Sunday, January 06, 2008

Sub-Internship

I'm post-call from the first call I've taken since May. God, I love being a fourth year med student. I'm post-call, but it was a really easy call--I only admitted one patient and so got to sleep several hours last night. I may be the "acting intern", but I'm still a med student, which means one important difference: the pager. Yes, I carry a pager, but no one actually pages me on it; nurses don't have the number, and my residents just don't bother (I usually try to stick around the resident or the intern in case there's work to do). Since the floor doesn't have my number, they always page the intern, Jersey Girl, when there's an issue, even on my patients. Sure, I could write out my pager number on everything I write, but I doubt anyone would bother to page me, since it says "MS-IV" next to my name. Fine by me! Therefore, I've decided that "acting internship" is still nothing like actual internship, because it would be hard to give a student the kind of scutwork an intern gets, and because I do get some autonomy with my patients, but as I'm not a pediatrician I rely on my residents heavily. I'm definitely stuck in the middle, a gray area between the MS-III's and the residents, but at least it's a pleasant shade of gray.

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After a patient encounter of significance last night, I came home to find this running debate between Graham at Over!My!Med!Body! and Panda Bear, MD about social justice vs. free-loaders. It was particularly apropos, because I've been pondering what I think the right answer is in this situation:

Mother brings her 15-month-old toddler to clinic for a weight check. His weight continues to be well below the 5th percentile, so he is admitted from clinic to the hospital with a diagnosis of "failure to thrive". A lengthy series of lab tests is ordered: blood counts, celiac disease autoantibodies, stool studies, calorie counts, etc. We ordered all these tests even though we knew why this kid was so thin. During the history, mom gave a constantly changing account of how when she/her dying mother/her 6-year-old son would feed the child, he didn't really take solid foods. She also said the family's only sources of income are food stamps and WIC, which must feed herself and three children; citing "health problems", mom said she left the children with their grandmother 4 days a week, but couldn't really tell us where she herself went on those days. We observed the child eating solids, and he was a finicky eater--as is fairly normal at 15 months of age. As my attending put it, "this is the age where they throw the food on the floor--someone has to sit there and feed the kid and it can take 30 minutes at a time."

We knew why this kid was so thin: nobody was feeding him. Sure, someone throws him a bottle from time to time, but no one is sitting down and feeding this child good foods--meats, vegetables, breads, etc. How well do you think a 6-year-old boy can feed a toddler? (The answer is: not very.) In this case, it's an issue of time and money. Mom doesn't have time to make sure the kid is properly fed (which takes more work at 15 months than as a newborn), nor does she have the money to make sure the kid gets good food. Between Medicaid, WIC, and food stamps, this family is living entirely off the government (mom denies any welfare benefits). Apparently, that wasn't enough, and that's how a 15-month-old is the size of a 6-month-old.

My dilemma is this: what do we do? What do we do for the children of those parents who won't do for them? This kid isn't quite neglected enough to call CPS, and even if we called CPS there's no guarantee they'd intervene. On a national scale, how often does this happen? Pretty often, apparently: eMedicine estimates the prevalence at up to 10% of kids in primary care. In the United States, "non-organic" failure to thrive, aka kid doesn't eat enough without a truly physical problem, is more common; we do the workup for organic causes because they'd be devastating if they continued, but more often than not the kid isn't eating enough. Another common cause of FTT is "over-mixing": mom can't afford formula, so she mixes it half as strong as it says to. Eventually the kid will get skinny and/or have seizures from hyponatremia if this continues. Sometimes, the food stamps aren't enough, and the family runs out of food by the end of the month.

What do we do? What should we do? Should we do anything?

If we do nothing, and say that her kid is her responsibility, what happens to that kid? The kind of poverty I'm describing can only lead to further insults to the child: crappy schools, crappy neighborhood, possibly with drugs, etc. I'm stereotyping/over-generalizing on purpose, but the kind of poverty that won't allow a small child enough food to eat tends to be associated with other things that promote a poor outcome. The more obstacles we stack in front of this kid, the harder it will be for this kid to become anything but another burden to the system.

But are we responsible for her kid? How do we intervene? I'm pretty sure this mom is going to give this baby as much food as she can now, as well as high-calorie supplement, but what happens to the older kids? Is food really so tight in this house? It can happen that feeding all the high-calorie foods to the baby takes them away from the older kids. What do we do when food stamps and WIC aren't enough?

Panda tends to see most of these moms as system-abusing freeloaders, the ones who will never work because the government keeps them just well-fed enough so that they can go out and support their crack habit and have carloads of welfare babies. Graham tends to sympathize with the poor, and sees (most of) them as hard-working, too busy to even get healthcare. Sure, the truth is somewhere in between. Is it worth feeding these children if it encourages mom to go have more children she can't support because she doesn't work? If we don't feed them, will she have more babies anyway, and will their blood be on our hands?

I'm emotionally involved here, because I love children and I personally think that if we give our children better early nutrition, education, and healthcare, there is evidence that this promotes better outcomes. I also think that our society in general will benefit from having more children nurtured in this way. 7 years ago, if you'd asked me this same question, I'd have answered very differently. People are responsible for themselves, and I'm not responsible for them; if she wants to raise her kids to be beholden to the government for survival that's her problem (although I didn't think the government should be involved at all).

What changed for me? I saw more working poor people; the kind who do grueling work 80+ hours/week to put food on the table. I saw the effects of neglect and malnutrition on innocent children, in one of the world's wealthiest countries. I did become more liberal as I saw more in medicine. Some of my classmates have become more liberal with me; others have become more conservative, as they encounter more of the "welfare queen" type patients, or those who use food stamps so their income goes to their drug habit, or the Medicaid recipient who is an ER frequent flier because "it's free." I see those things, and they annoy me, but I guess I'm more of an "err on the side of caution" type. Better to feed the kids of the crack whore than to allow the kids to starve.

Fortunately, in our kid's case, the mom really is concerned for her baby; she keeps her pedi clinic appointments and tries to follow instructions. She was neglectful, but I think after all the education (and a little tough love) we've given her, she'll improve. The kid seems okay developmentally, so hopefully we've caught this in time. Even good parents make mistakes, after all, and even bad parents have redeeming qualities.

But I'm stuck in a gray area here, too. I'm too liberal to be a Republican and too conservative to be a Democrat (although I'm probably left of center). I want this mom to take responsibility for herself and her kids, "pull herself up by her bootstraps", but at the same time I don't want her kids to suffer for her mistakes. What to do, what to do.

This is some awfully deep thinking for post-call, no? Too bad I didn't reach any actual conclusions. I guess I'm better at identifying problems than reaching solutions, which in the long run is not terribly helpful. Oh well, what the hell.

1 comment:

The MSILF said...

I did become more liberal as I saw more in medicine. Some of my classmates have become more liberal with me; others have become more conservative

Heh, funnily enough, medical school and seeing the real freeloaders pushed me toward more conservative! It is like some randomized experiment - where do your political beliefs come out at the end of medical school.