The Spider Bias

Poor Itsy Bitsy.
Poor Charlotte.
Poor Miss Spider.

All Itsy Bitsy did was climb up the water spout.

Charlotte saved Wilbur's life.

And Miss Spider-- remember her from Roald Dahl's James and the Giant Peach?--she was a kind and gentle soul to poor little James. Miss Spider says it best: "I am not loved at all. . .And yet I do nothing but good. All day long I catch flies and mosquitoes in my webs. I am a decent person. .  It's very unfair the way we spiders are treated."

Human beings' blame game with spiders is one of the strangest and most pervasive cultural biases I have discovered in my role as a family physician. Without evidence. Without a trial. Without a second thought. We believe spiders bite us. All the time. We see them around, we assume they are evil, and we blame them for strange otherwise inexplicable skin eruptions that have nothing to do with them.

http://www.roalddahl.com/roald-dahl/characters/beasts

The story goes something like this: 

Mr. human wakes in the morning with a sore red spot on his body. It may even have some pus. It hurts. He has no idea how it got there. He wants to know. There must be a reason, an identifiable cause. Incidentally, there are spiders in the world. In fact, the human saw one in the last week in his very house. Spiders are known to be evil. They bite. That's it! The spider did it. Case closed. 

This bias is surprisingly widespread. So much so that on any given day in any given emergency room, urgent care, or outpatient clinic in America, you will find someone reaching out for care for a "spider bite" caused by a spider they never saw. 

31 year old, spider bite, R arm (see photo)  
7 year old, spider bite, abdomen (see photo)
56 year old, spider bite L thigh (see photo)
2 year old, spider bite, leg (see photo)

Sometimes the 31-year-old is a drug addict, but he could be a veterinarian. The 7-year-old might have a dog or perhaps a bearded dragon. Sometimes the 56-year-old has had one of these bites before. Out of curiosity and playfulness, my first question for such patients is always "Did you see the spider?" The answer is always no. Did you catch that? No one has ever seen the spider. Occasionally, the "no" is followed by an "Ahem, well, a few weeks ago I did see one. I saw a spider."

Now, put yourself in the place of a spider, just for a second; what it must feel like to be blamed when you weren't even seen in the building since last week? What it must be like to be assumed at fault by an entire nation? This is a classic case of guilty until proven innocent-- and a cultural belief so strongly held that a review of the case (much less a trial) is deemed unnecessary.

Poor spiders!

In my ten years as a  family physician in Northern California, I can definitively tell you that while I have seen plenty of patients who believed they had a spider bite, I have never actually seen a spider bite. Not once. Not a single time. One study in Southern California found that of 144 people seeking care for a spider bite, only 3 had an actual bite (that's a whopping 2%) . 

In my (albeit anecdotal) experience, 100% of presumed spider bites have turned out to be either small pustules or larger abscesses from a cutaneous bacterial infection (i.e. a skin infection). These infections are famously caused by staph aureus, and most often a newer antimicrobial resistant strain called methicillin-resistant staph aureus (aka MRSA). Turns out somewhere upwards of 25-30% of humans have staph aureus living on their skin (sorry if you didn't want to know that), and about 2% of us have MRSA. 

Our skin is our major defense mechanism; it protects us from burns, cuts, and infections. And yet, the barrier is constantly being challenged in both major and minor ways. With relative frequency, we nick ourselves on a piece of paper or with a sharp object and know exactly when it happened, but much more often, we have micro-perforations of our skin barrier-- little nicks that are so small we don't even realize they happened. These micro-perforations make us vulnerable to our own commensal skin flora hanging out on our skin,  thereby turning a mutually neutral existence into a bad relationship. 

Usually, our remarkable skin spontaneously heals itself after such a perforation, and we go along our merry way. But occasionally, when the conditions are right, skin disruption meets staph aureus (or even worse, MRSA), and infection ensues. That means occasionally someone actually did have a bug bite that got infected or a preexisting scratch that turned into an abscess, but more often than not, there was no obvious initiating factor. 

Such infections are no fun-- I have had a few and treated many. They are painful and embarrassing and can make you quite ill. Often, they need antibiotics or drainage (think: scalpel). Recently a perfectly healthy young friend of mine was hospitalized for just such an infection. 

My husband once wisely said to me that people blame spiders for skin infections because it's less scary than knowing the truth-- that is, that our own friendly bacteria are capable of creating what could become a serious infection-- and that it could happen to anyone at any time. It's freaky, he said, to imagine that there isn't something (or someone) else to blame.  Spiders are an easy target. 

What can you do to prevent abscesses and skin infections? Take good care of your skin. Wear gloves when indicated. Wash your hands. Don't scratch. Don't pick. Keep your fingernails short. Keep your skin well hydrated (with a good lotion or cream) and pay attention to any particularly dirty cut or scrape as soon as it happens. Even so, occasionally things will get infected. Soak them (in a basin or with a hot compress) and talk to your doctor if the redness or swelling is worsening.

What else can you do?
An even harder undertaking is to stop blaming the spiders, to start questioning our own biased assumptions, and to practice tolerance. 

As we stumble through this complicated life, overwhelmed with fake news and social media-driven hyperbole, we should reserve blame-- for blame often enough will lead us to be more fearful and less curious.  

We should also continuously ask ourselves if our primary assumption is true.  In fact, it turns out that only about a dozen of the more than 40,000 species of spiders worldwide can actually cause harm to humans; and even the ones we know are bad (e.g. the black widow and the brown recluse) cause less harm than we might think. Just like Miss Spider said, spiders are mostly beneficial to humans by eating many insects that either infest our foods, are disease vectors, or are just plain annoying.

And we should practice tolerance. For being intolerant of spiders does nothing to decrease one's risk of a skin infection but does increase one's anxiety. Practicing tolerance allows us to peacefully coexist with other living creatures-- which sure sounds more pleasant than living in fear. Plus, you never know when you might be grateful to have a spider around. Right, Wilbur?


References:
https://www.ncbi.nlm.nih.gov/pubmed/17877450
https://www.ncbi.nlm.nih.gov/pubmed/21762981
https://arthropodecology.com/2012/02/15/spiders-do-not-bite/
http://spiders.ucr.edu/myth.html
Roald Dahl's James and the Giant Peach
EB White's Charlotte's Web

There are these moments

There are these moments between when a doctor knows something and when a patient does not.

Potential spaces.


And, while for patients, such space may be filled with hope or dread or some combination of the two, the same space means something different for the doctor. After all, it's not my pregnancy or my heart; it's not my father's chest x-ray or my son's leg bone. But it is my patient. And my patients' experiences inevitably become a part of my story. My story fills in every day with all of these unique moments-- the discovery of an unintended pregnancy, the surprising death of a father, the unanticipated complication, the missed lab finding, the remarkable recovery. The good and the bad.

What I say, the look on my face, or the gesture I make may be remembered forever. Especially if I do it wrong. Or even if I don't get it quite right.

Sometimes these potential spaces are wonderful--  the few seconds between when I put an ultrasound probe on an anxious pregnant woman and see the blessed heartbeat and when the words come out "all is well". The pathology report coming across my inbox announcing the mole was not cancerous. The marked improvement in a heart's ejection fraction.

Then there are times I wish I didn't know. Or at least I didn't have to be the one to tell. The times I must walk into a room, sit upon a stool, take a deep breath and deliver the bad news. The life-changers.

Three times this week, five times this month: the cancer in the colon of the woman who'd been losing weight, the non-viable pregnancy in a woman who tried for six years, the brain tumor in the young dad who'd been having headaches, the syndromic features in the baby born just yesterday.

Who am I to do the telling?

I am just a regular human being whose fridge has moldy leftovers and whose car is in desperate need of an oil change. I have children who I get impatient with, toenails that need trimming, and a tendency to be a bit of a know-it-all. But I also went to school for a very long time and have spent many years of my life trying to understand how to distinguish between health and sickness, learning how to communicate the difference effectively, and practicing how to be present with patients through all of it. Some days, I feel unequivocally qualified. Other days, I literally look around and think, "Me? You're trusting me?"

Am I sure?

So often, I am not. And yet patients want me to be. They want me to be sure when I reassure them: "No, don't worry. Yes, you will recover. No, it's not serious." They also want me to be sure when I give bad news. And so do I. I want to be 100%-absolutely-without-a-doubt sure. I want to know as much as I possibly can about this diagnosis or your lab result or this condition I am going to name for you.

Years ago, I told a young man I was confident he did not have cancer; several months later, we discovered, in fact, he did. He died shortly thereafter. I will never forgive myself for my naive certainty. I will never again be as sure as I want to be. But I do my best, my very best, to gather as much information as possible, to be informed, and to be thoughtful. I trust that there is tremendous science behind much of  medicine,and I try to be clear with my patients where the science gets soft and where my knowledge runs out.

All that said, to be perfectly honest, no, I'm never sure.

How much do I say? 

We were taught in medical school that when you deliver bad news, people hear the first few sentences and then shut down. I've seen it, it's true. Their eyes blur, their ears get fuzzy, they literally float away.

And there I sit. On the stool. With more to say.

In each of those moments, as I watch my patient hover overhead, I find myself confused, insecure, and surprisingly unprepared. Do I stop after the first few sentences? Do I leave them to their fuzzy blur? Do I smile? Do I frown? Do I give them the reference? Do I hand them a piece of paper? Do I hand them a tissue? Do I warn them to stay off the Internet? Do I . . ?

There is no one correct answer to any of these questions. For each of us is unique and needs something  different in each of these unique moments. And this is why relationship is so very important-- how, by knowing you, I can provide you with the right amount of answers in the right amount of time.  Too bad relationship is so undervalued. Too bad, too often you have no idea who I am. I just met you seven minutes ago. Too bad you don't know that I, too, struggled with infertility, that I lost a dear cousin to alcoholism, that I want nothing more than to be with you, right now, in this moment (despite my body language stating the opposite). It was for these very moments I became a physician, after all. Yes it was.

A few weeks ago, I supervised a physician in training giving bad news. I had literally never met the patient, and I stood there in the corner, watching the learner do what she will do hundreds of time, perhaps for the very first time. I wondered. Who is this woman? What does she need from us right now? How can we best serve her? Will I ever see her again? One thing I do know, from my experience as a patient and as a physician, she will flash back on this moment forever-- the buzz in the hospital room, the lighting, the words tumbling toward her. She may not remember the faces or the names, but she will surely remember the feeling, the emotion, the tone.

And it's not just her that remembers. It's me too. My big errors are not necessarily the procedural ones (though I have written in the past about some of those). My biggest errors are the human ones. The times I didn't say enough. Or the times I said too much. The time I put my hand on the doorknob before you were done, the times I was human.

What if I want to cry?

Sometimes I do cry. But usually I don't. And I'm not sure if it's professionalism or paternalism or some other -ism that prevents me from doing so. Probably mostly it's just that I am a private crier. 

But also, this moment, this little space in time, really isn't about me-- it's about you. I am merely a blessed witness, a privileged counsel, a space holder. Some higher force put me in this room, in this moment, in this space to be with you and to offer you-- I hope-- exactly what you need. If I cannot, if I did not, I am sorry.

What I can promise is this: when I leave the room, I stuff this moment into my bulging bag of moments, into my disorganized file cabinet of doctoring, and carry it around with me forever. It changes me and challenges me and teaches me and hopefully makes me better the next time I have to do it again.

So, thank you.

For these moments.

Are We at War? The Vaccination vs. Anti-Vaccination Situation

http://www.egmnow.com/platforms/

In light of the current measles outbreak, I'd like to take a moment to reflect on the tremendously divided nature of the vaccine debate (or lack of debate) that exists in our country. It feels eerily similar to the Red vs. Blue State divide that has plagued us now for several decades. In both conflicts, there exists such fear, such misinformation, such geographic isolationism, such supreme sensitivity, and such a lack of communication that we simply stand opposed to one another without any productive conversation. I'm afraid that if we never come together to talk about these things, we'll make no progress.

 And, like many, I'd really like to see progress.

Let me out myself first: I am pro-vaccine. I come to the table with a very strong opinion that vaccination is a good thing. My son is uber-vaccinated-- because we have traveled extensively since he was an infant, he had early vaccines for measles and hepatitis A and is even vaccinated against yellow fever and typhoid. Just this week, he had his kindergarten boosters. I always get the annual flu vaccine, and though I am not convinced the data on pregnant women getting a whooping cough vaccine in the third trimester is that robust, I pulled up my sleeve and ceded to vaccination just last month-- trusting that the risk is minimal. I'm a public health enthusiast.

All this being said, I work intimately with hundreds of families who believe otherwise-- and I don't only work with them, I love them and care for them, and counsel them.

As a family doctor caring for a population who chooses overwhelmingly to make alternative vaccine choices, I often find myself in the uncomfortable place where the two worlds collide. And while I consider myself a  vaccine believer, I also find myself intensely offended by the denigrating tone so many take with people who choose to make the choice NOT to vaccinate. Perhaps it's because I know them personally. And I know that they want what we all want-- what's best for our children. It's just what's "best" may not be so black and white for some as those of us believers want to believe.

I also know that berating parents for the decisions they are making for their children is unlikely to change their minds.

After all, what was your response the last time you were berated?  Did you say, Hey thanks for calling me uneducated and stupid and ignorant. You are soooo right, let me reverse my entire decision-making process and go with yours?

Doubt it.
                                                                         ***

Vaccinators (of which I consider myself one) are those I will call "vaccine believers". That doesn't necessarily mean we believe in God, Santa Claus, or the Republican Party. In fact, a large proportion  is made up of  liberals and skeptics: academics, journalists, returned Peace Corps Volunteers, scientists, and scholarly folk. But vaccinators are a mixed bag: we also include immigrants, the urban poor, and others who either aren't empowered enough to question authority or those who have personally experienced vaccine-preventable disease. Most believers have never read a book or a study about the safety of vaccines-- even the scholarly subset. They don't need to. They take the recommended schedule (available here), follow it like a road map, and trust in the integrity of the institution of medicine and the wisdom of their predecessors. Both instill in them a steadfast trust in the value of vaccines. Perhaps most importantly, believers are descendants of vaccinators. Their perception of risk is reinforced by the community in which they live and by stories of vaccine-preventable illness.They may have traveled to a country where they have seen victims of polio or meningitis. They may be from one of those countries. Or maybe not. They don't harbor suspicion about the morality of governmental recommendations-- in fact, they trust and embrace both the integrity of science and the righteousness of health policy-makers. They do question the morality of people who choose to put communities at risk for their own personal interest.

Anti-vaccinators are those I will call "vaccine atheists".  Again, this designation has nothing to do with religion-- in fact one of the largest outbreaks of measles prior to our current one involved an enclave of orthodox Jews in New York who were choosing not to vaccinate based on religious teachings (see report here). I'm just borrowing recognizable terminology. Where I live, most anti-vaccinators are not particularly religious, though many would call themselves "spiritual". Like believers, atheists are a mixed bag: some are quite educated, others are not. For a range of reasons-- I'm not always sure why-- they do not fear the diseases that vaccines are targeted to prevent. They don't believe in the inherent value of immunization-- and they believe that the potential risks of said vaccines are more likely and more dangerous than the diseases themselves. Just like believers, most vaccine atheists have not extensively read books or studies about the safety of vaccines. They, too, don't really need to. They know vaccines carry risks, and they choose not to chance those risks. Their perception of risk is reinforced by the community in which they live and by isolated reports of horrible outcomes after vaccination. Some specifically fear autism, but for most, the theoretically risks are much more complex. Importantly, most are descendants of non-vaccinators. They look at the CDC recommendations and scoff at the ridiculous number of immunizations recommended. They know that there is always uncertainty in any medical intervention, they wonder what the actual risk is for their child, and they question both the science and the moral integrity of those making official recommendations.

                                                                ***

So, you see, there might be more similarities between the two groups than we might have previously guessed. We are all products of our upbringings. Neither side has read much. Neither can quote validated data. We both dig in our heels and hold our positions. And thus we quickly forget that we share some commonalities-- namely we live on the same planet and maybe even next door to each other, and we should be TALKING to each other.

Here's what I propose we talk about:

1) Fear
Vaccinators fear vaccine-preventable disease. They do not want measles, influenza, meningitis, or polio to be running around our country (and our world) infecting vulnerable children or frail adults. They do not want to return to a place where people die or are disabled from vaccine-preventable illness. Vaccinators also fear that decisions of others not to vaccinate put their children at risk. I get it.

http://wrightliving.com/fear-feel-alive/

Anti-vaccinators fear side effects, preservatives, chemicals, and immune loads. They fear the unknown. And they fear these more than the risk of illnesses that most have never seen. They do not want to expose their children unnecessarily to toxins that may put them at risk. Vaccinators may dismiss these fears-- citing examples of millions of children who have received such toxins without untoward side effects-- but in so doing, they neglect to validate that science is terribly imperfect, that in fact, scientists have frequently historically reversed themselves on interventions once deemed safe and necessary.

Let's talk about what scares us, why it scares us, and see if we can find some common ground. Let's talk about why some are afraid of the diseases and others of the vaccines. Let's see if we can reasonably sort out what we should be afraid of. . .and which fears we can probably set aside.

2) Misinformation
This is the trickiest for me-- as a scientist, doctor, and general book nerd, I love reading the data. My patients will tell you that a most common phrase out of my mouth starts with, "Studies have shown. . .". followed up by some really cool meaningful information that helps back up my recommendation.

http://ninapaley.com/mimiandeunice/2010/09/17/misinformation/

And yet, as I have tried to find good information for my patients on the topic of vaccine safety, I have been terribly unimpressed-- by both sides of the topic. Most of the educational materials the CDC publishes is watered down, does not directly address my patients' specific concerns, and basically ends with "trust us". Now, I do trust the CDC, but not everyone does, and I can understand why. The CDC material often feels dismissive and, frankly, a little bit lacking. That being said, I find that most of the anti-vaccine material is inflationary and based in paranoia and fear rather than compiling what limited information is available. I have ordered at least half a dozen books to read on the topic and been thoroughly unimpressed by most of them.  For my vaccine skeptical families, I find myself recommending "The Vaccine Book" by Dr. Sears, which is imperfect but seems the best marriage of the two-- if you have other recommendations, please do let me know.

Let's talk about where you get your information. I'm curious. Can you please share resources you have found helpful? What about some that are unhelpful? Who do you trust? Why? Why not? What makes information trustworthy? What makes it untrustworthy? How much weight does anecdote carry in your decision making? What about a large population study? What can I do as your fellow human to make information feel more helpful?

http://www.washingtonpost.com/blogs/wonkblog/wp/2015/01/27

3) Geographic isolationism
Just like red versus blue, carnivore versus herbivore, and God versus not-God,  we humans tend to surround ourselves with people who have similar thinking and similar modus operandi. Research shows that differences in vaccine uptake are extremely geographical, which literally means that our neighbors reinforce whatever set of beliefs we tend already to have. When we geographically isolate ourselves, we conveniently reinforce our own beliefs (right or wrong) and protect ourselves from intelligent conversation that might challenge those beliefs. And in this way, we don't encourage ourselves (or our counterparts) to develop intelligible and meaningful responses to real and important questions. For example, why are some people so scared of preservatives in vaccines and others aren't? Why are some people so scared of vaccine-preventable illness and others aren't? Why might someone you love and respect make a totally different decision about something you find morally reprehensible? Shouldn't we know the answers to these most basic questions? . To get answers, though, we have to ask. And to ask, we have to not only come into contact with but also feel safe in the company of those who might think differently than us.

Let's reach across the aisle and be curious (and I mean non-judgey curiously curious) and cross over the line every once in awhile. We might be surprised to find ourselves more educated because of it-- being curious with my patients has certainly led me to read more and understand more what people are afraid of. And my patients being curious about my thoughts has hopefully helped them make informed decisions.

4) Sensitivity
Even in my own social circles, I have found the topic of vaccine choices to be off limits in mixed company-- other than in my exam room where I have some say over what conversations are cultivated. Living in Sonoma County, I am well aware that I am often in mixed vaccine company, and as a mother, I wouldn't touch the topic with a ten foot pole. Immunization in my town is right up there with super stigmatizing topics: how much money your family makes and whether you do crazy things in your bedroom. Rather than friends and family being a safe venue for intelligent conversation, I find that people are so sensitive about their choices (in both directions), that we're afraid to ask. In fact, I was out for coffee with a doctor friend just this week, and he casually inquired about another doctor friend's vaccination views. He knew my perspective and felt safe asking me about me, but had never discussed the issue with her, knowing it could get sensitive fast. This returns me to the important notion that we are so influenced by what is happening in our community, so that even people I might consider vocal vaccinators find themselves silenced. I am supremely aware that I may isolate and offend my patients if I simply try to bulldoze them with personal opinions-- I believe it is my duty as a physician to be sensitive to their vulnerabilities and present the topic in a loving and respectful manner-- even (or maybe especially) when I disagree.

Can we lower our own sensitivity about decisions we make for our families and temper our defensiveness so that we might have meaningful conversations on the topic? What might those conversations look like in a non-judgmental space? Might we find some more middle ground?


5) Lack of communication
Communication, of course, involves all of the above issues already mentioned and so much more. And while I personally feel strongly that my own children be fully vaccinated for their well-being as well as the well-being of our community, I am utterly turned off by the general blasting of non-vaccinators. It simply will not work to scare or judge or berate parents into making different choices. It won't work. This is not a war. This is not really about me versus you. This is an opportunity to engage in meaningful conversation about true risks of real disease and true risks and benefits of vaccine, true fears and true needs of parents to do what is right for their child AND for public health and feel comfortable doing so.

Do me a favor, and cool your jets. Ask someone you know and love but that you assume has a different opinion than you on the vaccine matter to share their reasoning. Listen. Discuss. And then share yours. Then listen some more. You might be surprised about what may come out of such a conversation. You might learn something, you might teach something, and we may all be grateful for the step forward.

Itchy butt, itchy butt please go away.

For those of you who've never had an itchy butt, the concept behind this post may seem funny (as my mother would say, both a little "funny ha ha" and little "funny odd"). But for those of us who have ever suffered from an itchy butt, this is no joke.

Itchy butt is disconcerting, anxiety-producing, and downright miserable.

It is one of those super embarrassing topics-- one of those oh-no-my-doctor-has-her-hand-on-the-doorknob-do-I-really-want-to-mention-this-topics, hanging right up there with discussions about the quality of one's sex life, underarm odor, and nose-picking. It's not something people like to talk about, even with their most intimate partners. It makes people feel dirty, anxious, desperate, undesirable, isolated, even crazy.  But estimates are that somewhere between 1% and 5% of the population suffer from itchy butt. So if you're lucky enough to never have suffered, say your prayers that you don't become the next victim.

I've seen young men certain they have a sexually transmitted disease, old women sure they have cancer, little kids (whose parents, having spent time googling, certain their child has pin worms, which sometimes they do) and everyone in between. It's thought that men outnumber women four to one, with the highest occurrence in the 40-50 year age range, but still common in people ages 30-70.

And-- big personal revelation-- I've suffered myself. It's wretched.

Itchy butt in doctor's speak is termed Pruritis Ani. Pruritis means itchiness; ani is an obvious reference to the anus, the anatomical structure that is the exit door for your bowel movements (or, as is my four-year-old's favorite word, poop). Yes, we have an actual medical term for it-- proof that it's prevalent enough to merit it's own diagnosis.

There are two types of itchy butt: primary/idiopathic (i.e. we have NO idea what causes it) and secondary (i.e. caused by something else). Somewhere between 25-75% of cases are secondary. That's a pretty big range-- a stat that basically means we can find an actual cause in only about half of cases. In the other half, who knows what started it?! An uncertainty leading to more feelings of insanity. That's why so many people have the experience of going to their provider to be seen, finally getting the nerve up to say something, and then feeling let down by the lack of answers. Too often, there are no answers to be had. Sorry.

The most common and obvious cause of itchy butt are hemorrhoids (swollen, inflamed veins in your anal region) and anal fissures (basically scrapes or little cuts in the anus that just have a hard time healing because, well, we all use our anus quite frequently). Hemorrhoids are caused by increased pressure down in your bottom. They are super duper common and often happen when people are constipated, have chronic diarrhea, are pregnant, or overweight. About 50% of the population will have a hemorrhoid by age 50. Ugh. Fissures are pretty common too-- you have an especially big poop or an especially hard one, it causes a little abrasion, and it takes awhile for that to heal.

Other less common causes of itchy butt include:
Skin stuff: allergic dermatitis (e.g. eczema or an allergic reaction to soap, lotion, lubricant, toilet paper) , psoriasis, seborrhea (cradle cap of the bottom), squamous cell cancer
Infectious stuff: fungus (e.g. yeast), parasites (pin worms are common, especially in kids)
Some medications: examples include tetracycline, colchcine, quinidine, local anesthetics, and neomycin
Some systemic illnesses: diabetes, lymphoma, obstructive jaundice, thyroid dysfunction, leukemia, chronic renal failure, and aplastic anemia
Foods: perhaps tomatoes, chocolate, citric fruits, spices, coffee (including both caffeinated and decaffeinated), tea, cola, beer, milk and other dairy products
Psych: anxiety, agitation, and stress
Other: fecal incontinence, excessive humidity, the use of soap, excess scrubbing of the anus, chronic diarrhea, and menopause.

Lots of reasons, many of which may apply to you. But, remember, HALF the time, there is no reason to be found.

Here's where itchy butt gets frustrating.

There is something about itchy butt that predisposes people to a vicious itch-scratch cycle in a very innervated area. Yes, our anus is super well innervated. And the combination of that cycle and the insane number of nerve endings down there, often leads to an intolerable impulse to scratch the perianal area. Again and again.The urge is classically worse after bowel movement, worse at night right before going to sleep, and sometimes even worse in the middle of the night.

This often leads to literally clawing the skin. Even for the most controlled human being, the urge to scratch can be tremendous, and even a little extra rub-dab-- with a wet wipe, a cream, a salve. And those very wipes and salves may be part of the problem.

Wet wipes, for example, which may seem to get you cleaner than toilet paper, contain preservatives that are commonly known to cause/worsen contact dermatitis. That means you use a wet wipe thinking it will make your itchy butt better, and it may only be making the problem worse. For these reason, it's reasonable to avoid all wet wipes (even those that claim to be gentle, unscented, etc).

Desperation also leads people to try all different kinds of products, natural and unnatural-- including hydrocortisone, witch hazel, calendula, lotions of a wide variety, Chinese herbs, Benadryl cream, cool water, hot water, comfry leaf, ice cubs. You name it, someone's tried it. Yes, even capsaicin (that's the stuff in chili powder that makes your tongue tingle). And, fortunately, in some cases, SOME of this stuff helps. But I'm here to tell you that, unfortunately, in most cases, most of these things just cause more skin irritation, give you further excuse to rub things on (furthering the itch-scratch cycle) and don't lead to ultimate relief.

The solution MAY be simpler than you would have thought.

Here's my prescription for itchy butt--  ridiculously simple, but often simple is the best!

First, if you are truly worried you might have a hemorrhoid, an STD or some other lesion down there, please go see your primary care provider. Let someone else take a look. If she sees something, she'll treat it.  And maybe you will get better. And try not to be embarrassed. If you've already done that and heard the disappointing, "It looks pretty darned normal back here, nothing to worry about",  please don't despair. It's not all in your head. It's real, it's itchy, but it's treatable. Go for simple.

1) First, STOP scratching! (So much easier said than done). Do anything in your power to stop scratching: cut your fingernails, wear gloves, wear tight pants, wear three pair of underwear, meditate. Anything that works to keep your hands away from those pesky little nerve endings. Break the cycle.

2) Next, stop putting any products down there, including soap when bathing, anti-itch creams, herbs, etc. Most topical formulations are probably contributing to irritating your skin, and you need to give the skin a chance to heal. Plus, any time you put something down there, it's an excuse to give a little scratch. And then you are back at it again.

3) Stop using wet wipes. I know, counter-intuitive, but trust me.

4) Get yourself a squirt bottle or spray bottle or some sort of other water container, and each time you either feel the urge to itch OR have a bowel movement, use water AND only WATER to clean yourself.

5) Resist the urge even to use toilet paper (it's just too tempting to give a little extra rub while your down there, and that little rub is part of the problem). It's not a matter of getting yourself cleaner-- even if you are convinced it's so.

6) If you are unbearably itchy, always go back to the cool water. Squirt, spray or sit in it. Do not rub it on.


No prescription is ever 100% effective, but I can offer you some hope. It really does work! And you can move on from focusing your crazy frenetic anxious all-consuming energy on your anus to somewhere more productive. 



Additional resources:
http://www.patient.co.uk/forums/discuss/browse/pruritus-ani-1740

What happens when a doctor does harm?

When I was in my third year of medical school, I remember telling my mom (a dedicated nurse for over 45 years) about a negative experience I had during a rotation on the hospital wards.

I don't remember even the vaguest of details surrounding the actual event, but I will never ever forget my mom's response that day: "Some day, honey," she said, "It won't be about you anymore. It will be about your patients."

I remember feeling rather hurt at the time, as though my mother was being dismissive of my feelings-- chastising me for thinking I had a right to be a medical professional and a real person at the same time. (And believe me, medical school already does a doozy on one's sense of person hood). I wanted to be part of the story. On some level, I wanted the story to be about me.

A few years later, as a brand new resident physician, I shared her advice with several of my similarly-green colleagues. We all chuckled at the time because so many of our first experiences as newbees (e.g. first deaths, first postpartum hemorrhages, first cancer diagnoses, first arguments with a floor nurse, first morphine prescriptions, first you-name-its) seemed to have everything to do with us. We were learning, after all. And though we were learning through the real life experiences of living breathing patients, we were still our own main characters in our own personal novels--  fumbling our way through a series of awkward and sometimes painful lessons on the way to becoming experienced clinicians and, hopefully, healers.

Now, surprisingly enough,  in the the almost-eight years since our conversation, my mom's once painful words have comforted me through many challenging situations.  I have carried her counsel through frightening birth experiences, challenging family meetings, heated discussions about end-of-life choices, angry patient encounters, awkward teaching moments, even through my own painful infertility journey while caring for a plethora of fertile patients.

When things have gotten complicated, I have repeated her counsel to myself, and I have found relief rather than resentment in the reminder. 

"This isn't about me," I tell myself. "This is about my patients."

It's about his sick body. Her mental illness. His struggle with weight and substances. Her wishes. I am so often privileged to bear witness, to hold hand, to give counsel, to be present, to help guide. But, in the end, it is not about me. It's about my patients.

This isn't to say that I have completely removed myself and any emotional investment from my patient care. No, no, no! Quite the contrary.  In fact, by reminding myself that a patient's particular situation is not about me, I am able to really hold the space for that patient and be as present as possible for them during his or her journey.

Except when I cannot.

Unfortunately, this month, I have been confronted with myself yet again (gosh darn it, I just cannot get away from myself as the main character in my own story)-- in a very raw and real way. This time, however, I am also featured as a main character in someone else's (i.e. my patient's) painful story, and I wish it weren't so.

This week, I must confront the most serious medical error I have made in my career. I messed up. I did not keep my patient safe. In fact, I caused harm. To another human being.


What happens when a doctor does harm?

And what happens when I am that doctor?

Is any part of it about me?

***

Obviously, my first responsibility in reconciling my error is to my patient, to the very patient to whom I have vowed to do no harm. That person to whom I have pledged to care for and guide and counsel, and who has entrusted his/her body to my skill, my experience and my fallibility. And to that patient, I must apologize. This much is very clear.

I am sorry. I am so sorry.

But then what?

Do I apologize again?
And again?
Beg for forgiveness?
Do I throw myself on the floor and cry?
Do I stay up all night trying to understand exactly what happened?
Do I stay up a second night trying to justify a known medical complication?
Do I consult a higher level expert? A more experienced clinician?
Do I dwell?
Do I stop doing what I am doing for fear it will happen again?
Should I second guess my training?
Even worse, second guess my judgement?

All of the above, I guess, and then some.

Yes, I have gone back to review the literature.  I have also reread my own documentation of the event, reconsidered the circumstances, imagined how I could have done something differently, sought the advice of my esteemed colleagues, talked to my boss, taken a long swim, summoned my inner perfectionist along with my well-trained professional side. And cried a little.

After all, I hurt someone. And I cannot really take that back. Ever.

In so processing, I have also to remind myself that errors happen-- that, in fact, that this error I made is actually well-documented and, to a certain extent, expected. It happen somewhere about 1 in a 1000, and I'm getting closer and closer to that thousand. The longer I am in practice, the more procedures I will perform. The more procedures I perform, the more errors I will make.

Ok fine. But is there room in my own head and heart for error? Can I forgive myself?

Like most physicians, I am a pretty much a Type-A-obsessively-compulsive-perfectionist who-- despite the appearance of both my refrigerator and my underwear drawer (both are always disasters)-- doesn't really let myself off the hook very much. I expect perfect from myself. Always.

***

And so, I ask myself--after I first make darned well SURE to take care of my patient-- isn't  my second responsibility to myself? Isn't there also a part of this that is about me?

Me the woman, me the physician, me the fallible one, me the healer?

"Oh big and dangerous ego," I say to all those mes, "Take a step down my dear, you are so fortunately imperfect. You screwed up." And, though this one particular case may have had a different outcome, screwing up is inevitable. "You will screw up again, no doubt."

While this is not my story, I am still part of the story. And though I have not been physically damaged by this turn of events, I will never be quite the same.

I am certainly not alone in making medical mistakes-- even big mistakes-- ones that my patients will have to live with forever. Knowing that I did nothing with mal-intent or beyond the scope of my training. Granting that next time I will be more nervous, more tentative, and hoping this is an acceptable outcome for myself. And that if I move forward from this circumstance changed, may the change be a positive one for all who I serve in the future.

My I continue to be as good as I can be.
May I be self reflective.
May I be humble.
And may I accept-- not just occasionally but always and inevitably-- my own imperfection.

Let's talk about death, baby

Let's talk about death, baby.

"After all, what’s a life, anyway? We’re born, we live a little while, we die."

Let's talk about you and me.
Let's talk about all the good things and the bad things that may be.
Let's talk abooooouut death.
Let's talk about death.

Tune stuck in your head yet?

Sorry, mine too.

On a recent NPR podcast from Planet Money, the reporter said something akin to, "Death is kind of like sex-- not exactly something a teenage daughter wants to talk about, especially sitting on the couch with her parents after dinner on a random Wednesday evening."

So true.

Ever since I heard this amazing report about a whole town that got their death wishes in order, I have been singing this song (yes, in a never-ending loop that you too are singing), hoping that, when the time comes, I'll feel comfortable enough to sit on the couch with my son to discuss sex, and pondering my own personal ambivalence regarding death.

My death, my family members' deaths, my patients' deaths. Heck, even my dog's death. 

This got me thinking. Death is happening all the time (just like sex).
Death is inevitable (sorry, mom and dad, just like sex).
And death is unbelievably hard to talk about (no argument here).

But why? 

My answer is pretty basic-- just like sex (ahem, fellow healthcare providers, another topic for another day), I don't talk about death enough. And I don't really know how to talk about it.

Give me birth control. Ear wax. Diabetes. Flu shots. Eczema. Anal itching. Vaginal discharge. Zits. Anxiety. Toe fungus. I can speak on any of these topics with ease and knowledge. I can educate, reassure, empower.

Death, however, is a different matter entirely.

Truth be told, I'm not particularly good at talking about death. Yup, you heard me correctly, I'm a physician-- a family physician, and I'm bad at death. I'm awkward, ambivalent, and surprisingly nervous. I'm too frequently under-prepared, always wishing I had better words, more polished form, and more grace. I'm also young and blessed by health, which means I can avoid death a little more actively. 

On this particular topic, I cannot help but wonder, shouldn't I be better at this?

Yes, I should.

And yet, perhaps not unlike yours, despite not talking about it much, my life is pretty full of death. Okay, so maybe I get a little more death than the average Joe, but I am certain that if you were to sit down and list your own death encounters in the last year, you would find you have quite a bit of death in your lives too. After all, death is an inevitable part of life.

Here are a few of my death memories that stand out over the last year:

• My previously-healthy father-in-law faced several tremendously close calls with death over the last ten months, including a battle with flesh-eating bacteria (unfortunately, he lost his left leg) and an autoimmune paralysis that left him on life support for many weeks and in the hospital for months. 
• An 85-year-old supremely accomplished patient of mine with horrible arthritis of the spine but a mind as sharp as a tack asked me the other day about how she might gracefully end her own life.
• My husband and I recently finished reading EB White's Charlotte's Web with my 3-year-old son. He loved the book and listened actively and patiently to the story every night over a week's time. I wasn't so sure my little guy understood Charlotte's death until he overwhelmed us both with an intense emotional response about an hour after we read the last chapter (poor, sobbing heart). Ever since then, he mentions death frequently.  And by frequently, I mean daily.
• The daughter and 24-hour caregiver of a very old, very demented man (he is my patient) told me she feels guilty about making the decision to transition him to hospice. She's worried her siblings will look down upon her. And so she won't sign the papers.
• A 69-year-old healthy cyclist made a visit to see me to talk about how to document his final wishes. He told me that none of his adult children wanted to be his surrogate decision-maker. He was wondering if I thought it strange if he chose his girlfriend instead.
• Last year, a friend's dear puppy fell severely ill over a relatively short period of time. My friend and her husband had to make the painful decision to either spend a lot of money and time dragging the pup to specialist vets hours away or euthanize her. Though they felt good about their final decision, it was terribly sad.
• My husband's 92-year-old grandfather had been failing gradually over the last year-- until, that is, he agreed to get hospice care. Since then, he started eating again and even makes it to some family functions. We thought he was dying. Turns out he wasn't-- at least not yet.

Each of these encounters presents an opportunity to tackle the topic head on: to discuss how my father-in-law might really want to die, to enrich my son's understanding of life in the context of mortality, to empower my patient to choose dignity for her father, to support the difficult decision that is euthanasia and suicide, to enrich my own skills by simply practicing having the conversation. And I am embarrassed to admit that, in too many of the examples above, I tripped and fell or just ran way.

This is hard stuff.

And so, in an attempt to work on this obvious weakness of mine, I wandered into a reflection on why death is so hard to talk about-- for ordinary humans, doctors, and even super heroes.

Death is morbid. Uh, duh, you might say. That sentence makes no sense; morbid and dead are synonyms. But that's not really true. In fact, according to the esteemed dictionary of Google, morbid actually means "characterized by or appealing to an abnormal and unhealthy interest in disturbing and unpleasant subjects." Is death actually morbid, then? Maybe only if you believe it's inevitably disturbing and unpleasant. I can think of plenty of ways to die that would be disturbing and unpleasant; drowning, for example, one of my least favorite ways to imagine my own death. Burning to death another one that comes to mind. Recent media coverage about botched lethal injections definitely seem disturbing and unpleasant. That being said, the act of dying need NOT be disturbing, particularly if the dying person is comfortable and surrounded by people he/she loves, having felt like life has been sufficiently fulfilling and that its end comes with dignity bathed in love.

Death is uncomfortable. Or is it? How many of you have actually watched a person die, and I don't mean on TV or in the movies. I mean, sat there at there and watched someone take his/her very last breaths, his/her heart beat its very last beats? I have-- at least a handful of times-- and I am here to tell you that death CAN be uncomfortable-- the most uncomfortable death I have seen was a young man dying of liver failure as a result of his alcoholism. He died extremely uncomfortably. And the memory of his gruesome death is seared into my consciousness forever. It didn't need to be that way-- we all knew he was dying-- but the system let him down, didn't prepare him to be comfortable with his own death, tended his symptoms without confronting his mortality.  I have been in beautiful, quiet, peaceful, comfortable deaths, deaths in which someone literally looked like he/she moved from a place of sleep, to a place of final rest. And breathed a sigh of relief. Death nurtured life.

Death is scary. Definitely scary. No doubt about it. I know I am not the only person on the planet who (morbidly) imagines my life ending amidst the screams of a crashing airplane, or trapped underneath a body of water, or in a beeping-tube-filled ICU hospital bed.

Death is definite. Perhaps this is where death and sex do converge. Sorry, parents, every single one of your sweet children will eventually die (and close to that same number will eventually have sex).  Henry David Thoreau wrote "Death has beauty when seen as a law. Not as an accident. It as as common as life".  Perhaps it's the certainty that it will happen to each of us that makes it the most overwhelming. Inevitability is not always a man's best friend. Particularly in the 21st Century when we feel inclined to employ amazing amounts of technology to keep people alive during their last weeks on Earth. We cannot, however, ever win. Death always wins. And that perhaps is the only truth in all of this.

Doctors are hypocritical too. Please don't misinterpret my words. I am no model. I am no expert. I, too, am scared shitless of my own death-- and don't even get me started thinking about my mom's or my son's death. I won't sleep tonight.  It is NOT easy to talk about death-- even when my graceful and brilliant 85-year-old patient, trained psyschologist says matter of factly to me, "How can I die gracefully." I, too, squirm. I hem. I haw. I WANT to be able to have as much grace and perspective as my patient, to guide her majestically into the netherworld. I think I'm generally pretty suave in uncomfortable situations-- I thrive on difficult conversations and want to be good at this. But, to be perfectly honest, I'm not. As many of my colleagues are not. For lack of training. For lack of cultural exposure. For lack of tools.

And so, I bumble along, doing my best to do my best in that moment with that patient-- be it in my office or at the bedside in the hospital.

And despite death's definiteness, we systematically avoid it, even as we sit before the oncologist facing our own mortality, even as our own parents face serious and grave illness. We act as though we will escape, we fail to fill out a living will or an advanced directive or a medical power of attorney.

Chances are, when you finish reading this, you'll do none of the above. Fine. Fine with me. But do this one thing-- for yourself. Call or email or take the person out to dinner who you think would be the BEST person in your life to make decisions if and when some complicated time come. It may be your first born or your neighbor, heck, it could even be your mailman. Sit with them, designate them, and give them some background, so if you find yourself unconscious in the hospital or ventilated in the ICU or even just sitting in front of the oncologist with a new diagnosis, you know that person will represent YOUR best wishes, be your advocate.

For death will come to all of us and it sure is nice to have some company on the way out.


Additional references:
http://deathoverdinner.org
http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?hpw&rref=health&_r=0
http://www.agingwithdignity.org/forms/5wishes.pdf
http://capolst.org/
https://www.youtube.com/watch?v=pX1csOAu1IM
http://www.npr.org/programs/death/readings/stories/ebwhite.html

The Meaning of Ear Wax

Poor earwax.

Yes, this came out of my 3-year-old's ear.

He is forever being talked about, dug out, probed at, messed with, dripped on, picked at and judged.

We think he's dirty, crusty, gross.

We want him out.

Out of our own ears. Our partner's ears. Our kids' ears.

He is not a hero.
 
In fact, though we all have some amount of earwax, studies show that around 5% of adults, 10% of children, up to 57% of older patients in nursing homes, and 36% of patients with mental retardation complain of earwax problems. Of those, about 4% consult a primary care physician for help with dealing with their ear wax-- and that translates to millions and millions of visits to the doctor every year.

What is ear wax?
Our ear canal is a literal cul-de-sac.  On the normal highways, byways, and side streets of our skin (think face, arms, legs, even between your toes), the stratum corneum-- the outermost layer of our skin, composed mostly of flat dead cells filled with keratin-- slough off with physical erosion.

In other words, we run around, we shower, and we shed.

But the unfortunate reality about life in a cul-de-sac is that the dead cells have nowhere to go. No job to serve and not much to do but to just hang out.

Enter Captain Cerumen (aka earwax), that very villain you have been acculturated to abhor!

He is a hero!  (Well, sometimes).

This unlikely hero is specially designed to help us shed our ear canal's stratum corneum. He is a mixture of oily fats (like cholesterol), proteins, glandular secretions from hair cells and other types of technical "gunk".

There are two main types of ear wax: wet and dry. Wet wax, which is brown and sticky, has a higher concentration of fat and pigment. Dry wax, more grey-tan and brittle, has less fat. There are ethnic differences too: wet wax tends to be most frequent in Whites and African Americans, dry  in Asians and Native Americans. Kiddos tend to have wetter wax (easier to break up than adults)-- thank goodness for those of us trying to get that wax out!

In addition to helping abrade the canal, Captain Cerumen cleans and lubricates the ear canal. Some scientists have theorized that wax is actually antibacterial, though studies have shown lots of different types of bacteria growing in wax, so how effective it is in protecting us against bacterial and viral illness is controversial.


Earwax isn't inherently problematic
If earwax does it's various jobs, it isn't actually problematic. After all, we all have some! It's when earwax gets impacted (in other words, stuck deep inside the ear canal) that people complain of problems: itchiness, pain, hearing loss, ringing, dizziness.

How does earwax get impacted?
As in many things in life, genes play a big role; our behaviors can exacerbate the issue. The same can be said for dental cavities, weight, and even perfect skin. Some of us happen to be lucky to have big open ear canals and soft wet wax, just like some of us were born with teeth of steel, skinniness we couldn't fatten up if we wanted to, and smooth, unblemished faces.

You have poor grounds for bragging rights just because your ear canals are clean (and your partner's aren't). You are mostly just lucky!

In the case of impacted earwax:

• Some people just have biologically small or twisted ear canals (yes, blame your mother). 
• Some people just have dryer thicker, more keratinous (and less waxy) wax (this time, maybe, blame your father).
• Some people stuff the wax in their with cotton swabs (aka qtips)-- This is why the doctor is always telling you not to put qtips in your ear. Not only because you could bust your eardrum with one (you can, but that's rare), but more because you think you are pulling ear wax out, and mostly you are probably stuffing it in further, particularly if you have that dry thick stuff

People do all kinds of strange things to get rid of their earwax.
 Here are a few of my favorites:

Chinese ear picks: Cute and very commonly used, particularly by Asian mamas to dig their kiddos' earwax out; may be dangerous in the wrong hands, but plenty of (particularly Asian) mamas swear by them (and are pretty skilled at these little buggers). Here's another example.

Ear candling: A little weird, right? This method has lots of believers (something to do with creating negative pressure, vacuum, blah blah blah) without much data, studies show it's as effective as placebo and may be dangerous. Careful!

Q tips: I am the biggest hypocrite doctor on the planet, advising my patients not to use, but oh, qtips feel so good. . .it's hard to resist these useful little guys after a long hot shower

Hydrogen peroxide: This is my hubby's favorite. He loves the bubbling sound in his ear. . .







What actually works?

Doing nothing: Most people don't actually need to do anything to their earwax. Unless it's literally causing you problems (pain, itchiness, hearing problems, etc), leave it alone. Having earwax doesn't mean you are dirty or unhygienic. It's normal and healthy! And check this out: even for those who presented to the doctor with problematic earwax, a study showed complete resolution in 5% of patients and moderate resolution in 25% after a few days of doing absolutely nothing. Take home: if you procrastinate, it may just resolve itself. Our body is powerful!


But. . .for those of you who feel compelled to do something about your earwax, there are few studies actually comparing what works best.

Manual removal (i.e. scoop it out): Manual removal refers to literally having someone dig out your ear wax. It should be distinguished from home tools like q-tips and Chinese ear picks; safe manual removal should be done by someone who can visualize your eardrum (i.e. not yourself) and who actually knows what he/she is doing so as not to cause more problems. It also requires a "cooperative patient" (i.e. not a tantruming, squirming, screaming child). I do this with some frequency in my office (especially if I am trying to evaluate a child for an ear infection and cannot see his/her eardrum);  my son's pediatrician has done it for my son (for the same reasons), and otolaryngologists (ears nose and throat docs) are definitely qualified to do this, particularly for someone with a complex ear history. No one know if this is a better way than the others listed below, but it's quick, safe if done by someone who knows their anatomy, and usually not terribly uncomfortable. Also, it avoids the use of moisture, which may be associated with increase risk of infection in certain cases.

Ceruminolytics (i.e. soften it/break it up): "Cerumen", as you know, means wax, and "Lytic" means literally "break up". These cerumnolytics include all those products you see in the "ear section" at the drug store, including Debrox, Cerumal, and Earax, as well as home remedies like hydrogen peroxide, mineral oils and olive oils. Most ceruminolytics are thought to help make wax softer and, well, more waxy than it may be naturally.

There are three types: oil-based, water-based, and non-oil non-water based. There are a few small studies comparing different types, and most studies are pretty equivocal (in other words, they are all the same). Buy the cheaper one. Or the one you like the most. I have found that individuals (including myself) have super strong opinions about what actually works. Probably whichever type you use, the longer you use it (i.e. for several days in a row) is the most important factor in how successful you are.

Just a note: my favorite ceruminolytic is olive oil. It's cheap, easy, you already have some at home (or you better, because it's one of the best oils to be cooking with), it's has minimal side effects, and it works pretty well. Try it! Just a few drops (with a dropper or a small syringe) in each ear.

Irrigation (i.e. spray it out): Irrigation, also, should be done by someone with some experience. Though you can certainly try this at home, the tools we have in the office (fancy water bottles with specially designed tips) are probably more effective and safer. There are a variety of products on the market designed to limit trauma to the ear and maximize effectiveness. My medical assistant is a super professional with the ear irrigator and can clear almost anyone with enough time to hang in there with her. (I've been trying to get my husband to see her for years). It's considered effective and safe, though anyone with a known ruptured eardrum should stay away. One study found it worked alone 70% of the time. Irrigation should NOT be done in someone with ear tubes or with a questionable ruptured ear drum. It has been associated with a low risk of infection of the ear canal.

Ceruminolytics + irrigation: If irrigation works about 70% of the time, then irrigation after a course of ceruminolytics is thought to increase the probability of success to about 97%. Putting in some lytic about 15-30 minutes before irrigation has been shown to be more successful than doing it immediately and not any better than in the days leading up. So, I might suggest that at the start of your visit, ask the medical assistant to instill a ceruminolytic of your choosing. You can meet with your primary care provider for 15-20 minutes, and then finish up with an irrigation. Walk out of the office feeling like a new guy/gal. Voila!

                      
                                                       ***

In truth, people have an unbelievable attachment to their earwax. Or perhaps the proper term is detachment. They grant earwax a ton of negative attention and more meaning than it merits without appreciating it for its inherent utility. And everyone always want to talk about it (comes up in my office at least 3 or 4 times a day)!

Most of you should just LOVE your earwax-- after all, it serves a good purpose. Plus, there is no real point in having spick and span ear canals. Earwaxlessness=overrated.

Those of you with issues, though, consider something cheap and easy (e.g. olive oil) or go see your primary care provider and ask for a washout. The visit may also be a good opportunity to talk about your weight, your mood, or your blood pressure. While that ceruminolytic is soaking in. . .



Additional References:
http://www.aafp.org/afp/2007/0515/p1523.html

http://qjmed.oxfordjournals.org/content/97/8/477.long
http://udel.edu/~mcdonald/mythearwax.html
http://www.webmd.com/cold-and-flu/ear-infection/news/20080829/earwax-too-much-of-a-good-thing
http://www.ncbi.nlm.nih.gov/pubmed/14979962