Dr. Barry Dworkin » Communication

A headline’s tale of two flu stories: Reality vs deliberate misrepresentation of risk

Dr. Barry Dworkin — Sat, 17 Oct 2009 22:03:26 +0000

I am not a fan of how newspapers use headlines to misrepresent stories to provke unwarranted fear, and heightened risk perception. Today, the Ottawa Citizen published two stories about seasonal and H1N1 vaccine. The first story, For Guillain-Barre survivors, flu shot stirs up unwelcome memories, emblazoned on the front page has all the elements of what is regrettably become the norm in newspaper headlines. Headlines are not under control of the journalist. The article was written by Sharon Kirkey.

Ottawa Citizen journalist Dan Gardner’s book, Risk: The Science and Politics of Fear discusses this journalistic approach to sensationalizing news called the Example Rule.

This rule is used to present rare occurrences as if they are common or lurking among us, misrepresenting true risk. Therefore, it was no great surprise to read the front-page headline of today’s Ottawa Citizen continuing this tradition. It outlines the history of a woman who develops a rare neurodegenerative disease called Guillain Barre Syndrome (GBS) and implies a link to the flu vaccine.

The medical content of the story accurately presented the risks of developing GBS, about 1-2 per 100, 000 people. There is some evidence that indicates that the flu vaccine may add an extra 1 per 1 million people. However, the headline clearly did not reflect this. It cites one Ontario study that the seasonal flu vaccine increases the relative risk of contracting GBS by 45 percent.

The absolute risk change of the 1 in a million increase was mentioned immediately following the 45 per cent claim. This former should have been the only statistic cited.

Relative risk is presented to emphasize dramatic change. It is used by media, pharmaceutical companies, food manufacturers, and the Natural Health industry among others to bolster their health claims.

Relative risk does not provide context for the change in risk and should not be included in health reporting. However, it is the number that will be cited by the reader when they discuss this issue with others, hence the problem of skewed risk perception.

The story ends with the woman who had GBS stating, “I made a promise to myself, that if I ever walk again, I will do whatever it takes to keep whatever doesn’t belong in my body out of it.” Although it is understood that traumatic experiences can influence one’s sense of risk, the statement is used to conjure up the idea that unnatural substances are implicated in the disease process and are to be avoided.

If that were the case, one could argue that we should avoid touching any manufactured product, walking down the street and being exposed to car exhaust’s polyaromatic hydrocarbons, and using chemical cleanser’s and agents among others. Exposure to some of these potentially harmful compounds is likely in the parts per million or billion as well. We do not routinely think about this because our sense of risk from these everyday products and activities is low.

News reporting should present information with context. The public should be treated with respect, which includes removing the fear mongering for the sake of selling newspapers, TV and radio shows and magazines. Globe and Mail health reporter Andre Picard has commented on this issue as well as Dr. Noni MacDoanald in an article written for the Canadian Medical Association Journal.

The second story written by Pauline Tam, Our best shot against swine flu?, deserves kudos to the reporter for excellent evidenced-based content and science writing.

Ms. Tam accurately represented the uncertainty that is inherent in medical research yet clearly emphasized the strength of evidence against many misperceptions about the flu vaccine.

She covered the issue about adjuvants or immune system boosters and reviewed how the adjuvant improves efficacy of the vaccine. The adjuvant, squalene, is produced by our liver and is found in many foods as natural oil.

One wonders why, given the focus by some groups on how natural products are better than synthetic, there is such controversy. It would make sense that the logic should remain consistent.

Ms. Tam also reviews the preservative thimerosal found in some multidose vaccines and cites evidence from numerous reputable sources regarding its safety profile.

What Ms. Tam accomplished it to foster critical analysis of health information and present it in context allowing the reader to make an informed decision and risk assessment. She shows medical research is always evolving and is not perfect (nor should it ever be if we are to continue to learn) and how it is a jigsaw puzzle of information pieces that are brought together to create the best picture to date about flu vaccine efficacy and indication for use.

Background:

The evidence-based website Up to Date cites this data:

Vaccination — Guillain-Barré syndrome has followed vaccinations, but this danger may be overstated.

Influenza vaccination — In the United States, an increased risk of GBS was associated with the swine influenza vaccine in 1976, although the severity of the risk has been controversial. Subsequently, no increased risk was observed up to 1991.

Individuals who received either the 1992-1993 or 1993-1994 influenza vaccinations were not at significantly increased risk for GBS, but combining the two seasons suggested that influenza vaccination resulted in approximately one additional case of GBS per million patients inoculated. This risk appears to be substantially less than the overall health risk posed by naturally occurring influenza.

The annual reporting rate of GBS following influenza vaccination in adults declined significantly from 1996-1997 through 2002-2003 in the US. Nevertheless, the long onset interval for post vaccination GBS compared with other post vaccination adverse events (median 13 days versus one day, respectively) is consistent with a possible causal association between GBS and influenza vaccine.

Other data are conflicting, but suggest that influenza vaccination is associated with a low or negligible risk of GBS. In a self-matched case control series from Ontario, Canada that identified 269 hospital admissions for GBS diagnosed within 42 weeks of receiving influenza vaccination, the estimated relative incidence of GBS during the primary risk interval (weeks two through seven after vaccination) compared with the control interval (weeks 20 through 43) was 1.45 (95% CI 1.05-1.99). However, a separate time-series analysis of 2173 hospitalized cases of GBS showed no statistically significant increase in hospitalizations for GBS after institution of the universal influenza vaccination program in 2000.

References:

Guillain-Barre syndrome following influenza vaccination.
Haber P; DeStefano F; Angulo FJ; Iskander J; Shadomy SV; Weintraub E; Chen RT
JAMA 2004 Nov 24;292(20):2478-81.

The Guillain-Barre syndrome.
Ropper AH
N Engl J Med 1992 Apr 23;326(17):1130-6

Guillain-Barre syndrome after influenza vaccination in adults: a population-based study.
Juurlink DN; Stukel TA; Kwong J; Kopp A; McGeer A; Upshur RE; Manuel DG; Moineddin R; Wilson K
Arch Intern Med. 2006 Nov 13;166(20):2217-21.

The Guillain-Barre syndrome and the 1992-1993 and 1993-1994 influenza vaccines.
Lasky T; Terracciano GJ; Magder L; Koski CL; Ballesteros M; Nash D; Clark S; Haber P; Stolley PD; Schonberger LB; Chen RT
N Engl J Med 1998 Dec 17;339(25):1797-802.

The betterment of the family

Dr. Barry Dworkin — Tue, 03 Feb 2004 22:48:20 +0000

Originally published in The Ottawa Citizen February 3, 2004

Original Title: The betterment of the family

Last of two parts

Deborah decided she had had enough of smoking marijuana. Last week’s column reviewed how her addiction affected her psychosocial development. Deborah was pondering why she continued to smoke four to 10 joints a day to the detriment of her health, desires and life goals.

The Adolescent Toolkit provides a solid framework to provide insights into the reasons behind particular behaviours. Deborah returned with her answers to these three questions in early November:

What do you like and dislike about yourself?

What are your good and bad qualities?

What are your definitions of a friendship and relationship?

Her answers that follow reflect years of unrecognized inconsistencies and conflicts.

Deborah embraces her adventurous and creative spirit. She is musically and athletically inclined. She takes pride in her trustworthiness and organizational skills, and fulfils her responsibilities at work. Her independence lets her successfully adapt to new situations. She feels she is self-sufficient and does not have to depend upon others for assistance. Empathy, compassion and generosity are cornerstones in her friendships.

She dislikes confrontation, avoids contentious problems and buries her emotions to minimize interpersonal conflicts. She admits she “cares too much about what people think of me.” There are some regrets when she says, “I never really followed my passions/goals/dreams. I gave up at everything too soon. I got relatively good at lots of things, but not great at anything.”

Her behaviour and reactions to conflict parallel the actions of her 15-year-old self. Indeed, many of her social skills stalled at age 15 because of her drug use. She hates that her cannabis use takes priority over her friends and family. “I’m smart enough to know better, but not smart enough to quit.”

Her definitions of friendship and relationships reflect the normal idealism of the teen years. There is a tendency to focus on the positive attributes of each and omit any consideration of the potential conflicts, hardships and frustrations inherent in close relationships. Her desire to avoid confrontation combined with a need to be liked by people paralyses her ability to make decisions in her best interest. Her fear of rejection makes it difficult for her to say “no.”

When people decide on a course of action that runs contrary to their conscience and sense of propriety, they can become angry with themselves. This anger can damage a person’s self-respect. Others will pick up on this; some will take advantage of this vulnerability. We all know people who share these characteristics.

Drug abuse is a means for some to escape from problems. This escapism became so ingrained in Deborah that it buried her true spirit. People always do things for a reason. For Deborah, her inability to face the fact that she was giving in to her false self (not following her conscience), not having the tools to change her approach to problems and her anger were compelling reasons to escape. This insight is the first small push forward to change her life. Using this knowledge she began to assert herself in an atmosphere of support from friends and family.

My advice to her in late November was to use her excellent organizational skills to create a new “life agenda.” Deborah’s agenda included spending more time with her family, losing weight, exercising, singing, helping her sons with their homework, practising her bass guitar every day, participating in theatre, photography, developing an outreach program to help adolescents in rural area high schools, and buying a motorcycle.

By Dec. 4, she stopped her daytime smoking. She returned with a prepared calendar of events that included her goals, family activities and a cannabis cessation date of Dec. 19.

Upon her return on Jan. 9, she was smoking one joint every four to five days instead of the usual 16 to 40: remarkable progress. She was spending more time with her sister, mother, children and friends. Her urge to smoke was waning. Indeed smoking was no longer a pleasurable experience. Other, more meaningful, humanizing activities were soul-cleansing. Indeed, Deborah said, “I thought I was happy when I smoked, but the difference is night and day.”

Sometimes you have to take that first difficult step by brute force of will. No one else can do this for you. Counselling and psychotherapy have their place, but ultimately the agent for change comes from within. There are no magic answers, only support, dignity and honour to guide us all. Deborah returns next month for a follow-up visit.

Life continues.

© Dr. Barry Dworkin 2004

How do you get herpes?

Dr. Barry Dworkin — Wed, 26 Mar 2003 04:27:39 +0000

Originally published in The Ottawa Citizen March 25, 2003
Original Title: What teens want to know: Real Questions, Real Answers

How have society’s changing attitudes about sexual activity and responsibility affected our teenage children?

The Medical Institute for Sexual Health, a U.S. non-profit group promoting sexual abstinence outside marriage, lists the devastating toll laissez-faire attitudes have had on our teens.

Its data are supported by similar reports by the U.S. Centers for Disease Control.

The medical institute raises concerns that providing sexual health information without moral context and consequence is harming our children.

The institute’s review of the data indicates that our children’s emotional and physical health is at risk.

Half of all 13- to 17-year-olds will become sexually active. Twenty-five per cent of all sexually active teens have a sexually transmitted disease.

Over 20 years, the prevalence (number of existing cases in a given population) of genital herpes in children 12 to 19 years old increased by 500 per cent. Chlamydia, a leading cause of infertility in women, occurs in one in 10 teenage girls, half of all cases in 15- to 19-year-olds. Human papilloma virus, a leading cause of cervical cancer, is reaching epidemic levels in the teen and young adult age group. Teenage girls with the virus are more susceptible to cervical cell changes that lead to cancer, compared with adult women.

Oral sex is a means for some girls to maintain they are virgins. Many do not see oral sex as being sexually active. Many teens do not even have a definition of what “sexually active” means.

As many as one in five of our teenagers are clinically depressed. Suicides have increased threefold in 30 years.

After nine years of giving health clinics at Canterbury High School, thousands of patient visits and hundreds of handwritten anonymous questions answered during classroom visits, these reports and statistics lead me to accept them for what they are: the truth.

Before writing me off as alarmist, please read what your children have had to say:

Grade 9

“What happens if when you’re having oral sex, you swallow sperm?

“If a girl swallows my sperm, will she be pregnant?”

“How is abortion performed?”

“What is the average of females being raped and beaten in the ages 14 to 16?”

“How does Viagra work?”

“As a male, if I impregnate a girl, what are my obligations?”

“Can you get pregnant without having sex?”

“My friend used to have a boyfriend who hit her and treated her like crap. He even used to use her for sex. Now he wants to get back together with her and she hasn’t made up her mind. As a best friend, what should I say to her to make the right decision without hurting our friendship?”

“Do males have to ejaculate or is it something they choose to do?”

“Can you arrange an abortion without our parents knowing?”

“Can a girl get pregnant if a guy ejaculates in a pool and she is near him?”

Grade 10

“Are there any risks for girls under 14 years other than pregnancy and STDs?”

“If you have intercourse with someone who has an STD, are you guaranteed to get the STD?”

“What is herpes? How can you get it? And how do you get rid of it?”

“My friend might be pregnant but she doesn’t want to have it. She doesn’t want to go to the doctor. She wants her friend to punch her in the stomach to kill the baby. I don’t think it’s right. What can I do to convince her to not do this?”

“Does the size of a man’s penis affect his personality?”

Grade 11

“Would it be safer to have sex now while we are younger, considering that the number of people who have AIDS is rising very quickly?”

“Is it illegal for a 15-year-old girl to be having sex with a 20-year-old guy? What if she’s 16?”

“Can you have an abortion when you are 16 without letting your parents know?”

“I just can’t handle it with the workload any more. I’ve had it trying to balance out school, homework, work, sports, friends and a boyfriend and especially parents. I’ve gotten to the point of nervous breakdown. I don’t sleep, hardly eat. I feel helpless. What can I do? P.S. What is hepatitis B and how do you catch it?”

These questions cut across all socio-economic and cultural strata. We must face this growing trend. We cannot ignore what is happening to our children. Many parents come into my office gravely concerned about their teen’s behaviour.

Teenagers, despite their protestations and efforts to act as adults, need guidance and support to become mature, caring adults.

The guidance centres on responsibility, respect, sexual behaviour and following the rules of the house.

Many parents try to be their children’s friend. The idea is the child will be more likely to accept you into their life. Parents hope they will have more influence on their child’s life decisions and actions.

This strategy, well-meaning and caring as it is, will not stand the test of time.

Friends do not tell friends when to go to bed. At some point, circumstances will dictate that parents will have to switch hats from friend to parent. Viva la revolucion!

Despite their challenges to your authority, teens do need their parents to be a foundation for morals, limits, rules, understanding and love, regardless of what the teens might say or do. Too many feel adrift in a sea of confusion. They need to know they can return safely to port.

As the questions above show, what possible benefit is it to a 15-year-old to have to worry about whether their boyfriend or girlfriend is cheating on them?

Why should they have to deal with the complications inherent in a sexual relationship on top of their educational, social and family responsibilities?

Why should they have to come into the office freaking out over whether they are pregnant or have an STD? Why are they worried about the effects of swallowing sperm? What can parents do? Quite a bit, but it is not an easy road.

Tomorrow night, Dr. Joanne Tannenbaum and I will present at the Citizen conference centre a forum for parents and teens called “What your teens want to know: Real answers to real questions.”

——————————————————————————–

Tomorrow’s column will look at teens and drugs.

Dr. Barry Dworkin is a family physician and an assistant professor of family medicine at the University of Ottawa.drbdworkin@hotmail.com

Read previous columns at members.rogers.com/barrydworkin/

Web Sites:

Medical Institute for Sexual Health: www.medinstitute.org

Centers for Disease Control: www.cdc.gov/nchstp/od/news/RevBrochure1pdf.htm

National Mental Health Association: www.nmha.org/infoctr/factsheets/24.cfm

Teen Sex: What You Need to Know

Saturday: The demise of dating: Why school kids have ‘buddysex.’

Sunday: In their own words: Students talk about hooking up.

Monday: In search of guidance: Health educators try to guide students through the morass and attempt to curb date rape by teaching the dangers of mixing alcohol and sex.

Today: Sex ed: What are they teaching our kids in elementary and high school? And Dr. Barry Dworkin on what teens really want to know about sex.

Tomorrow: High-school confidential: the Canterbury health clinic. And Dr. Barry Dworkin on kids and drugs.

Thursday: A look at what parents and teens have to say in Wednesday night’s public forum. And Dr. Barry Dworkin on the angst teens are dealing with on the subject of sex.

Friday: The consequences of the hooking-up culture: Where will society and divorce rates be in 20 years if we continue in this direction. And a reality check — teens are not the libertines they are portrayed as.

Public Forum on the Culture of Teen Sex

Parents, teens and others interested in the culture of ‘hooking up’ are invited to a Citizen-sponsored public forum held by Drs. Barry Dworkin and Joanne Tannenbaum, tomorrow at 6 p.m., at 1101 Baxter Rd. Register by e-mail at dworkinforum@thecitizen.canwest.com or by phone at 596-3664. Please include your name, phone number, and the number of people who plan to attend.

What teens want to know

Dr. Barry Dworkin — Tue, 23 Apr 2002 16:35:22 +0000

Originally published in The Medical Post, VOLUME 38, NO. 16, April 23, 2002

School children tend to set the agenda when it comes to what health info they want

Despite numerous health advisory and information campaigns, inroads into curbing or modifying deleterious adolescent behaviours remain wanting. There are many reasons, including competition from television and movies, advertising, peer pressure, academic responsibilities, development of independent attitudes and rebelliousness, and their own social calendar

The messages and ideas we try to impart to them are lost in information overload. It is not that they don’t want access to accurate and practical health information—they certainly do. The problem is fitting it into their day.

If, as physicians, we are to influence adolescent health, it must start from the ground floor. We have to go to their schools and engage them in classroom discussions. In my nine years of classroom visits at Canterbury High School in Ottawa, I am consistently surprised by what the students want to know. Each class has its own focus and interests. This is yet another reason why single-message ad campaigns fail. They miss a great number of their intended audience.

Health information tends to be broadcast with a sense of urgency: “If the kids don’t hear this now we will have lost our chance.” Classroom visits of an hour per week throughout the school year will deliver all these health messages, but it will be the students who set the tempo and discussion topics. Ceding this control to them makes them responsible for their health concerns and respects their interests. They always listen to what is being said. Their questions are relevant. They also force us to evaluate our own biases.

The students’ questions vary by grade. Each class can have a different area of interest that can include health and fitness, diet, STDs, contraception, abortion, depression, eating disorders, musculoskeletal complaints, cancer, smoking and drug abuse among others. Obviously it requires more than one visit to cover these topics in any detail. It also requires a consistent presence in the school. Students talk to each other. They will know who you are and, if they like you, you will have a greater chance of success getting the message out.

In the course of one Grade 10 classroom visit, I was asked the following anonymously written questions (verbatim):

• Every woman in my family has been depressed at one point or another. My mother warns me about it. Is there anything I can do not to get it?
• What is the average penis size? What is the biggest? How long when erect? What is shrinkage?
• Is breathing helium bad for you and why?
• How can I gain weight? I eat at least twice what normal people eat and weight-gain shakes and still never gain an ounce. If I occasionally miss a meal I tend to lose a lot of weight.
• Why do some men go balder faster than others?
• Can you have an abortion when you are 16 without letting your parents know?
• Why do people shy away from people with disabilities or physical disadvantages or limits?
• I’ve heard smoking pot does not harm you because it is a natural drug and all that is harmful is the smoke. Is this true?
• What are the long-term effects of LSD?
• I keep telling my doctor I am depressed a lot but she just tells me it’s a phase. I don’t think it is. What should I do?
• My joints crack and snap (painfully) all the time. Is this something I should have looked at?
• Is there any proof steroids cause cancer?
• Why is it that the Olympic federation includes such things as Aspirin and cold or cough suppressants on their banned substances list?
• I get excessively angry and violent at times. When I feel this way I feel like hurting or destroying someone or something. Is there something wrong with me?
• What is the best diet to be on?
• What is worse, smoking cigarettes or grass? If cigarettes are so bad for you why are they legal?

If anything, these questions keep us on our toes. They are all answered in class. A common followup from the students is asking about the rationale for our drug laws given alcohol and cigarettes cause most of the morbidity and mortality compared to recreational drugs.

I think the millions spent on ad campaigns could be put to better use establishing permanent teams of physicians and nurses in all our high schools. School-based clinics complement classroom visits and provide a good followup for students who have expressed concerns through questions. A contract for trust grows and the students will seek us out for medical services. It is also one of the more enjoyable aspects of family medicine.

Up in smoke

Dr. Barry Dworkin — Tue, 22 Jan 2002 16:33:31 +0000

Originally published in The Medical Post, VOLUME 38, NO. 3, January 22, 2002

Throw away those old truisms about cigarettes. Here are some new ways to talk to teens about smoking

Our governments spend millions of dollars a year to combat the scourge of teen smoking. Many “hip” public health campaigns have been tried with limited success.

There seems to be no magic formula to tap into the psyche of teens that would reduce the incidence of smoking. The dilemma is that, in our zeal, we may come across as patronizing. Teenagers are in the process of developing their sense of self. They strive for independence, yet conform to their peer group.

The ability to project future consequences is not firmly established in all 15-year-olds. Telling them they will develop heart disease and lung cancer doesn’t cut it. They cannot conceive of these eventsn and ignore the message. If the message is ridiculed by the peer group, the game is over.

What other approaches can be used for this problem? During our classroom visits many students ask about smoking. The questions cover primary health issues to comparative risks between cigarettes and marijuana. Repeating the same old truisms about cigarettes, although factual, does nothing to further the debate.

Fifteen-year-olds tend to be idealistic. Issues such as social justice are seen as black or white, fair or unjust. They want to be independent and to be treated as adults. Using several hypothetical scenarios, we approach smoking from a different angle.

One scenario takes place at 2 a.m.: “You are out of cigarettes. A winter storm rages outside. Do you go to bed or make a dash for the corner store?” We ask the class if they know of any friends who would venture out into the storm. There are always a few nods and hands raised in response.

A discussion ensues about what constitutes reasonable behaviour. Do they think this robs them of their independence? To further emphasize the point we recount an event that occurred in Italy about five years ago. Italy had a dockworkers’ strike that cut off cigarette imports. A cigarette shortage ensued. Smokers from all walks of life were in desperate straits. They began hunting for cigarette butts on the street and yanking the cigarettes out of the mouths of passersby.

We explain independent people would not behave in this manner. Their actions are being directed by their addiction to nicotine. Further, they are paying for the privilege for this loss of independence.

The smokers in the class are asked how they behave if they run out of cigarettes. Do they get irritable? Have difficulty concentrating? Snap at their friends and family? We submit to them the following:
• They are not in control of themselves, the drug is.
• They risk not becoming fully independent. The cigarette companies bank on this and could not be more thankful.
• The cigarette companies benefit at their expense. They have ensnared them, possibly for life, robbing them of their independence, health and money.

Many students have younger siblings. When we ask them, all say the image of their eight-year-old brother or sister smoking is abhorrent. They respond with the same message we give them: That it’s bad for their health. I am always amazed by this compartmentalized thinking.

We bring up reports that cigarette companies have exported millions of dollars of free cigarettes to developing nations. Since the North American market is shrinking, they seek to increase their markets in these countries. Cigarettes ultimately fall into the hands of young children. Addicted, they become lifelong smokers.

Given that the students have already voiced their complete disapproval of childhood smoking, they are now faced with a dilemma. This is a black-and-white issue. Should they continue to smoke, they will be supporting the cigarette companies’ endeavour to find new smokers, usually children in Third World countries. In fact, they will be no better than these companies because they become a contributing member of this system.

They have been presented with a problem requiring an adult decision. Does their sense of social justice overcome their desire to continue smoking? Do they quit smoking and stand up for their principles or partake in hypocrisy? Are they independent enough to follow through on their convictions? Health concerns are not important in this instance. It becomes a moral issue.

We leave them with these thoughts to mull over. This planted seed is effective. They can never erase the images nor run away from their own conscience. They become responsible for their actions with all its social implications.

This information is presented to them at their request. I have outlined our approach in a format that might seem like a lecture in the interest of clarity. However, it is the students who set the agenda. Responding to their questions and concerns creates a more receptive environment. This technique can be applied to many situations. You will have their rapt attention. That is a start.

Like, do you know where your teen is?

Dr. Barry Dworkin — Sat, 21 Jul 2001 04:29:25 +0000

Originally published in The Ottawa Citizen July 20, 2001

You are in a line for a movie and you pass gas or do some other embarrassing activity. Your first reaction usually is “Oh my god, they all know I did it!” This is a remnant of your teen years. Teens are naturally self- centered and experience that reaction you had about ten times more intensely sometimes on a daily basis. Despite the teen horror stories, most adolescents cope well with their development process.

Eight years ago, I, along with Dr. Peter Côté, established at Canterbury High School the first school based full service medical center in Canada. It was incorporated into the family medicine teaching program at the University of Ottawa providing to residents the opportunity to learn about adolescent issues.

It is also important for parents to have an introduction to adolescent development. In order to understand the dynamics and interactions between adolescents and their parents a brief general description of the three stages of adolescence is in order. These are not hard and fast rules becuase children develop at different rates.

The early stage (girls 11 to 13, boys 12 to 14 years of age) focuses upon the rapid physical changes of puberty. They are concerned about their body image and sexual changes in comparison to others their age. They have to adapt to new school environments and the social structures. Their dependence upon their parents conflicts with their desire to be independent. A battle rages within them between the safety of childhood and the need to enter the new adolescent world. Many times I have heard a parent lament that “Steve used to go out with us on family outings but now he wants to spend time with his friends. He can be like his old self at times and then be just impossible to deal with!”

In the middle stage (girls 13 to 16, boys 14-17), there is a consolidation of body image and sexual identity. The school environment is comfortable. Peer groups become their new family and safe haven. They are a form of tribalism with all its rituals, markings and lingo. Peer pressure becomes the dominant behavioral influence. In the quest for independence they test their limits and compare themselves to their friends. Paradoxically, they conform to their peer group in order to feel more independent.

In the late stage (17 to independence) there is a crystallization of identity. Career choices and their future plans become important. After graduation high school friends head off in their own direction. The need to associate with peer groups diminishes and they seek more intimate one-on-one relationships. They leave the tribe and come back to their family for guidance and help.

The natural instinct for parents is to protect their children from harm. When a child is ill we tend to their needs. This normal parental response can interfere with a child’s foray through adolescence. They can stall at one of the three stages. Parents need to be mindful and encourage their child through this process as much as the situation allows. Completion of these stages is essential for normal social development. Alcoholism and drug abuse can forestall successful passage into adulthood.

Prior to the age of 16, teens live in the here and now. In general, areas of the brain that are responsible for abstract reasoning have not yet fully developed. They have difficulty understanding the consequences of their actions with risk taking behavior becoming more common. This can be bewildering for parents.

Teens are masters of body language. If they perceive through your body language that you are not listening to them they will tune you out. Look directly at them when communicating even if they do not reciprocate. It may seem that they ignore your words but in reality they do hear everything you say. Use metaphors when explaining your point of view. They do not use the word “like” for nothing!

So what to do? Our children must inevitably break away from us. The challenge is to maintain a good relationship and avoiding festering conflicts. Teens need and want limits with well-defined consistent positive and negative consequences. Without these limits they are adrift without direction. They usually test your rules. But rules that are reasonable, age-appropriate, fair and consistently enforced have the best chance of guiding your teen through these times. They build upon this foundation on their path to adulthood.

Trust and confidentiality are of paramount importance. Adolescents are concerned that their family doctor will talk to their parents about their problems. Rightly or wrongly, that is their perception. Teens need to know that this will not happen unless their life is in danger or they are suicidal. Our experience at Canterbury has been that although behaviours are difficult to change, you can minimize the potential of a bad outcome. Talk to your doctor with your teen as an equal participant about confidentiality issues. It can provide your teen with another safe place to go for help. Adolescents will continue to obtain care and health information in a haphazard manner through different walk-in clinics, the ER, their friends, or not at all if we do not give them better options.

End of days, beginning of life

Dr. Barry Dworkin — Tue, 17 Jul 2001 22:19:43 +0000

Originally published in The Ottawa Citizen July 17, 2001

Mr. H., a World War II veteran was posted 24 times in 27 years while serving in the Canadian Armed Forces. He is proud of his accomplishments and his actions demonstrate quiet dignity and honor. He has told me stories of his military life. Stories about sacrifice, dedication, honor and integrity that children, not to mention some adults should hear. Now, at age 78 I have told him he has inoperable kidney cancer because it has spread to his lungs. He would not survive the operation.

We talk openly about palliative care and his funeral arrangements. He discusses it in a matter of fact way. He has prepared himself and set his affairs in order. His eyes betray great sadness and fear. He is a man without a family. He never married. His friends are gone. He is alone. He talks to my patients in the waiting room. One patient asks me if he is okay. He is “such a sweet man” she says, “but he looks so lost and alone.”

As he limps into my office, cane in hand, I wish I could change his future. The unfairness of life once again is cruelly played out upon those who have sacrificed the most. This man helped protect our country. And he is already forgotten. His wish is to die in a veteran’s hospital. This is arranged but he hopes they can accept him in time with the waiting lists such as they are. His pain is noticeably worse but he refuses pain relief for now. My nurses and I offer him whatever help he needs. Despite the rationing of care now-a-days, he is grateful for what he has received. This man deserves better but he would never say so.

Last March at the Ottawa General Hospital, I had the privilege of meeting Mr. R., a strong, independent fifty six year old man admitted to our family medicine service. Five weeks earlier he was on a “trip of a lifetime” cruise with his wife. After the trip he went to see his doctor because of fatigue. Two weeks later he was hospitalized for liver failure due to spreading cancer. His family was devastated. There was no warning, no time to prepare themselves. His liver could not produce the protein his body needed to keep water in his blood vessels. Everyday fluid would leak into his abdomen, legs, hands and lungs. He would always be thirsty. But the more water he drank, the more bloated he would become. Each day his lungs would fill up just a little bit more with fluid. His breathing became more labored, his skin more yellowed. Toxins that normally would be neutralized accumulated in his body.

He was a man losing control of his life, a completely new and frightening experience for him. Yet, he wanted to be in control to the very end. He wanted to know how he was going to die. He asked the dreaded question, “How much time do I have?” The residents and I answered all his questions. He had about 2 to 6 weeks to live. We were determined that he would die with honor and dignity. We talked about pain control and that he should be comfortable. His family wanted a private room so they could personalize it for him. We shook hands. When we left the room one of the residents burst into tears. I cannot imagine someone I hardly know telling me I am about to die a horrible death in front of my family.

He resigned himself to his fate. Instead of withdrawing he spent the rest of his days telling his family how much he loved them and how proud he was of his children. His family remained with him. Seven days later he died. His family was with him until the end.

I am truly privileged to have met these courageous and selfless men. Facing the ultimate fear they demonstrate the strength of the human spirit. One alone and in silence, the other more concerned for the well being of his wife and children and dying in the loving embrace of his family. At the end of one’s days all that one has is dignity, honor and respect. I have seen many throw their souls away for the most trivial of reasons. My fear of the slow decline of these societal values is somewhat eased when I meet people such as Mr. H and Mr. R.

Right after seeing Mr. H., a beautiful sweet 2 year old girl comes into the office with her mother who is expecting her second child. The girl has that high-pitched voice that just melts your heart. I balance her upon my knee so she can hold the Doppler to her mother’s abdomen to hear the baby’s heart beat. She is so happy. Her world is wondrous.

From life to death, from innocence to life’s final destiny and all the experiences in-between— all in one day. Teach your children well.

Trust, teens and the family doc

Dr. Barry Dworkin — Tue, 17 Oct 2000 16:32:16 +0000

Originally published in The Medical Post, VOLUME 36, NO. 35, October 17, 2000

Eight years ago, two Ottawa doctors went back to high school to start the first in-school medical centre of its kind in Canada

Adolescents are an under-serviced population — and there are several factors that contribute to this phenomenon.

The most trusted source of information among teens is their friends; next, the Internet; finally, an adult such as a guidance counsellor, teacher or parent. Most adolescents have a family doctor but few feel comfortable speaking with that doctor about their most important health concerns (more on this later). While adolescent health care is one of the areas identified by the College of Family Physicians of Canada where residents require more training, the realities of budget cuts have led to a low level of prioritization for this discipline. Adolescents will continue to obtain care in a haphazard manner through different walk-in clinics, the ER, their friends, or not at all if we do not give them better options.

As physicians there is a tendency to be less comfortable when dealing with the sensitive issues of our adolescent patients. How does one approach the adolescent patient? How do we prepare ourselves to talk to a 13-year-old versus a 16-year-old? How do we sit in our chair? Do we take notes while they are speaking? Do we glance at our watches? Although these questions may seem superfluous, they embody an approach that can contribute to either a strong or weak doctor-patient relationship.

The information I will present is based upon eight years of experience running the only full-service high school medical clinic in Canada. Eight years ago, Dr. Peter Cote and I established a high school-based medical centre that was incorporated into the family medicine program at the University of Ottawa, Elisabeth Bruyere campus. It provides residents with the opportunity to deal with adolescent issues on the students’ own turf.

Canterbury High School is an arts and science school with 1,200 students from around Ottawa. The male/female ratio is 30/70. The program there includes the medical centre and classroom visits. The hours of operation are Monday afternoons and Thursday mornings for 2.5 hours and three hours respectively.

Classroom visits are scheduled on Monday afternoons. Students are given the opportunity to ask questions written on slips of paper. Anonymity is preserved. Most questions are answered, but we usually run out of time. The visits give us more exposure to the students and increase their level of comfort with us. In fact, one of the first questions we ask the class is how many have their own family doctor. Most will raise their hands. The followup question is: “How many of you feel completely comfortable talking to your doctor about any subject?” Few if any hands remain raised. This response is universal for the hundreds of classes we have attended. This lack of trust is one of the greatest obstacles to providing effective preventive care.

The classroom visits invariably attract the students to the medical centre. We have become a recognizable fixture at the school. Students can come to the clinic with their friends for support. They have brought friends who have been in crisis. Even though we are not employed by the school board, we interact with teachers and guidance counsellors who bring their concerns about particular students. Clearly, teachers are already strained for time and classroom sizes are increasing. This year, there will be 2.5 guidance counsellors for 1,200 students at Canterbury. Underfunding of the education system is similar to underfunding of the health-care system. Health or social problems cannot easily be noticed and dealt with as early as possible. The overall cost to society is greatly increased as a result of our ignorance.

Trust and confidentiality are of paramount importance. This is the challenge of adolescent medicine. Adolescents are concerned their family doctor will speak with their parents about their problems. Right or wrong, that is their consistent impression. We need to develop a means to reverse this trend.

In future articles I will focus on the formula we have used to make our centre a success, our experiences with the clinic, case histories, the issues brought forth by the family medicine residents, and the moral and ethical dilemmas encountered at the centre. We have compiled and collected all the questions asked over the eight years. I will present them to you with our responses. Stay tuned.

The hidden patient

Dr. Barry Dworkin — Tue, 08 Aug 2000 16:26:02 +0000

Originally published in The Medical Post, VOLUME 36, NO. 27, August 8, 2000

In June, my dad was hospitalized for some surgery. He related the following story to me: My dad walked the ward after his surgery whence he came upon an elderly woman near the nurse’s station.

She appeared frail and had several scars upon her scalp suggestive of old cranial surgery. Tied to her wheelchair by a drape of bed sheeting, he noticed that her right hand was moving.

At first he thought these hand movements were involuntary, and yet something did not seem right. He asked the nurses about her but was told that she was demented and was not aware of her surroundings.

During this brief conversation he noticed that her hand twitching was more deliberate. Not a man to accept incongruous answers to observations that demanded a better explanation, he did what any man of science would do, he tested his hypothesis. He approached her and took hold of her hand. He instructed her that if she understood his questions to squeeze his hand once for “no” and twice for “yes.”

“Do you understand what I have said?” Two squeezes.

“Can you hear me?” Two squeezes.

“Do you like your doctor?” One squeeze.

“Do you want to sue your doctor?” Two squeezes. (My dad is also a joker.)

He saw her eyes light up after this brief contact. He returned to the nurse’s station and demanded her doctor be called to the floor at once.

After a short spat of curt banter the nurse acquiesced and the doctor did indeed present himself. My dad related his observations to the doctor.

The doctor was skeptical and responded that she indeed was demented. My dad asked him to take her hand and to repeat what he had done but asking her different questions.

Again, she responded coherently to each question. My dad noticed that the doctor went pale and had a look of horror upon his face. He immediately transferred her to the rehabilitation unit.

My father felt on top of the world after that incident. He saved a woman from a life of hell; locked inside her body yet fully cognizant of her surroundings and with no one hearing her scream for help.

We, as physicians, can sometimes assume too much.

We have all committed this error to varying degrees during our careers. I think we all need a good reminder every so often about how we can affect someone’s life for good or for bad.

At times we can be so overwhelmed by our workloads and responsibilities that our empathy suffers.

Trying to provide so much to so many in so little time in our rush to keep up, we lose a part of ourselves that made us become doctors in the first place. At times we base decisions upon preconceptions.

My father experienced such joy that it brought him to tears. All of us should keep that feeling close to our hearts.

We cannot cure everyone but we can still make a difference to people if we take the time to listen. My father’s simple act of taking someone’s hand changed their life.

My father is not a scientist. He has never taken a science course. He sold insurance, drove a taxi, owned a grocery store and is an excellent butcher.

He has had to communicate well in all his endeavors. He notices people. We ask ourselves and are asked at times where we learn to be a good doctor.

I can proudly say I am my father’s son.