also states the physician must “breach the standard of care.” Those are key details, I think, in assessing what this decision means. In my own practice, I never outright deny an admission if someone calls me asking for one. I may suggest the child not come to the PICU, but I facilitate admission to the appropriate hospital unit. If my PICU is full so I don’t have a bed for the patient, I help the calling physician find one at another facility. But if I am accepting a patient I do give advice about what to do, and that advice is based upon what a person not trained in pediatric critical care is telling me over the phone. It is not uncommon for whatever I’m told to be wrong, or at least incomplete. I would hope that would offer me some legal defense if ultimately necessary.
The court did go into what it called standard curbside consultations, and described why this particular interaction was not such: “Our decision today should not be misinterpreted as being about informal advice from one medical professional to another. This case is about a formal medical decision — whether a patient would have access to hospital care—made by a hospital employee pursuant to hospital protocol.” The court also provided some examples of how this expanded definition of professional duty has been applied in the past to both medical and legal practice. Also, a conversation between a nurse practitioner and a physician is intrinsically not a a conversation between professional equals. I think this carried some weight with the court.
The bottom line for me is that this decision is somewhat concerning, although much less so if narrowly applied. Anybody deeply concerned should read the actual decision linked above.
Over the past decade child development experts have produced an increasingly large body of evidence on the dangers of too much screen time for children, especially preschoolers. These include increased risk of attention deficit hyperactivity disorder (ADHD) and other learning problems. The consensus opinion is that the rapidly changing images, coupled with the passive nature of the experience, are not good for the developing brain, and the brain continues to develop well into late childhood. This is especially the case for preschoolers. A potential problem is when parents use the screen, whether a television or computer screen, as a sort of babysitter. Now there is nothing wrong with this for short periods, but the American Academy of Pediatrics has offered guidelines on how much is too much. It’s a good resource. The AAP and child development experts particularly recommend reading books to toddlers as a way of fostering the back-and-forth interactions that promote emotional and cognitive development. But now, of course, we have a hybrid — the book on a screen, the ebook. Many people I know do their reading these days almost exclusively on the screen. My own books sell more electronic versions than paper ones. What do we know about reading to your child on an ebook? Is the experience the same as an actual physical book?
Some previous research suggested when preschoolers read electronic books with parents, parents offer less dialogue, and talk is often focused on the technology rather than the book contents. What about other interactions besides talking, the more subtle things? A recent study in the journal Pediatrics offers some information about this. The authors conducted a videotaped study of 37 parent-toddler pairs reading on the different book formats and observed what happened using some standardized criteria for shared positive affect and collaborative reading. They found that the pairs reading an ebook verbalized less to each other and collaborated less, meaning pausing and interacting with each other. These differences were statistically highly significant, with p values of < 0.001 for those of you who like statistics.
For myself, I don’t think these differences are necessarily intrinsic to the medium. It’s certainly possible to be as interactive with your child with an ebook as with a physical, paper one. But for whatever reason parents don’t do this. Perhaps it’s because our own interactions with computers and iPads are somewhat passive and self-centered, different than jointly with our child holding an open book in the lap. But whatever the reason, it gives evidence for the benefit of the well-worn and much loved copies of favorite children’s books we recall. Certainly my daughter’s dog-eared copy of Curious George was like that.
A seizure in response to a fever, called a febrile seizure, is an extremely common event in childhood. They affect 2–5% of children between 6 months and 5 years of age and have a peak incidence between 12 and 18 months of age. They generally occur after a rapid rise in temperature; it appears the rate of rise is more important than the actual temperature. Febrile seizures probably represent an age-dependent response of the immature brain to fever. They are more common in boys and in children with a family history of febrile seizures. Neurologists divide them into simple and complex: simple ones last less than 15 minutes, generally less than 5 minutes, and the child is back to normal in an hour; complex ones last longer than 15 minutes or occur several times in less than 24 hours. The overwhelming majority are simple febrile seizures and the child completely recovers. Generally no further testing is required to diagnose them and typically no therapy is needed because they stop so quickly. They can be scary, though, for parents who have never seen such a thing. A child who has one is at increased risk of having another before the age of five. You can read about them in detail here and here if you want to learn more.
Vaccinations can occasionally be associated with febrile seizures because a child may have a fever after receiving a vaccine. Some parents are concerned that this variety of febrile seizure could somehow be worse than one from another source of fever, such as an ear infection. This is a particular claim I often see on social media where vaccine denialists gather to promote their often wildly fallacious claims about vaccines. They often insist febrile seizures following vaccinations somehow injure the brain even though simple febrile seizures from other causes do not. There has never been any evidence in support of these false claims, and now there is new evidence refuting them. It appeared the most recent issue of Pediatrics, the journal of the American Academy of Pediatrics.
Investigators in Australia compared children experiencing their first febrile seizure following vaccination with those who had their precipitating fever from other sources. All children were otherwise completely normal. There were 1,022 children altogether, of which 6% had vaccination as a fever source. The median age of the children, 20 months, fits what we would expect. In sum, there were no differences observed between the two groups. In particular, there were no difference in the nature of the seizures, their duration, or the treatment and tests required. Children who had a fever with an infection were, unsurprisingly, more likely to be admitted to the hospital on account of their infection. Their conclusions are important:
This study confirms that vaccine-associated febrile seizures are clinically not any different from non-vaccine associated ones and should be managed the same way. Our findings can be used to counsel concerned parents that although some vaccines have a known associated risk of febrile seizures, clinical severity and outcomes of these are no different to those from another cause. This information helps support the recommendation to these patients and their families that additional required vaccinations can be administered in the future.
This study supports previous ones that have found the same thing. The advantage of this new one is that the Australian system allows very complete tracking of these children, correlation with vaccination records, and follow-up of how they did later.
Here is another post from my book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor who I call “the poor examiner.” The point is that, as with my previous posts about difficult to deal with physicians, there are things you can do when you encounter one that can still allow you to get the best care possible under the circumstances.
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, the process itself, 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.
Here is another post from my book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor whom I call an avoider. The point is that, as with my previous posts about difficult to deal with physicians, there are things you can do when you encounter one that can still allow you to get the best care possible under the circumstances.
Most of us are, to some degree, procrastinators. We avoid or postpone doing unpleasant things. In this sense, physicians who are avoiders are no different from anyone else. For a doctor, however, avoiding things often leads to poor, or at least less than frank, communication with parents.
One kind of avoidance behavior is when the doctor avoids answering your questions. These doctors do not behave this way because they are poor listeners; they just find it uncomfortable to answer your questions. Often this doctor takes the oblique approach of not quite answering the question you asked, and instead rephrasing it into a question he would rather answer. He tends to talk around issues, especially those that are part of serious, unpleasant, or intractable medical problems. He also tends to use euphemisms for unpleasant things, commonly retreating into medical jargon because medical language seems more sanitized and neutral.
I have considerable professional experience with avoiders because my own subspecialty of critical care often presents parents and physicians with difficult choices, situations in which there are sometimes no good options, just less bad ones. Many times I have spoken with parents who, after an interview with a physician who is an avoider, must ask me what the doctor really meant to say. And that is the key to the avoiding-type of physician: he probably thinks he is doing what is best by filtering what he says and not speaking directly, but parents invariably want their questions answered as directly as possible. If you find yourself in an interview with a doctor like this, you really have no option except to press him for an explicit answer to the question you actually asked, not the one he chose to answer.
There is another variety of the avoiding physician encountered by parents whose child has ongoing medical problems. This is the doctor who just plain avoids them and their child. These are doctors who only reluctantly return your telephone calls or, if your child is admitted to the hospital, always seem to miss you when they come around to see your child in her room. This seems like odd behavior for a physician, but it is not rare. The reason for it is that the doctor procrastinates or even avoids conversations that he believes, for any number of reasons, will be difficult or uncomfortable either for you or for him. Of course, that is all the more reason to have the discussion. Nothing interferes more with a conversation than one of the parties not showing up to partake in it.
How Your Child Heals An Inside Look at Common Childhood Ailments
This book takes you on a tour of the inner workings of a child's body as it heals from injury, illness, and common diseases.
How To Talk To Your Child's Doctor A Handbook for Parents
"A great read for any parent. It really helps you get inside the mind of your child's doctor and figure out how best to communicate."
Your Critically Ill Child Life and Death Choices Parents Much Face
Personal stories of children and their families and how they and their doctors together learned the best way to understand and take care of each other.