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Second Hand Smoke; from the WSJ
Topic Started: Jun 14 2006, 08:10 AM (64 Views)
QuirtEvans
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I Owe It All To John D'Oh
THE DOCTOR'S OFFICE
By BENJAMIN BREWER, M.D.

The Doctor's Office is a first-hand online column about the issues, challenges and rewards facing physicians today. The column is written by Benjamin Brewer, a doctor with a family practice in the rural village of Forrest, Ill., 100 miles south of Chicago. The column runs every other Tuesday.
Dr. Brewer, 37 years old, grew up in Normal, Ill., where he attended Illinois State University. He received his M.D. from the Southern Illinois University School of Medicine in 1994. After working at Union Hospital Family Practice Residency in Terre Haute, IN, he established his own practice in 1998. Dr. Brewer lives in Gibson City with his wife Kim and their four children.

Dealing with Parents Who
Smoke Near Their Kids
June 14, 2006

At 11 p.m., I arrived in the emergency department to see a twelve-day-old infant with a runny nose, cough and fever.

It turned out the baby had a respiratory infection. I'm confident she got it mainly because her parents smoke.

I see a scene like this unfold nearly every day in the office or hospital. The parents are concerned about the child's illness and would like a quick fix for their feverish, fussy infant who is having difficulty breathing.

They just don't seem to see that their children's problems are inflicted by second-hand smoke exposure. Or they see it but don't want to deal with it.

Smoking around children isn't illegal of course, but I view it as a legal form of child abuse. Children are harmed by it and they can't get away from it.

When I smell smoke on patients as they come in for their appointments, I'm sure their children's little noses can smell it and breathe it in, too.

What's at stake? Increased risk of sudden infant death syndrome (SIDS), ear infections, respiratory infections, asthma, as well as increased risks long-term for cancer and many other illnesses.

When talking with parents who are smokers, I try to be sensitive and non-judgmental about discussing the health effects of their smoking behaviors. Some parents are conditioned to ignore most messages about smoking but will respond to a more assertive approach. Sometimes humor helps get the message across. Sometimes I get though to smoking parents in a teachable moment when their child is ill. A minority of patients are ready for some help with quitting.

Others aren't. They may appear concerned about the effects of smoking on their children, but not concerned enough to quit. Or they seem annoyed and defensive when I bring it up.

I hear all kinds of excuses. Some parents tell me they only smoke outside or always roll the window down in the car when they smoke. Sometimes they take false comfort in having a relative that lived a long time despite smoking heavily. (I often ask them how many 90-year-old smokers they know, and the answer is usually just one.)

I've had patients leave my practice because we've told them that they were harming their children's health and their own by smoking. (My staff is instructed to ask about smoking status at each office visit.) I feel bad for the kids, but I don't miss dealing with their stubborn parents.

The parents of the sick infant in the emergency department are committed smokers. Dad is sporting a case of chronic bronchitis and mom smoked a pack a day throughout her pregnancy. I tried to talk her out of it, but she didn't want to consider stopping.

She wanted to leave the hospital one day after her Cesarean section because the hospital has a smoke-free campus, but I wouldn't let her. Their toddler has a chronically runny nose. They think he has allergies. I think he's allergic to smoke, and I tell them that.

The father of this sick infant was thinking about leaving his current physician (not me) because "My doctor tells me that all my problems are due to smoking." I told him that I wouldn't be any easier on him than his current doctor, so he might as well stay put.

I'd like to see what six months in a non-smoking foster home would do for the breathing of some of my pediatric asthma patients. Maybe that would be a wake-up call for their parents.

We have emissions standards for automobiles but we don't have clean-air quality standards for the air that children breathe.

As much as I'd like to see it, I don't expect anyone to outlaw cigarettes or tax them out of existence anytime soon.

If we had the courage to do that, I'd be making fewer late-night trips to the emergency department and my littlest patients would be breathing easier.

Please write to Dr. Brewer at thedoctorsoffice@wsj.com. He cannot always respond to all the reader mail he receives but he does review all mail. If you do not want your name reprinted in association with an email, please indicate that.
* * *

In his last column, Dr. Brewer wrote about screening tests, and why some patients don't get the tests they need. Here are some reader responses.

Having my colonoscopy tomorrow. I'm 51 and your message hit home. My fears about the discomfort are real (still) and I almost cancelled today ... now I won't, thanks to you and my husband, age 56, with family h/o colon cancer. You did us a great service. Hope you are feeling better after your surgery :)
* * *

Like you, I'm a healthy 38-year old guy (who has regular checkups and never says no to a test recommended by my GP). But I'm curious -- where can I find the 11 different health maintenance and screening items that should be tracked for someone my age? Is there a Web site that lists these? I'd like to take more responsibility of my own healthcare (and also make sure that I'm not missing any of these tests).
* * *

My personal experience is that doctors generally use fear and a lack of their knowledge to diagnose patient problems (based on what patients tell them) to prescribe tests that are generally unnecessary, very costly, or may do more harm than good.

Until the costs of some of the more expensive tests come down, or can be shown incontrovertibly to be safe, there will always be patients who decline certain tests. My husband and I found ourselves paying $1000s of dollars for blood tests that went absolutely nowhere in the course of investigating the sources of relatively annoying, but probably benign symptoms with the past 2-3 years alone. Had we not had insurance, we would have learned a much more painful lesson. The doctors we dealt with were surely covering their proverbial [xxx], instead of just stating the obvious: that they had no clue what these problems were.

Instead of wanting to become a better salesman to your patients, you would do much better to lobby for the drop in the costs of some of the more effective, important tests, so that they are readily available to more people, or to initiate more research on many common tests to determine efficacy and safety (like mammograms for 40-year old women that have absolutely no family history of breast cancer). Tests, like antibiotics, have become the cure-all generalized solution for doctors of our time who have no real knowledge of how to deal with patient problems, who simply who don't listen to or acknowledge their patients, or who have been conditioned by the threat of lawsuits to order tests no matter what.
* * *

For about the last 20 years, every auto dealer and independent mechanic with whom I have done business has managed to employ an effective tickler/reminder system for when my car may need service. Unfortunately, the doctors, the insurance companies, and even the test providers do not see the financial incentive to engage in this practice. Perhaps the test providers, be it blood services or the radiological services, could be taught that their profits would increase if more people used their services. Whatever it takes.
It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010.
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